Fifty inpatient suicides occurring in an English health region during 1987-91, were identified from two data sources. Male inpatient suicides (mean age, 40 years) were younger than females (mean age 58 years). Around a third of the deaths occurred in the week after admission. More than half the deaths had occurred outside the hospital. The authors felt the health service’s untoward incident reporting seriously under-enumerated cases of inpatient suicide.