We read with interest the study by Gairin et al (Reference Gairin, House and Owens2003), which highlighted the suboptimal working relationship between the accident and emergency department as a first point of contact and psychiatric services. Thirtynine per cent of suicide victims got in contact with the accident and emergency department at some point in the last year of their lives and, according to the National Confidential Inquiry into Suicides in England and Wales, only a quarter of suicides are preceded by mental health service contact in that same period.

Although I appreciate the above point, I still think that contact with primary services has an equal if not greater role to play in reducing suicide, especially in those age groups whose members are less likely to attend the accident and emergency department at times of crisis, such as children and the elderly.

Duckworth & McBride (Reference Duckworth and McBride1996) have reported that 80% of elderly suicide victims received no psychiatric referrals, and according to Harwood et al (Reference Harwood, Hawton and Hope2001), only 15% of elderly people who died by suicide were under psychiatric care at the time of death.

In our study, analysing coroners’ inquests of 200 cases of suicide in old age in Cheshire, 1989–2001 (Reference Salib and El-NimrSalib & El-Nimr, 2003), the role of primary care was emphasised. Interestingly, even those victims who were known to psychiatric services still preferred to contact their general practitioners (GPs) in the last few weeks before the fatal act.

One conclusion might be that people whose GPs acknowledged their mental health problems and cared to refer them to a specialist service were able to build a more meaningful therapeutic relationship with their doctors and readily contacted them as a final desperate act in the last period of their lives. A well-trained GP can act not only as an effective first point of contact but also a final one!