Aliment Pharmacol Ther 31, 1310–1321SummaryBackground  Recent data associated higher mortality with medical rather than surgical intervention in patients with ulcerative colitis who require hospitalization.Aim  To examine factors influencing UC‐related mortality in Scotland.Method  Using the national record linkage database 1998–2000, 3‐year mortality was determined after four admission types: colectomy‐elective or emergency; no colectomy‐elective or emergency.Results  Of 1078 patients, crude 3‐year mortality rates were: colectomy elective 5.6% (n = 177) and emergency 9.0% (100); no colectomy elective 9.8% (244) and emergency 16.0% (557). Using elective colectomy as reference, multivariate analysis [OR (95% CI)] showed that admission age >50 years [OR 5.46 (2.29–11.95)], male gender [OR 1.92 (1.23–3.02)], comorbidity [OR 2.2 (1.38–3.51)], length of stay >15 days [OR 2.04 (1.08–3.84)] and prior IBD admission [OR 1.66 (1.06–2.61)] were independently related to mortality. Age was the strongest determinant. No patient <30 years died. Mortality of patients aged <50 years [10/587 (1.7%)] was significantly lower than mortality of those aged 50–64 years [26/246 (10.6%)] (χ2 = 32.91; P < 0.0000001) and >65 [96/245 (39.2%)] (χ2 = 218.2; P < 0.0000001). For those patients aged more than 65 years, mortality in the four groups was 29.4%, 33.3%, 28.1% and 44.7%– all greater than expected in the Scottish population on assessment of standardized mortality ratios.Conclusion  Hospital admission in UC patients >65 is associated with high mortality. Management strategies should consider this by treatment in specialist units, early investigation, focused medical treatment and earlier surgical referral.