Coronial determination of suicide: insights from inquests

ABSTRACT

The purpose of this article is to extend previous discussion of the relationship between coronial verdicts of suicide and suicide statistics, through a detailed examination of coronial decision-making during 130 inquests in Queensland, Australia between 2004 and 2018. This research suggests that the official category of suicide does not have the same meaning for different coroners, and it is unlikely that coroners follow the same rules in assigning particular cases to given categories. This is complicated by several factors: the feedback loops between researchers and coroners, where researchers rely on coronial data and coroners rely on research findings; beliefs about ‘suicide prone’ populations; and the role of coroners in offering closure for families and meaning for society. Suicide is a social fact, and how it is counted depends upon the norms, protocols and concepts operating within any given coroner’s court. We conclude that administrative options beyond the binary of suicide/not suicide would have the most impact on enabling suicide findings to be more consistent and defensible.

KEYWORDS:

• Suicide
• coroner
• inquest
• Indigenous
• legal decision making

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/13576275.2022.2114823.

Notes

1. We use suicide cues as an alternative to the term ‘risk factors’. It encompasses the ways in which coroners engage with information from the death and from the suicidology research.

2. In 2004 the House of Lords found that a coronial inquest into the death in custody of Colin Middleton in 1999 did not comply with article 2 of the European Convention on Human Rights. The resultant Middleton Judgment (R v. HM Coroner for the Western District of Somerset, ex parte Middleton, U.K.H.L. 10 (2004). (Eng.) clarified the requirement of the Coroners Act 1988 to include not only how a death occurred but also by what means and circumstances (Gunnell et al., 2011).

3. The rise in narrative verdicts from 111 in 2001 to 3012 in 2009 had implications for suicide statistics since narrative verdicts do not have a clear acknowledgement of intent and must thus be coded by ONS as an accidental death (Gunnell et al., 2011). Similar concerns about coding of suicide, due to the lack of a clear intent in the decision of the coroner, have been identified in both Australia (De Leo et al., 2010) and the US (Warner & Paulozzi, 2013).

4. It is worth noting that the use of the civil standard of proof for suicide determinations in Australia and US has not decreased concerns about under estimation by coroners (Dodds et al., 2014).

5. Queensland was chosen simply because it has the most comprehensive and easily searchable inquest date base in Australia. For a further discussion of this point. (see Jowett et al., 2018 fn 9).

6. For example, in Queensland in 2019, only 29 deaths resulted in an inquest, representing only 0.05% of all cases reported (Ryan, 2019, p. 6).

7. The time span was chosen for two reasons. The end point – 2018- was the most recently available at the time of the research. The start date – 2004 - coincided with the creation of a new Coroners Act, and the appointment of an inaugural state coroner. It was considered to usher in a modern coronial system in the jurisdiction

8. To protect the anonymity of involved parties, all inquests have been de-identified to the extent possible, prior to publication.

9. It is worth noting that previous research has demonstrated that while alcohol is seen as an Indigenous risk factor for suicide, it is often understood as a protective factor in non-Indigenous suicides. For further discussion see: (Tait et al., 2018).

Additional information

Funding

The work was supported by the Australian Research Council [Discovery Project (DP 150101402)].