Coroners (Recording of Suicides)

Madeleine Moon Excerpts

Wednesday 27th April 2011 Westminster Hall

[Mrs Madeleine Moon (Bridgend) (Lab)]

I look forward to taking part in the debate this afternoon under your excellent, impartial and always fair chairmanship, Mr Robertson. I must admit that I have already had a certain amount of generous time offered to me by the Minister and his team to discuss some of the issues that I wish to raise. However, these matters are of such importance that I want to rehearse them again here, so that the Minister can hear them outside the meeting that he had with me in his Department with Professor Keith Hawton from Oxford university and Professor David Gunnell from Bristol university, both of whom are from departments of suicide studies.

This is a very serious issue. Every suicide is a tragedy for the individual who takes their own life and for their friends, family and community. More than 4,000 people take their lives in this country every year. Only heart disease and lung cancer are responsible for the loss of more years of life. Suicide is the leading cause of death among young men. The figures are shocking, but it is vital that statistics about suicide are recorded accurately in our effort to ensure that fewer people feel that they have to take their own life and fewer people lose a loved one in such a tragic way.

Accurate statistics help academics to understand the causes of suicides and the key groups at risk. They help local and national Government and health care professionals to decide what prevention strategies will work best and where to target resources. Statistics about causes of death including suicide are collected by the Office for National Statistics based on reports submitted by coroners following inquests. As I will explain, the increasing use of narrative verdicts by coroners and the variation of practice between coroners risk undermining the reliability of the statistics that we have and our ability to combat suicide.

Like any cause of death, suicide rates vary by age, gender, background and geographic area. More than any cause of death, the way in which the suicide rate varies across those demographic groups changes over time. Twenty years ago, men aged over 75 had the highest risk of any group, but they now have the lowest. Men aged between 15 and 44 have the highest rate of suicide of any group, but women within that same cohort have the lowest.

External factors can have a dramatic effect on the rate of suicide and can affect different demographics. Economic recession and high unemployment have a particularly striking effect on the suicide rate of working-age men. Different areas have different profiles of suicide victims, and those demographic profiles change over time. A paper by Bristol university’s Professor David Gunnell and others published in December concluded that in the past 25 years

“there has been a marked change in the spatial epidemiology of suicide”.

Such changes must be accurately recorded if our work to prevent suicide is to be effective. I will return to geographic recording in a moment.

There is also the question of the occurrence of so-called suicide hotspots and suicide clusters, where suicides occur more often than would be expected. Those areas of research can help to have an impact on suicide prevention in specific geographic areas.

University researchers have been able to use statistics to identify trends in suicide methods and increases in the use of a particular method. Professor Keith Hawton of Oxford university has produced work on the use of smaller packets of paracetamol and co-codamol, which reduces the use of those medications in suicides. The fitting of catalytic converters to cars reduced the number of suicides from car exhaust fumes, and the move from coal gas to North sea gas reduced the number of incidents of suicide by gassing. Such an approach does not just reduce the number of suicides by a particular method; it reduces the number of suicides overall because people do not tend to simply move to another method. Tackling and understanding the methods used is very important.

Information about geographic regions and suicide informs Government interventions and where resources need to be targeted to have the best effect. They also help us to understand the nature of suicide itself. However, the reliability of suicide statistics is being undermined by a significant rise in the use of narrative verdicts by coroners. In 2001, 111 deaths were recorded by narrative verdict. By 2009, the number had increased to 3,012.

Narrative verdicts were introduced to the UK as a requirement of article 2 of the European convention on human rights, which includes a duty to investigate and prevent deaths and a duty for the Government to take action to prevent further deaths. Narrative verdicts were intended for fairly limited use. Although they can provide more details about the circumstances of a death, they do not use a standard verdict to express the conclusions. That presents a challenge for coders at the Office for National Statistics, which is responsible for collating coroners’ verdicts into usable data. Many deaths given a narrative verdict are likely to have been suicides, but they might not be identified as such by coroners.

The ONS uses international classification of disease rules, so it is not permitted to infer anything from the coroner’s narrative verdict. Coroners must use certain key words in their narrative verdicts for them to be properly categorised. Unless there is a clear reference to an intention to cause self-harm, the death must be recorded as accidental by the ONS, regardless of any other information given. Even a narrative verdict that gives a number of details surrounding a death could fail to specify the intention of the deceased.

Let us consider the following hypothetical example, which is used by the ONS to illustrate the problem. I apologise if this description causes distress to anyone, but it is hypothetical. Mr X, after being found hanging in his cell at X youth offenders institution on date X, died on date X at X infirmary. It was a serious omission by X young offenders institution not to have informed X’s parents on each occasion that X had self-harmed. The jury’s verdict was that X died from hanging, which caused his death. In that example, there is evidence of intent to self-harm because previous instances of self-harm are mentioned in the narrative. However, there is no mention of intent surrounding the initiating act that caused the death. Therefore, the death is classified as “accidental”.

The ONS has estimated that such examples could have resulted in the suicide rate being underestimated by at least 6%, which is a third of the target for reducing deaths by suicide established by the last suicide prevention strategy. If the use of narrative verdicts increases, the gap between actual suicides and those reported will rise further, thus making it difficult to estimate any progress that is being made in reducing deaths by suicide.

The Ministry of Justice was unable to provide me with information about the number of narrative verdicts given by each coroner’s district. However, narrative verdicts made up around 81% of the verdicts classified as “other verdicts” in MOJ figures in 2009. In one very large district, Birmingham and Solihull, more than 48% of the 962 verdicts were classified as “other”, compared to a national average of 13%. In contrast, there were four districts, each one recording dozens of deaths, in which no narrative verdicts were given. Almost a third of coroners’ districts used “other verdicts” less than 5% of the time. That is not a criticism of the way that any coroner practises. However, there is clearly a lack of consistency in the way that narrative verdicts are used and therefore in the records that can be collected.

At the root of the problem is the coroner system itself. In 2003, a review of the system concluded that

“the coroner is a law unto himself.”

Inquest, which operates a free advice service for bereaved people, has described coroners as operating

“as a fragmented, non-professional assortment of individual coroners who operate with no compulsory training and little accountability.”

The system, or the lack thereof, creates a lottery in how deaths are recorded. There is no consistency and no guidance on how narrative verdicts could be presented, so that they could include the information that is required by the ONS. Narrative verdicts vary from a couple of lines to a couple of pages.

The Coroners and Justice Act 2009 contained a provision to create the office of chief coroner. Under that Act, the chief coroner would have responsibility for driving up standards in the system through training, and they would issue guidance and set national standards of service. The performance of the system would be monitored and there would be a consistent way of operating, which is the point most relevant to the debate today. In addition, differences between coroner areas would be kept under review.

The Government have determined that the function of the chief coroner can be carried out by others. I served on the Public Bill Committee for the 2009 Act, and I must say that we need a senior legal officer who oversees the coroner operation and ensures consistency in coroners’ courts. That is my preferred option, but a second option is to issue regulations and clear guidance to ensure that all narrative verdicts contain all the necessary information, with clear direction that any narrative verdict must include a statement on the intention, if any, of the person who has died. That would allow the accurate recording of the information that we need.

I want to mention briefly a third option, which is discussed in a paper by Lucy Biddle, a researcher at Bristol university. It is to remove suicides from the coronial system altogether. I will quote briefly from her paper:

“Indeed, suicide requests seem to be more to do with tradition than functional necessity, since their origins relate to when suicide was a crime and the property of those committing the offence was forfeited to the state. The suicide case is a misfit that presents today’s coroner with something of a contradiction in practice, since it still hinges around establishing intent and attaching a moral classification to the cause of death.”

The primary recommendation of the British Isles suicide research group’s report on good practice and changes to court procedure in 2006 was that in non-complex cases, where the facts are not disputed and the family agrees, coroners should be allowed the discretion to process suicides without a public hearing. I hope that the Minister will at least agree to consider that option.

Finally, coroners’ offices are part of the judicial system, but they also play a vital role in assisting health services and researchers, so they should be considered as part of our health system, as well as part of our legal system. In the past, the MOJ has perhaps focused too narrowly on the judicial aspect of the coroner system. It has failed to recognise the importance of coroners’ work in the health care system and thus failed to ensure that coroners are provided with guidance and training that reflects that role. I hope that we can have a commitment to take a more proactive approach to the issuing of guidance and regulation. Anything that we can do to prevent further tragic deaths from suicide is vital.