Summary:
Suicide
rate reflects a change in the practice of Coroner's Courts rather than
the effectiveness of the service or any improvement in mental health of
the nation. Although not
all incidents of Fatal Self Harm have a 'legal' verdict of suicide
returned by coroners, it is wrong to assume that open verdicts or deaths
from undetermined causes should be simply regarded as probable suicide.
The National Confidential Inquiry into Suicide simply combined
suicide verdicts and open verdicts or death from undetermined causes.
Although not
every incident of Fatal Self Harm attracts a verdict of suicide returned
by coroners, it is wrong to assume that open verdicts or deaths from
undetermined causes should be simply regarded as probable suicide.
The National
Confidential Inquiry into Suicide (DoH 1999) estimated
the national suicide
rate at 9.7 per 100,000 people per year based on 10,042
notified suicides during 2 years.
The figures included 6,682 suicide verdicts and 3,358 of open
verdicts or death from undetermined causes.
The Coroner
returns verdict of suicide if there is clear evidence, beyond all
reasonable doubt, that the individual intended to kill himself and the
death was self-inflicted. If circumstances of death are such that it is
apparent that there was a deliberate act which resulted in death, but
in the absence of the intent to die, a verdict of misadventure
might be returned . If
there is insufficient evidence to reach any conclusion, then an open
verdict may be returned (Matthews 1993).
The suggested
form of conclusion in suicide cases is that the deceased "killed
himself" and the use of "whilst the balance of his mind was
disturbed" ought to be based upon some evidence to that effect
given at the inquest (Matthews 1993).
The element of subjectivity in the legal definition of suicide
allows the possibility of divergence of opinion amongst coroners on
suicide verdict, also applying legal rather than clinical criteria tends
to result in an underestimated suicide rate. The non-suicide verdict
may, in a certain proportion of cases, ignore the fact that individuals
may make a considerable contribution towards their death under
circumstances not ordinarily considered suicide.
Over the last
decade, there has been an increasing trend in Coroners' Courts to
increase the level of certainty, above the previous standards, in
proving that the deceased killed himself before returning a suicide
verdict. Open verdict on
the other hand is returned with any glimpse of doubt about the
circumstances of death, intention to die and the strength of evidence
i.e. increase the level of suspiciousness e.g. whether the hand writing
in the suicide note belonged to the deceased.
The verdict for a man who stood
still in front of a running train is returned as an open verdict rather
than suicide because of the possibility of that the man stood there
looking for a footpath, despite the fact that this man had past
psychiatric history of depression. The same principle applies to people
who die after overdoses, drowning or jumping from over a bridge without
leaving suicide notes or informing someone about their intentions. The
Coroners' Courts work on a rebuttable presumption that no human being
takes his own life until the contrary is proved. This trend led to
gradual increase in open verdicts and gradual false decrease in suicide
verdicts.
In a review
of all coroners' verdicts in North Cheshire over a 5 year period, Salib
(1996) reported that those who died from overdose, drowning or falling
from height, were more likely to be returned as an open verdict,
accidental death or misadventure compared to those that died by hanging
or using a car exhaust or shooting.
An open verdict was more likely to be returned if alcohol related
problems were reported.
The review
also found that single people were more likely to have a non suicide
verdict, it was not clear however, whether the single person was living
alone. The effect of having psychiatric history obtained directly
from a psychiatrist or via GP, from psychiatrist correspondences or
available documents such as hospital notes, appears to increase the
probability of returning an open verdict, whereas having a psychiatric
condition defined by other sources such as family, friends or neighbours,
is likely to result in a suicide verdict.
Older cases were generally more likely to have an open verdict
than middle age group for whom a suicide verdict was more likely. Those
younger than 30 had an increased probability to be returned as an open
verdict. The review also
noted that not all cases in which an intimation of intent had been
evident that suicide verdict was concluded.
In 23% of all open verdicts and 13% of misadventure verdicts
there was some evidence that the deceased intended to kill himself but a
suicide verdict was not returned.
The Home
Office Statistical Bulletin (1998) providing data on the verdicts
returned at inquests, 1987 -1997 for England and Wales (table 1),
appears to suggest there is a gradual decrease in the number of suicide
verdicts (from 3987 in 1987 to 3355 in 1997) with a 15.8% reduction in
suicide. However, The
reduction in total number of suicide and open verdicts added together
was 7.5% (from 6136 in 1987 to 5674 in 1997).
In the same period of time the ratio of open verdict to suicide
verdict has gone up by 28% (from 0.54 in 1987 to 0.69 in 1997) with an
increase in the open verdicts of 7.9% (from 2149 in 1987 to 2319 in
1997).
In an attempt
to apply a realistic 'clinical' rather than 'legal' definition criteria
for reaching a verdict, we made the assumption that all deaths in which
there was evidence of 'intent' whether by leaving a suicide note,
telling someone or having history of recent serious suicide attempts
should have been classed as suicide.
Using a 5
year review data in North Cheshire,
we allocated all cases in which a "clear" intimation of
intent was evident, regardless of official verdict,
to what we considered may have a probable act.
ALTERNATIVE VERDICT
(What we assumed the verdict could have
been from
a clinical rather than legal viewpoint
|
|
|
|
|
|
|
|
suicide
|
open verdict
|
misadventure
|
Total
|
|
Suicide
|
97
|
|
|
97
|
|
open verdict
|
47
|
12
|
|
59
|
|
misadventure
|
14
|
3
|
21
|
38
|
|
Total
(alternative
verdicts)
|
158
|
15
|
21
|
|
The suicide
statistics in our clinical model appears quite different to the official
verdicts, based on purely legal definition which does not always reflect
a true picture of what actually happened, with an increase in suicide
from 97 to 158 (63% increase) which we believe is acceptable as probable
suicide. If on the other hand we add all other verdicts as
probable suicide as the National Confidential Inquiry into Suicide did,
then there be a pseudo increase in suicides in North Cheshire from 158
to 197 (103% increase).
The total number of suicide and open verdicts or death from
undetermined causes is misleading figure because, unavoidably, it
includes a number of cases which are not suicide (36 cases (40% of non
suicide veridct) in our sample) and may therefore over estimate the
actual suicide. This may
plausibly suggest that the National Confidential Inquiry into Suicide
may have misclassified 1343 into suicide figures, an increase by about
13%.
Suicide rate
reflects a change in the practice of Coroner's Courts rather than the
effectiveness of the service or any improvement in mental health of the
nation. Although not every
incident of Fatal Self Harm attracts a verdict of suicide returned by
coroners, it is wrong to assume that open verdicts or deaths from
undetermined causes should be simply regarded as probable suicide.
Suicide rate
alone may be a misleading index and should not be used as a valid
measure for the quality of care just because it happened to be the only
measurable outcone (Hawton 1998).
Unfortunately we will never know the elusive number of suicide
that we have succeeded to delay, or arguably prevent,
because statistics can
only tell us about the
suicides that we have failed to prevent!.
*Correspondence
: 18 Broughton Close, Grappenhall Heys,
Appleton, Warrington WA4 3DR
References:
Hawton K. (1998) A
national target for reducing suicide. BMJ 1998. 317, 156 - 7.
Department of
Health. Safer
Services: National Confidential Inquiry into Suicide and Homicide by
people with Mental Illness HMSO 199
Home Office
Statistical Bulletin (1998), publications of the Home
Office, London, April 1998. The full data can be obtained from "
Office for National Statistics", Room 2300, Segensworth Road,
Tichfield, Fareham Hants, PO15 5RR.
Salib E.
(1996)
Predictors of coroner's verdict: a logistic
regression model
Med. Sci. Law, 1996, Vol.
36, p 237-241
Secretary of
State for Health (1998)
Our healthier nation a contract for health.
London.
HMSO, 1998.
