Suicide prevention: interim report Contents


27.Accurate and timely statistics are essential both for the development and evaluation of suicide prevention policy. Reliable data and early identification of suicide are also crucial to allow rapid responses to emerging patterns that could indicate clusters and trends which could help prevent further deaths by suicide. This rapid response might include reducing access to certain places or to certain (perhaps novel or emerging) methods of suicide or signposting to and providing appropriate help for those in acute distress who are contemplating suicide. Difficulties in collecting accurate and timely statistics are undermining the ability to prevent suicide. The lack of high quality data is causing us to fail future families and individuals.

28.Professor Louis Appleby (amongst others) underlined the importance of consistency across the coronial system, noting that coroners do excellent and vital work but that the system is heavily dependent on individual coroner judgment, and therefore can vary widely between areas.39 Concerns were also raised by witnesses about narrative conclusions. The use of narrative conclusions can provide coroners with a way to “alleviate the impact of the conclusion of suicide”40 but witnesses were concerned that a greater use of narrative conclusions has increased data inaccuracy, and can result in an underestimation of the number of suicides.41 The timeliness of the provision of data is another key problem, with coroners’ conclusions sometimes reached more than a year after a person has taken their life. This information is therefore available too late to identify suicide clusters or potential ‘cluster triggers’ which could inform important short-term public health interventions.42

29.The Chief Coroner noted that “coroners are independent judges” and that providing early information to public health officials and suicide conclusions themselves is a matter for individual coroners to decide upon.43 We recognise this but consider that further guidance could be developed for coroners in order to ensure increased consistency nationwide both between coroners’ conclusions themselves and between assistance provided for public health officials following potential clusters of suicides.

30.Currently a conclusion of suicide must meet the ‘criminal’ standard of proof, that is, that the coroner or jury must be certain, beyond reasonable doubt, that the person took their own life and intended to do so. We heard from witnesses that the standard of proof for conclusions of death by suicide should be changed to meet the civil standard, that is, on the balance of probabilities.44 As Professor Appleby told us, “its equivalence with criminal proof reflects the history of suicide. [ … ] There is a principle here, which is that that standard of proof is a reflection of a system that is full of prejudice and stigma, which we ought to dismantle.”45 As the Chief Coroner told us in written evidence, “what standard of proof applies in relation to conclusions in the coroner’s courts is a matter ultimately for Parliament”.46

31.Our evidence suggests the need for a more rapid provisional notification of suicide at the time when a suspected death by suicide occurs. We recommend that the Government take action to improve consistency between coroners and to make routine the use of provisional notifications of suicide. Furthermore, we recommend that the standard of proof for conclusions of death by suicide should be changed to the balance of probabilities rather than beyond reasonable doubt.

39 Q279, Q280, Q281 [Professor Louis Appleby]; Q59 [Ruth Sutherland]

41 Q51 [Dr Ann John]

42 Haringey Suicide Prevention Group (SPR0065) para 11

43 Chief Coroner (SPR0162)

44 Q296 [Professor Louis Appleby]; PAPYRUS (SPR0027) para 4; CALM (SPR0088) para 8.4; National Police Chiefs’ Council (SPR0073) para 4.8

45 Q296 [Professor Louis Appleby]

46 Chief Coroner (SPR0162)

15 December 2016