Part 1: Introduction
1.1
In this Part, we explain:
Why we did our audit
1.2
In 2013, suicide was the third-leading cause of premature death behind ischaemic heart disease and lung cancer in New Zealand.1 Figure 1 shows that the suicide rate in New Zealand has been steady for much of this century.
Figure 1
New Zealand's suicide rate for every 100,000 people, 1993-2013
Note: The rates are age-standardised rates for every 100,000 people, standardised to the WHO world standard population. Three-year moving averages smooth out year-to-year variation and help to identify and forecast trends. The extensions to 2014 and 2015 are estimates. Source: Ministry of Health.
1.3
When there is a steady suicide rate and an increasing population (as in New Zealand), the number of deaths from suicide each year increases.
1.4
Suicide affects all parts of the population, but some parts are affected more than others. Suicide rates for males, Māori, people aged 59 years and younger, and people living in greater deprivation are higher than rates for females, non-Māori, people aged 60 and older, and the less deprived.
1.5
To try to estimate the financial cost of suicide to society, the Ministry of Health has completed two studies, 10 years apart, and published reports showing the method used to estimate the costs and the results. The latest study, which used 2002 data, estimated that the economic cost of a single suicide was $448,250, and the non-economic cost was $2.5 million.2 We estimate that, with inflation, these figures would be about $602,700 and $3.4 million respectively in 2015.3
1.6
The World Health Organization considers that many deaths from suicide are preventable.4 The main aim in suicide research is to find out why some people with problems and in distress deliberately end their lives and others do not. No one has yet produced a comprehensive theoretical model that explains the causal processes for suicide and the interaction between different risks.
1.7
There are many potential pathways to suicide, and the reasons for it may be complex and individual.5 Cultural factors can play a part, which means that analysis cannot rely wholly on information collected in other countries. Understanding the factors that increase or reduce the risk of suicide in New Zealand is important for introducing effective actions to prevent it.
1.8
Even with better information, it could still be difficult to predict which individuals will have suicidal thoughts and who will act on them. Researchers have found that it is difficult to be certain which, if any, are the most useful risk scales for self-harm risk assessment.6
1.9
We consider that good information supports good decision-making, leading – eventually – to better results. So, we carried out a performance audit to determine whether information is used effectively to understand suicide and, where possible, prevent it. We hope that our audit and this report will help make collecting, using, and reporting suicide information more effective and efficient.
What we looked at
1.10
There is nothing standalone that you could call a "suicide information system". Rather, information on suicide is collected by multiple other systems, such as those established:
- to record births, marriages, and deaths;
- for expert committees to look into the deaths of individuals and groups to see what could be done to prevent deaths in similar circumstances;
- for coroners to inquire into certain deaths, such as those with an unclear cause or in special circumstances (including any suspected suicide); and
- to collect and report statistics about the causes of death in New Zealand.
1.11
For our audit, we took a high-level look at the information that those systems collect on suicide, how they interrelate, and what the information is used for.
1.12
Overall, we expected that good quality data would be systematically collected about suspected suicide and suicide. We expected that data would be systematically analysed and shared, and fit for purpose. And we expected data and analysis to be used to help prevent suicide.
1.13
We completed our audit at a time of change. Agencies finished some work during our audit, and will complete or decide on other work in 2016/17. This means that it is too early for us to comment on the effectiveness of some measures. Where this is the case, we say so in this report. We summarise in the Appendix how we did our work.
What we did not look at
1.14
We did not audit:
- any services available or delivered to people experiencing or displaying "suicidal behaviour"7 or to people bereaved by suicide, including making information available to the public;
- how effectively or efficiently any suicide prevention action plans have been implemented;
- the suicide prevention plans prepared by district health boards (DHBs);
- coroners' decisions or how they plan or carry out an inquiry, because they are independent judicial officers and therefore excluded from the Auditor-General's mandate; or
- any research on or evaluation of suicide or suicide prevention.
The structure of this report
1.15
The ultimate aim of collecting information on suicide is to use it for suicide prevention. In Part 2, we discuss how the Ministry of Health has used information from New Zealand and overseas to produce a national suicide prevention strategy and suicide prevention action plans at the national level and local (that is, DHB) level.
1.16
An important part of local suicide prevention plans is the immediate response to individual suspected suicides. In Part 3, we discuss the information-sharing system that the Ministry of Health, the Ministry of Justice's Coronial Services Unit, and the Chief Coroner have set up to tell DHBs about suspected suicide and to respond to it. We also discuss the measures that the Ministry of Health has taken to identify emerging trends in suspected suicides.
1.17
Expert committees – called mortality review committees – have been established to review the deaths of individuals with the aim of reducing preventable deaths, illness, and injury, and of continuously improving the quality of services provided. The committees make up the National Mortality Review Programme, which is managed by the Health Quality and Safety Commission. The committees relevant to our audit are the Child and Youth Mortality Review Committee and the Perinatal and Maternal Mortality Review Committee. In Part 4, we discuss how these committees do their work.
1.18
The Ministry of Health regularly produces and publishes reports on the causes of death for New Zealanders, including suicide. These are called Mortality and Demographic Data reports. The Ministry of Health also publishes special topic reports on suicide, called Suicide Facts. The reports rely on information supplied by coroners and others. In Part 5, we discuss how the statistics are collected and reported.
1.19
Whether or not someone has died from suicide is a legal decision made by coroners, not a medical decision made by doctors. In Part 6, we discuss the information typically collected during coroners' inquiries into suspected suicide, how they report their decisions, and the Chief Coroner's reports on suspected suicide statistics. We also discuss the coroners' role in helping to prevent suicide.
1: In 2013, the age-standardised rates for every 100,000 people for Years of Life Lost for were 1353 for ischaemic heart disease, 571 for lung cancer, and 512 for suicide. Source: www.healthdata.org/new-zealand.
2: O'Dea, D and Tucker, S (2005), The cost of suicide to society, page ix, Ministry of Health, www.health.govt.nz. The calculations used are complex and were the best estimates possible at the time. Briefly, economic costs refers to the resources that would be saved by reducing the suicide rate, such as police, healthcare, and coroners' costs, added to estimates of the value of lost contribution to gross domestic product because of suicide. Non-economic costs estimate the value of years of life lost (with every year lost being valued the same) plus the value of healthy years of life lost.
3: We used the Reserve Bank's calculator to estimate the costs. We used first-quarter 2002 costs and fourth-quarter 2015 costs.
4: World Health Organization (2014), Preventing suicide: A global imperative, Executive Summary, page 2, www.who.int.
5: A diagram on page 16 of the New Zealand Suicide Prevention Strategy 2006-2016 shows the range of potential pathways to suicidal behaviour. The strategy is available on the Ministry of Health's website: www.health.govt.nz.
6: Quinlivan, L and others (February 2016), "Which are the most useful scales for predicting repeat self-harm? A systematic review evaluating risk scales using measures of diagnostic accuracy", BMJ Open 2016;6:e009297 doi:10.1136/bmjopen-2015-009297. This article reports that no scales performed well enough to be recommended for routine clinical use.
7: Suicidal behaviour includes thinking about suicide, making a plan to deliberately end one's life, or attempting suicide.