Part 4: Mortality review of suicide deaths

Collecting and using information about suicide.

4.1
In this Part, we discuss:

Mortality review and review committees

4.2
Mortality review uses applied research methods to examine the circumstances resulting in death. Mortality review committees review the deaths of individuals or groups with the aim of reducing preventable deaths, illness, and injury, and continuously improving the quality of services provided.

4.3
In 2010, changes to the New Zealand Public Health and Disability Act 2000 enabled the Health Quality and Safety Commission to appoint mortality review committees. (Before this, the committees worked independently and reported to the Minister of Health.) The existing committees were brought together under a National Mortality Review Programme managed by the Health Quality and Safety Commission.

4.4
Generally, mortality review committees work by:

  • collecting data;
  • analysing the data and other information;
  • having experts review any preliminary analysis and some or all cases;
  • issuing reports to share information for others to use; and
  • making recommendations and checking on their implementation.

4.5
Committees may use different methods depending on the analysis that they are doing and as more information is gained about the value of different methods in particular circumstances.

Suicides covered by a mortality review committee

4.6
The mortality review committees that have suicide within their scope are the Child and Youth Mortality Review Committee (the Child and Youth Committee) and the Perinatal and Maternal Mortality Review Committee (the Maternal Committee). They were established in 2002 and 2005 respectively.

4.7
The Child and Youth Committee's scope allows it to look into the deaths of children and people aged 24 years and younger from any cause, including suicide and other self-inflicted harm, such as accidental deaths.

4.8
The Maternal Committee's scope enables it to look into the deaths of women of any age while pregnant or within 42 days of the end of pregnancy. These are called maternal deaths. The Maternal Committee also collects data on some maternal deaths up to one year after childbirth. It focuses on deaths where pregnancy or pre-existing or new health conditions contributed to the death, including suicides and some other kinds of self-inflicted harm. The Maternal Committee does not look into deaths from events unrelated to pregnancy or health, such as road crashes.

4.9
For the two years' suicide data we looked at (that is, total suicides in 2011 and 2012), we calculate that the Child and Youth Committee and Maternal Committee between them can review about 30% of suicides. This means that a national mortality committee does not review about 70% of suicides. These are mostly suicides of people aged 25 years or older who would not be considered maternal deaths.

4.10
Recognising this, the New Zealand Suicide Prevention Action Plan 2013-16 tasked the Ministry of Health with testing mortality review methods specific to suicide for broader age groups. The Ministry of Health and the Health Quality and Safety Commission together designed a trial.

4.11
The Health Quality and Safety Commission set up a time-limited Suicide Mortality Review Committee to test methods for analysing suicide during 2014-15. The Committee tested its analysis on three population groups that accounted for 71% of suicides from January 2007 to December 2011. The trial excluded open coronial inquiries from the period. The three groups were:

  • Māori youth aged 15-24 years;
  • males aged 25-64 years; and
  • people who had face-to-face contact with specialist mental health or addiction services in the year before their suicide.

4.12
The Suicide Mortality Review Committee's final report and recommendations were sent to the Ministry of Health and the Minister of Health in late 2015. The Health Quality and Safety Commission published the report in May 2016. We understand that the Government is considering the recommendations and announcements about them are expected in 2016/17, as the Ministry updates the Suicide Prevention Strategy and prepares a new national suicide prevention action plan.

4.13
If a Suicide Mortality Review Committee is re-established, the Health Quality and Safety Commission and mortality review committees have told us that they will decide jointly which committee would take principal responsibility for reviewing the suicides that are the Child and Youth Committee's and the Maternal Committee's responsibility at present.

4.14
If a Suicide Mortality Review Committee is not re-established, government agencies have told us that they will consider other ways to analyse adult suicides in more depth.

How the committees collect information

4.15
We looked at how the Child and Youth Committee and the Maternal Committee collect, analyse, and report information. Both committees start collecting information as soon as they are told about deaths, including suspected suicides.

4.16
The committees told us that they want early access to copies of initial police reports and post-mortem reports, including the results of toxicology and other tests. They had access to this information in the past, but for reasons that we are not clear on, the previous Chief Coroner stopped releasing the police reports about two years ago. The post-mortem report and other test results are shared after coroners complete their inquiries. The Chief Coroner and the Health Quality and Safety Commission are considering how to resolve this matter. We encourage them to do so, and to involve New Zealand Police in their discussions.

How the Child and Youth Committee collects information

4.17
The Child and Youth Committee's approach to collecting information involves national and local review processes, and national and local information collection processes. We consider that the approach used is systematic.

4.18
However, the published information about the approach does not give a clear account of how the Child and Youth Committee, Mortality Review Data Group,17 and DHBs' interagency mortality review groups, which we call local review groups, work together to collect information and consider it.

4.19
Figure 3 summarises the approach. It is derived from an unpublished document, the Child and Youth Committee's 2015 Policy. Appendix B of the Child and Youth Committee's Fifth Report gives more details.18 We suggest that the published information about the Child and Youth Committee's methodology be updated to explain more clearly who does what when.

Figure 3
Overview of child and youth mortality review

Following a death, the Mortality Review Data Group is notified and collects data from certain government agencies and enters it into a centralised database. This data is made available to DHB co-ordinators who decide whether the death will be reviewed. The Child and Youth Committee has set the method for selecting cases.* Each DHB is to review at least 70% of deaths in their area.

For the deaths being reviewed, the local co-ordinator contacts local organisations that are involved with the safety and well-being of children and young people and asks them to send in any information that they hold about the deceased.

The co-ordinator is to ensure that a standard set of information is collected. The co-ordinator enters the information into the database. All data entered by the local co-ordinator is available to the Mortality Review Data Group as soon as it is entered.

The local review group meets to review the data and identify opportunities for system improvement. One or more meetings may be needed, and extra data may be collected between meetings.

Local co-ordinators' last step is to complete an electronic post-review form for each case. This makes the local review group's findings and recommendations available to the Mortality Review Data Group.

The national and local data is analysed to identify actions aimed at reducing morbidity and death. This could include identifying and forwarding national recommendations to the Child and Youth Committee for its consideration.

* For example, preventable non-medical deaths (such as suicide) and deaths where the rate of death is higher than other age groups or for the same age group in other countries. However, this does not mean that all suspected suicide deaths would be reviewed at a local meeting.

4.20
In 2015, the Child and Youth Committee reviewed the way the local review groups were working, noting what was working well and suggesting areas for improvement. Of relevance to our audit is the information collection process and its completeness. The review found that some groups completed reviews at a high volume and to high quality standards, while others did not as they lacked the skills or experience necessary to do so.

4.21
DHBs told the Child and Youth Committee that the standardised form is long and complex, and not all fields are relevant to all deaths. The Child and Youth Committee revised the form to collect more meaningful information that is relevant to all deaths (including suspected suicides). The new form is being tested in the first half of 2016. The aim is for local review groups to complete all questions on the form and collect extra information about each type of death. Local co-ordinators were trained in using the form to promote consistency.

4.22
Local co-ordinators sometimes do not complete post-review forms for cases reviewed by local groups. When the forms are not completed, we consider that:

  • some of the value of the work done by local review groups is limited to their area;
  • the important "learning and sharing" aspect of the Child and Youth Committee's approach is undermined; and
  • the ability to make effective recommendations at the national level is constrained.

4.23
To get the most out of local review, it needs to be done as close as practicable to the time of death. Therefore, the Child and Youth Committee is planning to establish systems and processes to enable all local reviews (including those of suspected suicides) and post-review forms to be completed within twelve months of death, and no later than twelve months after a coroner's decision on the cause of death. This means that, if coroners' decisions into suspected suicide could be completed within 300 days (see paragraph 6.29), then local reviews could be completed within 665 days (about 22 months) after death.

4.24
The Child and Youth Committee and the Health Quality and Safety Commission plan to provide support to the DHBs and local review groups that need help to meet the quality and completeness standards required. We consider that this is crucial to ensure that the Child and Youth Committee's approach is effective.

4.25
We encourage the Child and Youth Committee and Health Quality and Safety Commission to ensure that case completion rates are monitored constantly so that timely information is available for effective and efficient national analysis. This would allow local recommendations to be collated, shared, and discussed promptly, and would enable the Mortality Review Data Group to recognise any need for new recommendations on suicide prevention at the national level.

How the Maternal Committee collects information

4.26
The Maternal Committee's approach is systematic and described clearly. Figure 4 summarises its approach, which is described in more detail in its annual reports.19

Figure 4
Overview of maternal mortality review

Since 2007, coroners must be told about all maternal deaths. The Ministry of Justice tells the Maternal Committee's national co-ordinator about each maternal death shortly after coroners are notified.

The national co-ordinator issues a 50-page form to a local DHB co-ordinator who ensures that it is completed. The form helps to standardise much of the information collected, which makes analysis easier.

Local co-ordinators send the completed form and relevant supporting documents (such as copies of health records, correspondence between health professionals, written reports from an anaesthetist or critical care staff, and reports from the local review of the case) to the national co-ordinator.

Coroners' reports are sent when they are available.

The information is analysed to identify factors contributing to the woman's death and actions that might have prevented death.

In 2013, a dedicated maternal mortality database was created. The Maternal Committee considers that this has improved the quality of data collected and access to it.

Note: Groups set up under the Health Practitioners Competence Assurance Act 2003 to carry out approved quality assurance activities could also complete local mortality and morbidity (that is, illness, disease, or injury) reviews of maternal (and perinatal) deaths.

Reporting on their work

4.27
The Child and Youth Committee and the Maternal Committee publish reports online20 with the aim of sharing them with researchers, healthcare workers, and others, and to demonstrate accountability for their work. The Child and Youth Committee's comparatively broad scope and the Maternal Committee's comparatively narrow scope are reflected in their reporting practices in ways that we consider are appropriate.

4.28
Since 2010, the Child and Youth Committee has produced an annual statistical report and released special topic reports, which include analysis and recommendations, when they were ready. (The Committee focused on suicide in its fifth report.) The Child and Youth Committee's special topic reports clearly state the report's aims, and we consider that the reports achieve the aims. The Committee's annual data reports do not have clearly stated aims, and they should. Without stated aims, we could not assess the reports' success, although we assume that transparency and accountability are two reasons for publishing some data. The Committee and the Health Safety and Quality Commission plan to address this in future reports.

4.29
The Child and Youth Committee also sends more detailed confidential reports to authorised persons, which is appropriate.

4.30
The Maternal Committee's annual report follows a similar structure and content each year. Some reports focus on certain types of deaths in more detail in some years; for example, the committee's sixth report discussed maternal suicide in depth. The Maternal Committee's reports clearly state the report's aims and its intended audience. We consider that the Maternal Committee's reports achieve their aims.

Some general observations about the National Mortality Review Programme

4.31
The focus of our audit was on suicide information. We did not audit whether the National Mortality Review Programme as a whole is effective or efficient. Nevertheless, we make some observations that we encourage the Health Quality and Safety Commission to consider.

4.32
We expect procedures for collecting and disclosing information to enable committees to share information when it is needed. For example, because of the different kinds of expertise involved, there could be value in the maternal suicide of a 20-year old being looked at by both the Maternal Committee and the Child and Youth Committee (and any future Suicide Mortality Review Committee). At the same time, we expect duplication to be avoided where possible.

4.33
Over time, it is logical to expect changes in the number and scope of mortality review committees. We expect the Health Quality and Safety Commission to ensure that any changes to the number of committees and their scope maintain access to information already collected. We expect the information technology used to store data to be compatible, or all data to be held in a single database with suitable restrictions on access.

Conclusions

4.34
Two mortality review committees have scopes that allow them to review the roughly 30% of suicides that are child, youth, and maternal suicides. This means that about 70% of suicides – mainly of people aged 25 years or older – are not covered by a mortality review committee. A decision on whether a mortality review committee will be established specifically for suicide is expected in 2016/17. If a suicide mortality review committee is not re-established, government agencies have told us that they will consider alternative methods of reviewing adult suicides in more depth.

4.35
The Child and Youth Committee's process is systematic, but is not clearly described or fully implemented. However, the Health Quality and Safety Commission is in the process of ensuring that data collection is consistent and that reviews are completed. Until these aims are achieved, the Child and Youth Committee will get partial information, which means that its analysis and reporting will be less effective. The Maternal Committee has a clear, systematic process for collecting and analysing data, and reporting its conclusions.

4.36
The committees want to get early access to copies of the initial police report and the post-mortem report, including the results of toxicology and other tests, before coroners complete their inquiries. The Chief Coroner and the Health Quality and Safety Commission are considering how to resolve this matter. We encourage them to do so and to involve New Zealand Police in their discussions.

17: The group is a third-party contractor.

18: Child and Youth Mortality Review Committee (2009), Fifth Report to the Minister of Health Reporting Mortality 2002-08 Appendices, Appendix B, www.hqsc.govt.nz.

19: For example, see the Eighth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2012 (June 2014), www.hqsc.govt.nz.

20: See www.hqsc.govt.nz.