Part 6: Coronial inquiries

Collecting and using information about suicide.

In this Part, we:

Deciding whether a death is suicide

Whether or not someone has died from suicide is a legal decision made by coroners, not a medical decision made by doctors. New Zealand coroners have legal training and are independent judicial officers.

Coroners inquire into about 3300 deaths each year. There is limited investigation into about half of these, involving obtaining witness statements and a report from the deceased's general practitioner, for example. Coroners complete more extensive inquiries into the other 1600 deaths, which include all suspected suicides.26 There are about 500 suicides each year, which means that suspected suicide inquiries make up about 15% of the coronial caseload.27 On average, each coroner inquires into about 31 suspected suicides each year.

Coroners collect information to find out, as far as possible:

  • the deceased's identity;
  • when and where the person died; and
  • the cause(s) and circumstances of their death.

There is a high threshold for deciding that suicide is the cause of death. Coroners must be sure that the deceased intended to end their life. Coroners must rule out all other explanations.28 A coroner may find that the cause of someone's death is "undetermined" if it is not clear whether death was accidental or suicide.29

Overview of the inquiry process

Suspected suicides are notified to a duty coroner by police officers or doctors through the National Initial Investigation Office (NIIO). After the body is released to family, the NIIO transfers information that it collects during the initial investigation period (about 48-72 hours after the person is found) to the coroner who will be inquiring into the death. In most cases, coroners are assigned the cases of people who died in their region. Coroners then write to people and agencies asking them to supply further information. Coroners may also ask police inquest officers30 to collect information for them.

We looked at files on completed inquiries where suicide was the cause of death. All files contained some common documents, but there were differences depending on the circumstances of each case and how people collected and reported information. Figure 6 lists typical documents found in these files.

Figure 6
Documents commonly collected during a coronial inquiry into suspected suicide

Certification of life extinct form Copy of email telling the DHB of a suspected suicide
Certificate of Findings Post-mortem and toxicology reports
Form ordering a full or lesser post-mortem† Reports from police and ambulance officers attending the death
Suicide note Form allowing release of body to family
Police form documenting officers' observations of the scene and other circumstances Photographs of the body, the place it was found, and any belongings found nearby, including any material used to cause death
Reports from primary or secondary health services about care provided to the deceased File notes of a coroner's reasons for certain decisions
Report of reviews or investigations by institutions where a death occurredˆ Statements confirming the person's identity and from the person who found the body
Correspondence with family updating them on progress of inquiry Correspondence with agencies attaching the coroner's decision
Provisional death certificate∞ Telephone and computer records

† A lesser post-mortem would be likely to involve an external physical examination and blood tests.
ˆ Examples of authorities that may provide reports to the coroner are the Department of Corrections, DHBs, and New Zealand Police.
∞ A final death certificate is issued after a coroner has determined the cause of death.

Most of the information that coroners collect is found in documents. Coroners can carry out inquests31 to ask questions of people who knew the deceased (such as family, friends, and service providers) or who looked into the circumstances of the person's death.

The information that coroners get is printed and put in a physical file, which is the principal record of each inquiry. Documents created by coroners and the Ministry of Justice are also printed and kept as a record of decisions made and actions taken.

A few agencies we spoke to during our audit want coroners to systematically collect more details on suspected suicides, which could be used for mortality review or by government agencies responsible for helping to prevent suicide. If this were to be done, we consider that agencies should work together to decide what standard information should be collected and how they could ensure that coroners were given this information to consider. For example:

  • We saw letters that coroners had written to people and organisations who provided the person who had died with health and other services, asking them to provide a written report on their contact with the deceased person. The reports provided are not standardised, but they could be if the agencies jointly created a reporting form. The coroner could issue the form when asking for a report.
  • The form that police officers use to record information when they attend a suspected suicide could be changed to ensure that standardised information is collected.32 There is a precedent for this: the Maternal Committee worked with New Zealand Police to introduce a special form for infant deaths.

We are not aware of any projects involving government agencies and coroners to enable coroners to collect a standardised set of information during suspected suicide inquiries. We understand that any such work could depend on the Government's decisions on the recommendations made in the Suicide Mortality Review Committee's report. If the committee is not re-established, we consider that the relevant government agencies should work together with the coroners to decide what information they want to collect and how. The Ministry of Health and the Health Quality and Safety Commission would be the main agencies for such work.

Coroners' reports and recommendations

When they have all the available information, coroners produce a Certificate of Findings that states, where they are known, the:

  • deceased's full name and last address, date of birth, sex, and occupation;
  • place and date of death;
  • cause(s) of death; and
  • circumstances of death.

Certificates of Findings from inquiries where suicide is the cause of death are routinely sent to:

  • family of the deceased;
  • the Director of Mental Health;
  • any government agencies involved in the inquiry or to which coroners' make comments or recommendations;
  • any relevant mortality review committee;
  • the National Coronial Information System (a copy of the post-mortem and toxicology reports and the written report of the police investigation are also sent); and
  • any other people identified during the inquiry as interested parties.

The aims of distributing the Certificates of Findings are to tell people about the cause of death and to allow responsible agencies to find opportunities for improving public health and safety.

Anyone can ask the Ministry of Justice for a copy of a Certificate of Findings on any death. The Certificate of Findings will state what information in it can be published. Unless the coroner has directed otherwise, there are restrictions on publication when suicide is the cause of death.

Coroners gave varying amounts of detail on the circumstances of the person's death and reasons for finding that suicide was the cause of death. A few Certificates of Findings we saw stated only the method of death, and that information was withheld for reasons of personal privacy or in the interests of justice. We understand that coroners have good reasons for doing this. Where it is possible for them to do so, we suggest that coroners include any information that could be used by the receiving agencies to help their suicide prevention work.

Coroners can make recommendations or comments aimed at preventing deaths in circumstances similar to the case they are reporting on. We asked the Ministry of Justice how often suicide Certificates of Findings included recommendations. The Ministry told us that coroners made fewer recommendations regarding suicides than other causes of death. From January 2007 to October 2015, 5% of suicide inquiries included recommendations, whereas 13% of all Certificates of Findings included recommendations.

We do not want to suggest that coroners should have made more or fewer recommendations. But we wanted to understand the factors that influence whether coroners made recommendations on suicide cases. The coroners told us that they tended to make recommendations when suicides happened within an institution, such as a hospital, prison, or police station. They were less likely to make recommendations if the institution was already acting on recommendations made in its own reviews and the coroner had agreed with them.

The coroners told us that their counterparts in Victoria, Australia, have access to a Recommendations Unit to help them arrive at recommendations. Similar support is not available in New Zealand. The coroners consider that such support would allow the information they hold to be researched to make recommendations from a broader base than the single case that is the focus of an inquiry.

Whether such a coronial recommendations unit is established in New Zealand is a matter for the Ministry of Justice to consider. In our view, the current reliance on physical files would make it difficult for any such unit to research and analyse coronial information. An electronic database would be needed to make a research-based approach feasible. From a whole-of-government perspective, care would need to be taken that such a database did not unnecessarily duplicate any databases already established by mortality review committees.

Perhaps a first step should be to make more use of information already held in the National Coronial Information System. The Ministry of Justice told us that it is training coroners on how to use the system to detect similarities between deaths that might otherwise seem unique. This might help coroners to make recommendations more frequently, but it is too soon to know.

Coroners do not necessarily direct their recommendations to individual government agencies. However, Certificates of Findings are distributed to relevant government agencies for them to consider. Each agency should have in place a system documenting how they have considered them and what action, if any, they will take in response.

The Coroners Act 2006 does not require government agencies to tell coroners what they have done in response to the Certificates of Findings sent to them. However, the Ministry of Justice told us that the Department of Corrections and the New Zealand Transport Agency usually do this.33 We consider that it is important for government agencies to be accountable for their decisions, and that all agencies sent copies of Certificates of Findings should respond to coroners.

The Office of the Chief Coroner keeps track of responses received on individual cases, and since 2007 has published the responses online on the website of the New Zealand Legal Information Institute (NZLII).34 The Chief Coroner's staff send through the information after a Certificate of Findings is released and when case managers pass responses on to them.

Since 2012, the Ministry of Justice has published Recommendations Recap reports on its website, which summarise all coronial recommendations made during a reporting period and any responses received from government and community organisations.35 The Recommendations Recap reports may also include case studies on particular topics.36

Although the responses section of the Recommendations Recap reports are not updated after publication, anyone wanting to see any later response could find it on the NZLII's website. We suggested to the Ministry of Justice that the reports include a comment to this effect and it has agreed to do this in future reports.

Time taken to complete suicide inquiries

During its targeted review of the Coroners Act 2006 in 2013, the Ministry of Justice recognised that coronial inquiries were taking longer. It said that coronial inquiries that take a long time to complete may increase the distress experienced by the bereaved, delay their ability to move on with their lives, and delay the adoption of public health and safety measures (because recommendations are made only in Certificates of Findings, which are released when inquiries are completed). The time taken to complete inquiries also affects when the Ministry of Health produces reports on mortality statistics (see Part 5).

Since 2013, the Ministry of Justice has focused on closing the oldest coronial cases, which has increased the average age of cases at completion. This can be seen in Figure 7, which shows the average number of calendar days taken to complete inquiries where suicide was found to be the cause of death. It shows that the average time taken has increased for inquiries with and without inquests. The Ministry expects the average time taken to decrease as older cases are resolved.

Figure 7
Average calendar days taken to complete suicide inquiries, 2010/11 to 2014/15

Figure 7 Average calendar days taken to complete suicide inquiries, 2010/11 to 2014/15.

Notes: The graph excludes data on cases of suspected suicide where coroners decided that the cause of death was accidental or of undetermined intent. 778 days is about two years and seven weeks, and 509 days is about 17 months. We calculate there has been a 60% increase in the time taken to complete inquiries without an inquest and a 15% increase in the time taken to complete inquiries involving inquests. Source: Ministry of Justice.

The coroners and the Ministry of Justice recognise that they need to complete all coronial inquiries more quickly and have introduced workflow targets to help with this. The Ministry produces monthly reports from the coronial case management system to show the:

  • number of cases accepted by each coroner each month (target 17);
  • number of cases completed by each coroner each month (target 17);
  • percentage of active cases that have been open for less than 12 months (target 65%);
  • time each coroner takes to decide the cause of death for each inquiry (target 300 calendar days or about 10 months).

To help achieve the targets, the Ministry of Justice is working to set timeliness benchmarks for the parts of inquiries that are within its influence or direct control. For example, an early benchmark is to complete 90% of coronial cases where death is from natural causes within one month of receiving the post-mortem report. The aim is to set suitable internal benchmarks for other coronial work and introduce timeliness requirements in contracts with external services providers. The Ministry says that it is "early days" for this work.

The Ministry of Justice told us that it has also increased its staffing and is centralising some functions to free up staff to manage cases. And it is working with the Chief Coroner to ensure that coroners are well supported with resources, training, and useful data reporting.

We support the Ministry of Justice's efforts to complete inquiries more quickly. This will mean that families get decisions earlier and information about each case will be shared with government agencies so that they can take any necessary steps to improve public health and safety. The Ministry of Health will be able to publish mortality data earlier. Quicker inquiries would allow more timely mortality reviews.

Access to coronial information

Access to coronial information on suicide inquiries varies depending on when it is sought:

  • during the initial investigation period;
  • during the inquiry; or
  • after the inquiry is complete.

The initial investigation period is the first 48-72 hours from the NIIO being first told of a suspected suicide to a regional coroner being assigned the case. The Chief Coroner shares some information with DHBs during this period, to allow the DHB to decide on its local response (which we discuss in Part 4).

After a regional coroner takes over a case, they decide whether to grant requests for information while the inquiry is in progress. Inquiries are legal proceedings, and this discretion is appropriate.

After a suicide inquiry is completed, access to any information collected during inquiries or about inquiries generally depends on whether it is allowed by legislation or coroners' decisions. However, reliance on physical files also affects whether information is easily retrievable for release. For example, the Ministry of Justice can produce quantitative reports on information held in its electronic case management system easily. However, for physical files, someone would need to read all the files to produce data on the percentage of suicides who were addicted to alcohol or other drugs. Whether the Ministry should be able to produce such information is another matter. We do not have a definite view on this because it depends on whether such quantitative data is available from another source, such as a mortality review committee.

Anyone wanting information from the National Coronial Information System in Australia can apply through its website, which explains who can get access and under what circumstances.37

Chief Coroner's suspected suicide statistics

Once a year, the Chief Coroner releases a report on the number of suspected suicides in the preceding financial year. The reports are available from the Ministry of Justice's website and aim to provide the most up-to-date, accurate, complete information available on suspected suicide and raise awareness of suicide. The first report was released in 2010.

The reports usually include data on the number of suspected suicides and the national suspected suicide rate. As far as it is known, data is reported by sex, DHB, ethnicity, employment status, the methods used to cause death, and the number of suspected suicides reported each month. The reports also highlight data on the number of suspected suicides before and after the major earthquakes in Canterbury in 2010 and later years. However, it is not clear whether the data is for Christchurch City, Greater Christchurch, or Canterbury. It would be helpful if data was for the DHB region so that it aligned with the Ministry of Health's reports.

The reports sometimes have inconsistent or incomplete technical notes, which means that they are not as clear as they could be. This contributes to some confusion over the Ministry of Health's reports. We consider that this could be easily resolved by including:

  • fuller technical notes in the reports;
  • referring to "suspected suicides" instead of "provisional suicides";38
  • grouping data on methods into the same groups as are used by the Ministry of Health; and
  • calculating suicide rates using the methods used by the Ministry of Health or Statistics New Zealand.39

We discussed our suggestions with the Ministry of Justice, so that the Chief Coroner can be provided with the support needed to adopt them.


For coroners to find that suicide was the cause of death, they must be sure that the person intended to end their life and that all other explanations have been ruled out. Coroners collect information for this purpose. The information is mainly held in physical case files, which makes it more difficult to analyse groups of cases.

There is a desire for coroners to collect a standardised set of information on suicide, to help coroners with their inquiries and to make the information available for further study by appropriate agencies, such as mortality review committees. We consider that relevant government agencies should work together to decide what standard set of information should be collected and how to ensure that coroners get the information. We are not aware of any current projects with this purpose. We acknowledge that this could depend partly on the Government's decisions on the recommendations of the Suicide Mortality Review Committee.

Coroners' findings are proactively sent to relevant people and organisations. We expect all government agencies sent Certificates of Finding to consider them systematically and tell the coroners the results of their deliberations. Any responses to recommendations are published online on websites managed by the Ministry of Justice or the NZLII.

From 2010/11 to 2014/15, the average time taken to complete suicide inquiries without an inquest increased by 60%, and with an inquest by 15%. The Ministry of Justice is aiming to complete coronial inquiries within 300 days, but considers that this will take some time to achieve. We support the Ministry's aim of completing inquiries more quickly so that the bereaved can get a timely decision, the Ministry of Health can publish suicide and other mortality statistics sooner, and mortality reviews can be completed. More timely information will help government agencies' decision-making to efficiently improve public health and safety.

The Ministry of Justice is planning to provide the Chief Coroner with support to improve the reports on suspected suicide statistics as we have suggested.

26: The Coroners Act 2006 requires coroners to inquire into all cases of suspected suicide.

27: About 30,000 people die each year in New Zealand. Anyone who finds a body must report it to the New Zealand Police or a doctor. A duty coroner is contacted when a doctor is not certain that they could or should complete a death certificate. Coroners settle most cases after a discussion with the doctor or after a post-mortem shows that death was from natural causes.

28: R v Lagos and Her Majesty's Coroner for the City of London [2013] EWHC 423 (Admin), which we saw cited in several coroners' decisions.

29: If a coroner does not specify whether a self-inflicted poisoning is accidental or suicide, for example, the coding rules require the death be coded to accidental poisoning, not undetermined intent (see paragraph 5.16).

30: Inquest officers help coroners with their inquiries and liaise with coroners. They are sworn officers who make formal investigative inquiries for coroners and attend and represent New Zealand Police at inquests and hearings.

31: Inquests are hearings held in a court. They are less formal than a criminal court hearing and there is no jury. The coroner may be given extra documents during an inquest and court staff keep a written record of what is said.

32: New Zealand Police told us that it is considering producing an app to replace the handwritten forms that police use to record information at the scene of a sudden death, including suspected suicide. They could design the app to ensure that essential information is collected every time and in the same format for coroners, and for later use by others. Many police officers now have hand-held electronic devices, which makes this a realistic proposition.

33: For example, the Department of Corrections sends quarterly reports to the Chief Coroner updating its progress in responding to findings and recommendations.

34: This organisation provides legal information free to the public.


36: For example, one case study brought together the cases, comments and recommendations, and any responses received on deaths were immunisation might have had a preventative effect. The case study discusses background information about the government's policy on immunisation, the supporting legal framework, and research results on vulnerable parts of the population.

37: See

38: In the Chief Coroner's reports, provisional means the number of confirmed suicides is likely to be fewer than the number of suspected suicides. In the Ministry of Health's reports, provisional means the number of suicides is the least number of suicides for that year. The number could increase until all coronial inquiries for that year are complete.

39: Statistics New Zealand publishes some high-level statistics on suicide as part of its annual reports on serious injury outcome indicators. It calculates rates based on the New Zealand population.