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BACKGROUND: To investigate the variation between coroners in the verdicts given to deaths thought by researchers to be probable suicides and analyse factors associated with the coroners' verdict. METHODS: Data were collected from 12 English coroner districts on all deaths in 2005 given a suicide, open, accidental or narrative verdict where suicide was considered a possibility. The data were reviewed by three experienced suicide researchers. Regression models were used to investigate factors associated with the coroners' verdict. RESULTS: The researchers classified 593 deaths as suicide, of which 385 (65.4%) received a suicide verdict from the coroner. There was marked variation between coroner districts in the verdicts they gave. The suicide method was associated strongly with the coroners' verdict; deaths from poisoning and drowning were the least likely to be given suicide verdicts. The other factors strongly associated with a coroner's verdict of suicide were: whether a note was left, age over 60 years and being married or widowed compared with being single. CONCLUSION: Coroners vary considerably in the verdicts they give to individuals who probably died by suicide. This may compromise the usefulness of suicide statistics for assessing area differences in rates for public health surveillance.

Original publication




Journal article


J Public Health (Oxf)

Publication Date





157 - 165


cause of death, classification methods, coroner's verdicts, mortality, risk factors, suicide, Accidents, Adolescent, Adult, Aged, Aged, 80 and over, Cause of Death, Child, Coroners and Medical Examiners, Death Certificates, Decision Making, England, Female, Humans, Male, Middle Aged, Regression Analysis, Suicide, Young Adult