Investigating suspected suicides: New Zealand coroners' experiences

To understand how suspected suicides are investigated in New Zealand we conducted a thematic analysis of in-depth interviews with coroners. Coroners identified the inquisitorial nature of the coronial system and coroners' wide powers of jurisdiction as key strengths of the system. Important influences in key areas of coronial decision making in cases of suspected suicides included; the need for more evidence - especially to determine intent, and family factors, including therapeutic jurisprudence. Coroners identified lack of follow up and monitoring of recommendations, poorly resourced coronial training and the personal impact of suicides as challenges of working in the coronial system.

Automated summary

A thematic analysis of in-depth interviews with New Zealand coroners revealed that the coronial system in the country is inquisitorial and allows for wide-ranging jurisdiction. Determining intent and considering family factors such as therapeutic jurisprudence were found to be important influences in coronial decision making regarding suspected suicides. However, challenges within the system were identified, including a lack of follow-up and monitoring of recommendations, inadequate resources for coronial training, and the personal impact of suicides.