Psychiatric morbidity in a sample of a London coroner's open verdicts

Evidence for Underregistration of Suicide

In this case report, we will present two cases in which the Dutch municipal coroner registered a natural death, but treating psychiatrists doubted the validity of this decision on the grounds of clinical data and investigation. For both cases, we present evidence that deaths likely resulted from suicide, raising serious doubts about the accuracy of the registered cause of death. According to the WHO bulletin on suicide prevention, the national registration of suicide is unsatisfactory in many countries. The Netherlands is listed by the WHO as having one of the most accurate registration procedures. Nevertheless, there are indications that national registration, even in the Dutch system, is not infallible. In this case report, we present several ways in which the registration process is liable to error and evidence for underregistration of suicide rates.

Factors influencing coroners' verdicts: an analysis of verdicts given in 12 coroners' districts to researcher-defined suicides in England in 2005

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.

Mental disorders in suicide and undetermined death in the Lundby Study. The contribution of severe depression and alcohol dependence

To evaluate the role of severe depression, i.e., depression with melancholic and/or psychotic features and alcohol dependence in suicide and undetermined death. The Lundby Study is a prospective, longitudinal study of a population consisting of 3563 subjects. In a long-term follow up 1947-2006 there were 66 suicide cases, including 19 undetermined deaths. Depression and alcoholism were as expected the major contributors to suicide (44% and 23% respectively). Severe depression with psychotic and/or melancholic features was diagnosed in 66% of all depressions and in 29% of all suicide cases, as compared to 15% for major depression only. Alcohol dependence was related to undetermined death. Major depressive disorder with melancholic and/or psychotic features appears to be an important contributor to accomplished suicide in the depression group, and alcohol dependence appears to be related to undetermined death.

The black-white suicide paradox: possible effects of misclassification

This research addresses the paradox that the crude and age-adjusted suicide rates of United States blacks are less than half those of whites despite similar risks. Upper and lower limits for true suicide rates are estimated to assess the potential for differential suicide misclassification by race. Construction of these two rate scenarios respectively incorporate one or all of the three cause-of-death categories identified in the literature as most prone to obscure suicides: injury of undetermined intent and unintentional poisonings and drownings. The data source is the US Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, and the observation period is 1999-2002. We found that as in the official rates, the racial suicide gap persists within the lower and upper limit scenarios. However, there is marked shrinkage under the upper limit scenario. That scenario even generates rate crossovers for males ages 45-54 years and females ages 85 years and older. Suicide data appear relatively more deficient for black females than for black males. Racial data disparities are minimal for youth and young adults, and maximal for middle-aged males and the oldest and younger middle-aged females. Results strongly indicate greater susceptibility of medico-legal authorities to misclassify black suicides than white suicides. To demystify the racial suicide paradox, research is needed on medical histories and other biographical information that are accessible by the authorities in equivocal cases. To meet the standards of evidence-based medicine and public health, high-quality suicide data are an imperative for risk group delineation; risk factor identification; policy formulation; program planning, implementation, and evaluation; and ultimately, effective prevention.

Psychiatric diagnoses in 3275 suicides: a meta-analysis

BACKGROUND

It is well known that most suicide cases meet criteria for a psychiatric disorder. However, rates of specific disorders vary considerably between studies and little information is known about gender and geographic differences. This study provides overall rates of total and specific psychiatric disorders in suicide completers and presents evidence supporting gender and geographic differences in their relative proportion.

METHODS

We carried out a review of studies in which psychological autopsy studies of suicide completers were performed. Studies were identified by means of MEDLINE database searches and by scanning the reference list of relevant publications. Twenty-three variables were defined, 16 of which evaluating psychiatric disorders. Mantel-Haenszel Weighted Odds Ratios were estimated for these 16 outcome variables.

RESULTS

Twenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death. There were major gender differences. Diagnoses of substance-related problems (OR = 3.58; 95% CI: 2.78-4.61), personality disorders (OR = 2.01; 95% CI: 1.38-2.95) and childhood disorders (OR = 4.95; 95% CI: 2.69-9.31) were more common among male suicides, whereas affective disorders (OR = 0.66; 95% CI: 0.53-0.83), including depressive disorders (OR = 0.53; 95% CI: 0.42-0.68) were less common among males. Geographical differences are also likely to be present in the relative proportion of psychiatric diagnoses among suicides.

CONCLUSIONS

Although psychopathology clearly mediates suicide risk, gender and geographical differences seem to exist in the relative proportion of the specific psychiatric disorders found among suicide completers.

Suicides hidden among undetermined deaths

The research phase of the National Suicide Prevention Project in Finland (from 1 April 1987 to 31 March 1988) included medico-legal investigation and psychological autopsy of all deaths suspected of being suicides, including 1397 official suicides and 61 undetermined deaths. In later analyses on suicide, undetermined cases were excluded. This paper presents an analysis of all officially classified undetermined deaths (n = 139) over the study period, consisting of all the initially suspected suicides (n = 61) and the remaining undetermined deaths (n = 78) where suicide could not be excluded. Poisoning by solids or liquids and drowning were the most common causes of all undetermined deaths. Suicidal intent was observed in 87% of undetermined deaths initially suspected of being suicides. In addition, 31% of these subjects had previously attempted suicide, and 34% had made suicidal threats. Depression was diagnosed in 23% of cases and alcohol dependence or abuse in 31% of cases. Undetermined deaths resembled suicides and appeared to reduce the suicide rate by 10%.

Sudden death in psychiatric patients

BACKGROUND

The present study investigated histories of prior psychiatric treatment in cases of sudden death reported to the coroner.

METHODS

A matching survey linked the register of deaths reported to the coroner with a comprehensive statewide psychiatric case register covering both in-patient and community-based services.

RESULTS

Sudden death was five times higher in people with histories of psychiatric contact. Suicide accounted for part of this excess mortality but deaths from natural causes and accidents were also elevated. Schizophrenic and affective disorders had similar suicide rates. Comorbid substance misuse doubled the risk of sudden death in affective and schizophrenic disorders.

CONCLUSIONS

The rates of sudden death are sufficiently elevated to raise questions about current priorities in mental health care. There is a need both for greater attention to suicide risk, most notably among young people with schizophrenia, to the early detection of cardiovascular disorders and to the vigorous management of comorbid substance misuse.

Suicide and the elderly

Impending demographic changes mean that the proportion of the elderly in the population will increase. Suicide rates increase with age. The literature on elderly suicide, with emphasis on methodology, cross-national rates and trends, correlates, cultural factors, location and method, attempted suicides and prevention, is critically reviewed in this paper.

A case cohort study of suicide in relation to exposure to electric and magnetic fields among electrical utility workers

OBJECTIVES

This case cohort study examines whether there is an association between exposure to electric and magnetic fields and suicide in a population of 21,744 male electrical utility workers from the Canadian Province of Québec.

METHODS

49 deaths from suicide were identified between 1970 and 1988 and a subcohort was selected comprising a 1% random sample from this cohort as a basis for risk estimation. Cumulative and current exposures to electric fields, magnetic fields, and pulsed electromagnetic fields (as recorded by the POSITRON meter) were estimated for the subcohort and cases through a job exposure matrix. Two versions of each of these six indices were calculated, one based on the arithmetic mean (AM), and one on the geometric mean (GM) of field strengths.

RESULTS

For cumulative exposure, rate ratios (RR) for all three fields showed mostly small non-significant increases in the medium and high exposure groups. The most increased risk was found in the medium exposure group for the GM of the electric field (RR = 2.76, 95% CI 1.15-6.62). The results did not differ after adjustment for socioeconomic state, alcohol use, marital state, and mental disorders. There was a little evidence for an association of risk with exposure immediately before the suicide.

CONCLUSION

Some evidence for an association between suicide and cumulative exposure to the GM of the electric fields was found. This specific index was not initially identified as the most relevant index, but rather emerged afterwards as showing the most positive association with suicide among the 10 indices studied. Thus the evidence from this study for a causal association between exposure to electric fields and suicide is weak. Small sample size (deaths from suicide) and inability to control for all potential confounding factors were the main limitations of this study.

The coroner's system and under-reporting of suicide

This study investigates the under-reporting of suicide with particular reference to differences between sex and age groups and the various modes of suicide. The study was performed retrospectively using the files of H M Coroner for South Yorkshire (West) over the years 1985 to 1991. There were 536 deaths judged on the balance of probability to be suicidal in nature. Only 60 per cent of these deaths received a suicide verdict and would therefore register in official suicide statistics. A significantly smaller proportion of females (51.7 per cent) received a suicide verdict than males (64.5 per cent). Of the young females (< 45) 61.7 per cent were given a suicide verdict compared to 46.6 per cent of older females (45+). These differences are explained by different preferences for mode of suicide, in particular for poisoning using solids or liquids. Only 40 per cent of cases within this category received a suicide verdict. Drowning showed an even smaller percentage (24 per cent). Self-immolation (42 per cent) and jumping from a height (51 per cent) were also under-represented. Of these, self-poisoning, drowning and jumping from a height were relatively popular among females. In contrast, common causes of death favoured predominantly by males--hanging and carbon monoxide poisoning--received a high percentage of suicide verdicts (81 per cent and 90 per cent). Thus official suicide statistics produce a distorted view of the suicide population with relative under-reporting of females, particularly older females, and marked under-reporting of some causes of death, notably poisoning using solids or liquids, drowning, self-immolation and jumping from a height.

Covert suicide among elderly Japanese females: questioning unintentional drownings

A hypothesis is generated that despite high reported rates, suicide among elderly Japanese females is substantially underestimated due to misclassification of drowning suicides (ICD-9 E954) as unintentional drownings (ICD-9 E910). Data are adapted from 1979-1981 age-, sex- and cause-specific mortality tabulations for Japan, the United States, Australia, France, New Zealand, Norway, Sweden and the United Kingdom. Between ages 55 and 74 years, unintentional drowning rates for males and females in Japan begin to diverge sharply from those of comparison countries. By ages 75 and older, the rate for Japanese females is 13.5 per 100,000, which exceeds comparison rates by 7- to 15-fold. Although drowning suicide rates in this population are also high, its ratio of drowning suicides to unintentional drownings declines precipitously beyond ages 35-44. Excess drowning suicide underestimation among Japanese females is suggested by the absence of a similar change among the males and evidence of both a lack of drowning witnesses and sex differentials in life expectancy, living arrangements and suicide methods. A preliminary test of the drowning suicide hypothesis is proposed which incorporates psychological autopsies.

Suicide among forensic psychiatric patients

This paper examines the problem of suicide among patients discharged from a Regional Secure Unit. The stereotype that emerges is a young man with anti-social personality traits, suffering from an affective psychosis, with a history of substance abuse and impulsive violence directed both towards himself and others, who is alienated from care staff and social supports because of his provocative and uncooperative behaviour. In contrast with the general population, forensic patients are more likely to commit suicide using a violent method and are more likely to have a suicide verdict recorded by the coroner. The implications of these findings for treatment and preventive interventions are discussed.

Violent death and mental illness. A study of a single catchment area over eight years

The names of 412 residents of the catchment population of a district general hospital unit who died potentially self-inflicted deaths in the eight years 1974-81 were identified. They were classified as suicide (245), accidental death (126), and undetermined (41). In each group, over half had a lifetime history of psychiatric treatment and over a third were psychiatric patients at the time of their death. The relative risk of a violent death for those who died within a year of their last psychiatric contact was 27 times greater than that of residents with no recent psychiatric contact. The relative risk was highest for those aged 35-44 and lowest for those of 75 years and over.

Suicide in England and Wales 1946-1985: an age-period-cohort analysis

Four decades of suicide mortality data for England and Wales were analysed within an age-period-cohort framework. Marked differences in results were found by sex. The analysis of the male data showed that the risk of suicide increased with age until men were in their mid-fifties (after allowing for period and cohort effects), and that suicide risk declined for males born from 1876 to 1915, but had increased over 4-fold for certain later-born cohorts. Female suicide risk was found to decline with later nativity (after adjusting for age and period effects). The identification of period effects in terms of known changes in the carbon monoxide (CO) content of domestic gas successfully accounted for temporal variation in male suicide risk, but fitted less well to the data for females.

The psychological autopsy: methodological considerations for the study of adolescent suicide

The psychological autopsy has been employed to study risk factors for completed suicide for more than three decades. Despite a wide range in methods of approach to families and interview techniques, the studies show high compliance and remarkable consistency of results across a wide age range and diverse geographic samples. The convergent evidence is that the diagnostic information obtained is both reliable and valid, although it is likely that such an approach will be more specific than sensitive. Integration of data obtained through psychological autopsies with data obtained through biochemical, toxicological, and epidemiological approaches is likely to deepen our understanding of suicide. Successful completion of careful psychological autopsy studies should enable investigators to examine intensively patients who resemble suicide completers, thereby transcending the inherent limitations of this important first step in the investigation of suicide.

A consideration of the validity and reliability of suicide mortality data

The question of the validity and reliability of suicide statistics may be considered at three levels: (1) Are suicide deaths misidentified or differentially identified across jurisdictions or over time? (2) To what degree are suicide deaths misidentified? and (3) Is the degree to which suicides are misidentified sufficient to threaten the validity of research based on suicide statistics? There is general agreement that suicides are likely to be undercounted, both for structural reasons (the burden-of-proof issue, the requirement that the coroner or medical examiner suspect the possibility of suicide) and for sociocultural reasons. There is also substantial anecdotal and empirical evidence suggesting that the mode of death for some true suicides is in fact certified as other than suicide. Overall, it does not seem that very many true nonsuicides are incorrectly certified as suicides. There is not, however, much agreement as to the degree to which true suicides are undercounted. At least some of the inconsistencies in the findings of different investigators arise because the validity of suicide certification seems to vary from place to place. But the source of apparent conflicts in many of the findings is undoubtedly the lack of a "gold standard" against which the verdicts of any given death certification process can be measured. At best, we can estimate that the sensitivity with which coroners and medical examiners certify true suicides varies from approximately 55% to 99%. A central question in estimating the sensitivity of suicide certification is this: What proportion of true suicides are either equivocal or likely to go unsuspected by the coroner or medical examiner? Very little has been done to investigate this issue. Yet the sensitivity of suicide certification clearly varies for equivocal versus unequivocal suicides. As shown in Table 1.2, specificity is also at issue when it comes to certifying equivocal cases. The final question--whether the degree of undercounting of suicide deaths is so great that it threatens the validity of research based on official statistics--is at the crux of the general concern about suicide certification. There are examples of studies in which conclusions based on crude comparisons of reported suicide statistics appear to be invalid. For the most part, these are comparisons among nations with substantially differing death certification procedures. When official statistics are interpreted with a degree of caution and an understanding of the source and direction of biases likely to affect the published rates, however, it seems unlikely that major conclusions based on these statistics will be in error.(ABSTRACT TRUNCATED AT 400 WORDS)

Suicide, and other causes of death, following attempted suicide

The number of deaths in a large series of suicide attempters followed up after their attempts was 3.3 times greater than expected. Suicide or probable suicide occurred in 2.8% by the end of the eighth year of follow-up, the rate of suicidal deaths being 26.9 times the expected rate. The highest risk of suicide was during the first 3 years, especially in the first 6 months, following an attempt. Factors identified at the time of the attempts which were associated with suicide risk included: being male, advancing age (females only), psychiatric disorder (especially schizophrenia), long-term use of hypnotics, poor physical health, and repeat attempts. Recent disruption of a relationship with a partner and major rows rarely preceded the attempts of those who later killed themselves. Factors predicting long-term risk of suicide also predicted short-term risk. There were more than double the expected number of deaths from natural causes, the excess being greatest in females. Markedly high death rates were found for endocrine, circulatory and respiratory diseases, and accidents.

The suicide rate of epilepsy

Evidence from follow-up studies concerned with the mortality of epilepsy suggests the suicide rate is increased. The risk of suicide seems to be higher from temporal lobe epilepsy, for epilepsy with a greater degree of handicap and in the early years of the condition.

Patterns of consultation and parasuicide

Parasuicide is common; its treatment depends on its prevention, which in turn depends on accurate identification of those at risk. When the rates of consultation and the number of prescriptions issued each year for patients who had survived parasuicide were compared with those for controls matched for age and sex the patients who had survived parasuicide were found to have attended much more frequently; their pattern of attendance had accelerated up to the time of the attempt and then decelerated. This variation was not seen in the control group. The number of prescriptions received per visit was static in both groups at all times. General practitioners should regard more frequent attendance by patients who already attend often as indicating that those patients are at risk of parasuicide.

Recent changes in suicide among adolescents in England and Wales

This paper examines suicide statistics in the 15-19 years group in England and Wales between 1950 and 1984. There was an increase in suicide rate for both sexes between 1950 and the mid 1960's, largely due to suicide using domestic gas. The rate then decreased as domestic gas was detoxified, and this was followed by a further increase in suicide associated with poisoning with solids and liquids until the late 1970's. More recently there has been an increase, particularly for males, in suicide by hanging, strangulation and suffocation, poisoning with vehicle exhaust gas and firearms and explosives.

Recent trends in suicide amongst the young

Suicide is rare under 14 years but thereafter increases with increasing age, with males predominating. The suicide rate for 15-19 year olds in England and Wales has increased since the nineteen fifties for both males and females, with a recent substantial rise in males. There has also been an increase in the small number of female suicides aged 10-14 years between 1941-50 and 1971-80. In younger age groups there is a higher proportion of undetermined deaths compared with officially recorded suicides, and this category has recently increased disproportionately in the young. The number of deaths by poisoning with solids or liquids recorded as suicide, accidental poisoning or undetermined poisoning has increased markedly in young people, and the relationship between the three groups might repay investigation.

Estimating suicide risk among attempted suicides. II. Efficiency of predictive scales after the attempt

We predicted that the closer the resemblance of attempted suicide to completed suicide, the greater the risk of patients later killing themselves after an unsuccessful attempt. Using two risk scales, one of 6 and the other of 18 socio-demographic and clinical items, weighted according to their value in discriminating between suicides and attempted suicides, and a rating of intent to die during the index suicide attempt, we followed up 1263 attempted suicides for two years. Ten of the twelve suicidal deaths in the first year occurred in patients scoring in the top quartile on the 6-item scale; and among high-risk scorers there was an excess of those defined as 'failed suicides' at the index attempt. The 18-item scale was superior to the shorter one, but both scales were improved by taking into account the rating of intent-to-die. The potential value of these findings is discussed in the light of some inherent problems of predicting suicide in the clinical setting.

Neurosis and mortality: investigating an association

Neurosis is not a cause of death, but at follow-up neurotic patients are found to experience increased premature mortality. Suicide and accidental death are considerably increased in this group. There is also an excess of deaths from natural causes; amongst hypotheses to account for this there is some evidence to incriminate arteriosclerosis, and increased toxicity from cigarette smoke may be a factor. The increased mortality is not explained by confusion over the term depression. Those neurotic patients who subsequently die are more likely to have suffered from a more severe degree of neurosis at the time of initial treatment.

The relationship between suicide, undetermined deaths and accidental deaths in the Australian born and migrants in Australia

Australian data pertaining to Suicide and Accidental Deaths (I.C.D.7) for the years 1962-69 are compared with those for suicide, undetermined deaths and accidental deaths (I.C.D.8) for 1968-71, specific for country of birth. The data strongly suggest that deaths classified as 'undetermined' after the introduction of that I.C.D. category in 1968, had been classified as accidental prior to that data, especially deaths from poisoning. There was some differential between the Australian and U.K. born and the European born. It was estimated that Australian suicide rates are possibly underestimated by 5-10% for males, and 10-20% for females by categorising some deaths from poisoning as being undetermined or accidental.

The accuracy of officially reported suicide statistics for purposes of epidemiological research

Suicide is underreported for a number of reasons and the reliability of the official rates is subject to error from variation in defining and reporting cases--the kind of inaccuracies encountered when ascertaining cases in studies of mortality from any cause. Nevertheless, the evidence from studies designed to see whether these sources of error invalidate the differences reported between cultural and social groups indicate that they are randomised, at least to an extent that allows epidemiologists to compare rates between countries and districts within them, between demographic groups, and over time.

A comparison of suicide and undetermined deaths in psychiatric patients

Those people who had previously been patients of the Department of Mental Health of Missouri who died in the three year period 1972 through 1974 and whose deaths were designated as suicide or "undetermined whether purposely or accidentally inflicted," were identified by matching statewide death tapes against the DMH data base. The demographic characteristics of the two groups are compared to ascertain if the members of the undetermined group are essentially similar to the suicides, as has frequently been hypothesized. It is found that, in general, the similarities are in areas which would not have had a direct influence on the medical examiner/coroner's verdict, whereas, the differences do highlight areas which could cause an indecisive verdict. The significance of the undetermined deaths is discussed.

Undetermined deaths-suicide or accident?

A consecutive series of 110 undertermined deaths (U.D.) was compared with matched samples of suicides and accidents recorded in the same metropolitan Coroner's District. The hypothesis tested was that U.D. are mostly concealed suicides and will resemble known suicides more closely than accidents. The samples were compared on social and demographic variables, psychiatric and physical illness, evidence of suicide intent, information available to the Coroner and the circumstances of death. The results did not confirm the hypothesis. The study widens the investigation of the mortality of mental disorder from unnatural causes beyond the category of suicide.

Hypotheses linking neuroses with premature mortality

The death risk for psychiatric patients has decreased over the last 30 years but still remains higher than that of the general population. The death risk for patients with a diagnosis of neurosis is higher than that for the general population. Previous studies are enlisted to investigate this mortality for socio-economic characteristics, alcohol and drug abuse, psychopathy and accident proneness. Possible psychosomatic aetiology of disease and subsequent death is examined. Psychological theories for premature death are discussed and some recommendations made for future areas of enquiry.

Do newspaper reports of coroners' inquests incite people to commit suicide?

A statistical association has been found between reports of suicide inquests in a local paper and the subsequent suicide of men under 45 years.

Clinical and social variables which differentiate suicide, open and accident verdicts

A study has been made of cases coming before the Brighton coroner in the period 1970-2. Fifty cases in which a suicide verdict was recorded were specially studied, and relatives and acquaintances of the deceased were interviewed. The information thus obtained was compared with information available to the coroner in considering his verdict in 83 further cases in which he made a verdict of 'suicide'. The reliability of the contemporary information on which the coroner's decision is based was largely validated. A study was made of variables which differentiated 'suicide' from 25 'open' and 33 'accident' cases considered by the same coroner. The prevalence of depression did not differentiate 'suicide' and 'open' cases, and this finding contradicts suggestions that the association of depression and suicide might be an artefact of the method of arriving at a suicide verdict. A number of other demographic and clinical factors did however significantly vary between 'suicide', 'open' and 'accident' cases.

Suicide and "The Befrienders"

The short-term effect of "The Befrienders"--an 11-episode weekly series on B.B.C. 1 portraying the Samaritans as a suicide prevention service--on suicide and undetermined deaths was monitored in Edinburgh. No preventive effect was observed though the series was associated with a dramatic rise in new client referrals to the Edinburgh branch of the Samaritans.

The comparability of suicide rates

Programmes of suicide prevention require for their planning accurate epidemiological surveys. Doubt has been cast on the accuracy of many existing surveys because of the realization that suicide is under-reported and because of the lack of consistency in the procedure for suicide ascertainment. Two studies are described in this paper which attempt to examine the problem. The first is part of an international study supported by the World Health Organization. In it, Denmark and England are compared, and it is shown that there are striking differences in suicide ascertainment procedure between the two countries. Next, on a blind basis, coroners and their opposite numbers in Denmark examine a sample of each other's case records. It is found that the Danes consistently report more suicides than do the English coroners on the same case material; thus considerable doubt is cast on the supposed difference in suicide rates between the two countries. In the second study, deaths by poisoning are examined for certain coroners' districts in England and Wales. It is shown that there is considerable variation from one district to another in the relative proportions of these deaths which achieve an accident, an open or a suicide verdict. This suggests that in England and Wales coroners may not be consistent in their suicide ascertainment criteria. Hypotheses attempting to account for differences in suicide rate based on such epidemiological surveys should be viewed with great caution.