Minutes of Central Statistics Office (CSO) Liaison Group on Suicide Mortality Statistics held on October 7th 2016 in the CSO Offices, Rathmines, Dublin.

In attendance:   Dr Myra Cullinane ( Dublin City Coroner), Eileen Williamson (National Suicide Research Foundation), , Suzi Lyons (Health Research Board),  Colm Desmond (Department of Health),  Sara Parsons (Garda Commissioner’s Office), Ciaran Austin (Pieta House), Paul M. Crowley, Gemma Duff, Carol Anne Hennessy (CSO).

Ella Arensman (National Suicide Research Foundation) by teleconference.

Apologies from:  Bernadette Smith (General Registration Office), Gerry Raleigh (National Office for Suicide Prevention).

Apologies to Deirdre O’Reilly (Irish Prison Services) whose name was erroneously deleted from list of email addresses when notification of meeting issued.

      Agenda 

Date:  Friday, October 7^th 2016 at 11.30 am 

      Meeting of Central Statistics Office (CSO) Liaison Group on Suicide Mortality Statistics 

CSO Offices, Ardee Road, Rathmines, Dublin

1.            Welcome/Introductions

2.            Agenda item No 2 - Agree Minutes of previous meeting of the 23rd June, 2016 

              and matters arising.

3.           Review of the Form 104 with Coroner’s perspective.

4.           Systematic in-depth research into murder-suicide cases between 2000-2016;

              Briefing attached.

5.            Research into patterns of repeated suicide clustering in geographic regions in Ireland.

6.           AOB

Agenda item No 1 - Welcome and Introductions

Paul Crowley welcomed everyone to the meeting, made the relevant introductions and conveyed the apologies of the non-attendants to the meeting.

Agenda item No 2 - Agree Minutes of previous meeting of the 23rd June, 2016 and matters arising

Minutes agreed. 

Actions arising from meeting of the 23rd June, 2016.

• Sara Parsons to revert to the CSO with information of whether a directive exists to get Gardaí to return Form 104.   Sara Parsons advised that a directive to complete and return the Form 104 is in existence since 1998. 
• CSO is to contact the Head of Training in Templemore to arrange meeting re training on completion of Form 104.   Letter issued to Head of Training and meeting arranged for the 10^th October, 2016 in Gardaí Training College, Templemore. 
• CSO to issue reminders within 3 months of the issue of the original Form 104.  Reminder letters are now being issued as necessary within 3 months of the issue of the Form 104.  
• A letter is to be drafted and issued to all superintendents outlining the importance of the Form 104 to the determination of the most accurate underlying cause of death.  Letter issued to all Superintendents in September, 2016.
• Electronic version of the Form 104 to be circulated to members of the group.  
• CSO to write to Chairperson of the Coroners Group to request inclusion of 2 new questions on the Coroners form that is being reviewed (i.e. In the Coroner’s opinion was the death (a) a suicide or (b) not a suicide).    Coroners agreed to amend Coroners certificate to include verdict of Open, Accidental, Suicidal or homicidal. 
• The NSRF to provide the CSO with the names and addresses of ‘cluster’ suicides in both the Mayfield\Glanmire and North Cork areas.  List of cases received and analysed by the CSO.  Results presented to the Liaison group. 
• CSO to put table of late registered suicide deaths on Statbank    Tables VSD33 and VS34 on statbank. 
• CSO to carry out further analysis on the geographical location of the late registered deaths.  Analyses carried out and presented to the group. 

Agenda item No 3 – Report on the Form 104 from Coroner’s perspective

Firstly theCSO outlined that the information in the sections of the Form 104 that are coloured in green is supplied by the CSO.   Secondly, the group, mainly the Dublin City Coroner, made the following contribution:

Question 2:

Date of adjournment or

Completion of inquest *

The Dublin City Coroner stated that if the inquest has been adjourned then by definition very little evidence will have been heard that could assist the Garda in the completion of the Form 104.  Furthermore if the inquest was adjourned pending a criminal trial then completion of the Form 104 in those circumstances could be viewed as prejudicial.

• Recommendation:  the option on adjournment should be removed.

Question 5: 

Address at which death occurred

(if not at home)

The group suggested that the wording ‘if not at home’ be removed.

• Recommendation:  Remove the text ‘if not at home’.

Question 13: 

Medical evidence as to cause of death.

Medical Details:  the Dublin City Coroner suggested that the wording should be changed to ‘Medical Cause of Death’ rather than ‘medical evidence as to cause of death’.

• Recommendation:  Use ‘Medical Cause of Death’ instead of ‘medical evidence as to cause of death’.

Question 16:

 It was suggested that the Garda is not in a position to answer this question and wouldn’t be aware of the drugs a person was using.

• Recommendation:  remove ‘type of drugs’ and ‘were drugs prescribed’

Question 17: 

Deaths caused by poison:

Please state type of poison,

how and where stored. 

It was suggested that the word ‘poison’ in this context is out of vogue.  Instead of ‘poison’ use ‘drug toxicity’.

• Recommendation:  substitute ‘drug toxicity’ for ‘poison’.

Question 24:

There was a lot of discussion around this question.  The Coroner views this question from a legal viewpoint and will only return a verdict of suicide if it is beyond reasonable doubt.  However, the CSO is interested in getting the Garda’s opinion as to whether in the balance of probabilities the death was suicide, accidental, undetermined or a homicidal death.  From the CSO perspective this is the key question on the Form 104 and must remain in the Form 104.   The CSO, views this question as being of the utmost importance in the avoidance of under recording of deaths from suicide.

• Recommended to substitute ‘whether the manner of the death was’ for ‘whether the death was’.

It was stated that the research being undertaken by Eileen Williamson (NSRF) will inform the group of the validity of collecting or not collecting the Form 104.  Eileen’s research is covering Dublin City and Dublin County and three Coroners in Cork and this covers a significant number of cases.

The CSO clarified for the group that the Form 104 is unique to Ireland.

Ella Arensman (NSRF) requested that The Health Board (HRB) expand their work on alcohol abuse for more reliable information from post mortems.  Suzi Lyons advised that the data is collected by medical staff and information is collected in a standardised way by medical personnel and is available to researchers.

Action:   The CSO to is to redraft the Form 104 in advance of the next meeting of the Suicide Liaison Group.

Agenda item No 4 – Systematic in-depth research into murder-suicide cases between 2000-2016

Ella Arensman (NSRF) presented this research to the group.  She highlighted that in the years 2004 to 2014 a variety of methods have been used in murder-suicide cases.  In this 10 year period there was 1 case that involved stabbing.  Subsequent to 2014 there have been 6 cases of murder-suicide that involved stabbing.

Agenda item No 5 – Research into patterns of repeated suicide clustering in geographic regions in Ireland

Ella Arensman (NSRF) provided the group with links to 2 reports on the Suicide Support and Information System.  Suicide clusters and extended suicide is covered in section 4.4 of the first edition of the report and is covered in section 5 of the second report.  The CSO and the NSRF were pleased that in 18 cases (where the names and addresses were known)  deaths that form part of a perceived ‘cluster’ of suicides, in 2 particular geographical areas in Cork, were recorded as deaths from intentional self-harm.  The exercise confirmed that there was no under counting of suicides arising in this particular exercise.

Actions arising from the Meeting:-

• The CSO to redraft the Form 104 in advance of the next meeting of the Suicide Liaison Group.

AOB

The next Meeting is to be held by the end January 2017 on a Friday preferably to facilitate the attendance of the Dublin City Coroner.

Carol Anne Hennessy

13^th October, 2016.