Suicide is the leading ‘external’ (non-natural) cause of death in Australia. Australian coronial courts play a critical role in reporting suicide deaths. Coronial findings contribute to the data used by the Australian Bureau of Statistics to compile mortality statistics, which underpin suicide prevention strategies and their evaluation. The public interest requires that coroners report suicide when it occurs so as to allow accurate statistics about the incidence of suicide to be collated, to promote efficient suicide prevention strategies and enable suicide prevention objectives to be achieved. It is widely recognised that suicide is underreported. The Coronial Council of Victoria (Council), whose membership includes medical and legal professionals as well as community and police representatives, has investigated problems with suicide reporting in the Victorian coronial jurisdiction. The Council aims to promote change within the Victorian coronial jurisdiction with a view to parallel changes being implemented throughout Australia. The key problem identified by the Council is that inconsistencies in coronial practices hinder the accurate collection of suicide data. Too often, when the deceased took an action that caused their death, the circumstances of death are described generally but an explicit finding is not made about whether or not the deceased intended to end their life. The Council has formed the view that there is a need for a legislative requirement that coroners make a clear finding about the intention of people whose actions cause their own death, where the evidence permits. There are a number of circumstances that may apply to such deaths, including accident and suicide. In some cases, the deceased may not have had the capacity to understand the effects of their actions or there may be insufficient evidence for the coroner to come to a conclusion about the deceased’s intent. In these cases, it would be useful for suicide prevention activities for the coroner to identify whether death was a reasonably foreseeable consequence of the deceased’s action. The primary recommendations of the Council are that the Attorney-General:

1. propose amendment to the Coroners Act 2008 (Vic) to require that coroners make a finding of intention, as supported by the evidence, in relation to all investigated deaths found to be caused by an action of the deceased; and
2. raise the issue of standardisation of coronial legislation and/or coronial systems in Australia in the Standing Council on Law, Crime and Community Safety and propose that changes be implemented in parallel in all Australian jurisdictions. The Council’s recommendations are set out in further detail at the end of the report.