Coroners' Recommendations and Suicide Prevention in Specialist Mental Health Services

Abstract

Suicide is considered to be a serious health and social issue and the improvement of services that cater for those affected by mental disorder is one of the principal targets for suicide prevention. All cases of suspected suicide are investigated by a coroner in New Zealand and the key purposes of these inquiries is establishing the circumstances of death and making recommendations that may prevent a similar death occurring in the future. Specialist Mental Health Services (SMHS) are often involved in the inquiries and are recipients of the recommendations. However, to date there has been a very limited amount of research that has examined the impact of coronial recommendations on the delivery of SMHS.

A two phase qualitative dominant descriptive mixed method design was used to conduct the study. The first phase involved the retrieval and content analysis of 136 coroners’ recommendations directed to SMHS that relate to cases of suicide. The second phase of the study aim to gain an understanding of how the recommendations are handled by SMHS and to explore the first phase themes from the perspective of SMHS and individuals that work with families in SMHS. This was investigated with semi-structured interviews of SMHS leaders that are responsible for the implementation of the recommendations across 12 DHBs in New Zealand, as well as a local family and whānau worker focus group. The first phase findings produced six major categories of coronial recommendations. These included communication, restrictive management, staff education, working with family, risk assessment, and service delivery. Further exploration of these categories from the perspective of SMHS leaders responsible for their implementation revealed that the majority of the recommendations were perceived as appropriate; however, concerns were raised regarding recommendations in the risk assessment and restrictive management categories. Overall the SMHS leaders portrayed the perspective that the recommendations have a limited positive influence on the delivery of SMHS and suicide prevention. The family and whānau worker focus group findings corroborated that coroners are accurately identifying significant shortcomings in the way SMHS are including families in the treatment of mental health consumers. The findings highlight that SMHS need to consider how they could improve their response to coronial recommendations that have clinical credibility, particularly in regard to communication, and family inclusive treatment. A starting point may be the promotion of a more positive, learning and transparent organisational culture. It is also essential that coroners promote organisational learning by consistently adopting a wider systematic focus during inquiries and avoid individual scrutiny of practice. Furthermore, better resourcing of Coronial Services of New Zealand may be required to ensure all recommendations have clinical relevance and take a more balanced and considered approach to risk, containment, and therapeutic autonomy.