Suicide and the Therapeutic Coroner: Inquests, Governance and the Grieving Family

This study of English Coronial practice raises a number of questions about the role played by the Coroner within contemporary governance. Following observations at over 20 inquests into possible suicides and in‐depth interviews with six Coroners, three preliminary issue emerged, all of which pointed to a broader and, in many ways, more significant issue. These preliminary issues are concerned with (1) the existence of considerable slippages between different Coroners over which deaths are likely to be classified as suicide; (2) the high standard of proof required and immense pressure faced by Coroners from family members at inquest to reach any verdict other than suicide, which significantly depresses likely suicide rates; and (3) Coroners feeling no professional obligation, either individually or collectively, to contribute to the production of consistent and useful social data regarding suicide, arguably rendering comparative suicide statistics relatively worthless. These concerns lead, ultimately, to the second more important question about the role expected of Coroners within social governance and within an effective, contemporary democracy. That is, are Coroners the principal officers in the public administration of death; or are they, first and foremost, a crucial part of the grieving process, one that provides important therapeutic interventions into the mental and emotional health of the community? days and there were some Coroners who will go to almost any lengths not to bring in a suicide verdict. Coroner Freckelton Therapeutic jurisprudence … is in part a practical orientation towards minimizing adverse outcomes. And it is in part about working with the realities of the broad repercussions of the law to fashion them as constructively a possible.

Much is often made of changes over time in our published suicide rates. As a society, we are relieved when we are informed that fewer people are ending their own lives (Australian Bureau of Statistics 2012), confused when we are told exactly the opposite (Haesler 2010), and concerned when our own rates are compared unfavourably with other nations and peoples (Georgatos 2013). It is often difficult to ascertain the precise trajectory of our suicide rates, let alone where we stand in relation to anyone else.
The difficulty here is that suicide statistics are notoriously unreliable, with most research in the area suggesting that alternative ways of counting, classifying, and reporting would lead to significantly higher rates of suicide (Harrison, Abou Elnour and Pointer 2009). This systemic under-counting may be for a range of reasons. Walker, Chen and Madden (2008) contend that factors such as disparities between jurisdictions, lack of standardisation in the reporting of Coronial deaths, and issues over forms for police reports put a particular slant on the data. They also point to the reluctance of some Coroners to reach a finding of suicide in the first place. It is this final factor that constitutes the central problematic of this paper. After all, if Coroners are reticent about reaching suicide verdicts, what are they there for? Why bother with suicide inquests at all?
From the inception of the role in the eleventh century, one of the central responsibilities of the Coroner has been to investigate deaths 'considered worthy of inquiry' (Burney 2000: 3). This would include deaths such as those by accident, where there was some suspicion of wrongdoing, and those by suicide. This eventually became seen as a largely administrative task, conducted in a non-adversarial environment, as part of the effective administration of the populace.
However, in addition to the recording, assessing and categorising of death, the Coroner's role has more recently expanded, throughout all Commonwealth countries, to incorporate elements of social management and prevention of harm (The Victorian

Institute of Forensic Medicine 2013)
Much of the operation of the office of Coroner or Coroners courts in Australia is centered on injury and death prevention, with the Coroner empowered to make recommendations on matters of public health and safety and judicial administration.
Consequently, the Coroner is not only an essential part of our legal system in that they manage the relationship between the State and the death of its citizens and, in particular, those deaths deemed to warrant investigation; now they are also an important element of the process by which the State accumulates social data which are used to identify problems and shape policy. The difficulty here is clear: if Coroners are reluctant to reach a finding of suicide, as Walker, Chen and Madden (2008) contend, then their role in production of suicide statistics, which in turn direct social policies and programs (targeting, for example, suicide prevention), becomes problematic.
In addition to these two roles -death investigation and social management -this research suggests that there is a third function, one which may often sit at odds with the first two. As Coroner 3 states in this research: It's all about enabling people to get on with their lives … giving them closure, actually lifting them up and explaining things … it's not what the law tells us it's about, but that's the reality of what it should do … That is, Coroners have been allocated or, perhaps more accurately, have allocated themselves a role in the process of giving closure to grieving families. This 'therapeutic' role may often result in Coroners managing inquests in ways that go well beyond the simple finding of facts, and which has significant implications for the administrative elements of the task.

Democracy and the Coronial inquest
This research investigates the English Coronial Inquest system, particularly as it relates to the investigation of potential suicides. In doing so, it also makes some comparisons with how similar deaths are managed in Australia. There are a number of important differences between the two systems. The most significant concerns the role played by the inquest. In England, all deaths that are considered worthy of inquiry -which includes potential suicides -are necessarily the subject of a public inquest. In Australia, the same deaths are assessed solely on the basis of the documentary evidence unless specific circumstances dictate otherwise.
It is important to note that the role of the Coroner and the functioning of the Coronial inquest are not just matters of abstract social and administrative interest. It has been argued that, historically, both are central to how English democracy came to be shaped and understood and, as such, questions about how well the Coronial system works, and about how different former British colonies have chosen to refract this original office for their own purposes, continue to be asked. In Bodies of Evidence, Burney (2000) examines the historical role played by the public inquest in placing important checks on State abuse of power, by insisting that all prison deaths -and most famously, the deaths of 18 protesting workers killed by in the Peterloo Massacre in 1819 -face public scrutiny and judgment. This notion that questionable deaths be the subject of public investigation, an investigation accessible to and readily understood by all interested parties within the community, became central to English conceptions of justice and democracy. Indeed, much of Burney's book examines the complex tension that arose within the Coronial inquest between the voices of this participatory tradition and the bearers of new, scientific knowledge that sought to bring medical expertise to the inquest process, often at the expense of public understanding and involvement. … the benefit of expert governance, particularly in an era of mass democracy, was that it could draw upon advanced, universalizing knowledge in the service of public well-being and, ultimately, public education. Its shortcomings, however, lay in its tendency to stifle the very instruments of civic education -the local, participatory institutions in which an active, informed, and morally elevated citizenry was forged. (Burney 2000: 9) Arguably, this tension -or at least a modern variant on it (that is, between medicine and the law) -can still be clearly seen within the fabric of contemporary death investigation (Carpenter and Tait 2010). Certainly there was some expectation that this tension would be evidenced within this study, and there were some minor examples of this.
However, what was uncovered was a far more significant tension between the governmental and the pastoral functions of the Coroner, between what appears to be an investigative and preventative role -investigative in delivering an appropriate finding; and preventative in contributing the necessary data to inform social policy -and a therapeutic role -in looking after the well-being of bereaved families. This paper will address this specific issue in some detail.

Coronial inquests and interviews
This study was conducted within one geographic area in England. The Research consisted of observations made at public inquests into possible suicides, followed by interviews with six of the coroners who had presided over the above inquests. i From the observations made at inquests, three relevant conclusions were drawn ii . First, there appears to be no single model for running a Coronial inquest. Far from being a uniform and consistent element of the English legal system, the Coronial inquest takes a wide range of different forms. Though the Coroners are uniformly professional, patient and skilled at managing grieving families, each Coroner seems to organise their own courtrooms as they see fit. For example, some Coroners focused largely on testimony of the police and the bereaved family; others placed greater emphasis on the available scientific evidence; some appeared to prefer a brief inquest, focused on reaching a finding as quickly as possible; others appeared willing to allow anyone who felt they had something to contribute the possibility of doing so if they wished.
Second, to be able to reach a finding of suicide, the standard of proof is extremely high.
In England, suicide determination is based around the criminal standard of 'beyond reasonable doubt', whereas the Australian model has adopted the civil standard of 'on the balance of probabilities'. On the basis of the observations made at the 20 inquests, the required standard of 'beyond a reasonable doubt', as deployed within the Coronial inquest, appears an exceptionally difficult level to attain.
Finally, the Coroners are often placed under significant pressure throughout the proceedings by the deceased's family not to bring in a finding of suicide. Almost all inquests are attended by family members and, even where the Coroners appear inclined to accept a finding of suicide, attempts are still continually made to control the general narrative. These efforts at control extended beyond the Coroner to courtroom staff, to any newspaper reporters present, and to anyone else present at the proceedings, including Australian academic researchers.
However, from the semi-structured interviews conducted with Coroners, three further issues emerged which are not only tied to the above observations but which also raise some important questions about just what is going on in Coronial suicide investigations.
Having set the groundwork by addressing these three issues, the subsequent question about the governmental role of the Coroner and the degree to which this role extends beyond the administrative into the therapeutic, can be addressed.

Inconsistency between Coroners
Firstly, there exist considerable slippages between different Coroners as to what is likely to be considered suicide, and what is not. There are likely to be a number of reasons for this. As mentioned previously, there has always been tension within Coronial death investigations between those who regard the process as a useful application of the scientific quest for truth -often exemplified by a different approach to the use of invasive autopsy -and those who place far more weight upon legal processes and information gathered at the scene of death. This tension extends to disagreement of who should, and who should not, be eligible to be a Coroner:

I have nothing against my medical colleagues, but I do think it's a job for a lawyer … I think that
Inquest law is now becoming so complex -it's nothing to do with intellectual ability, but I think you need legal training, and to have performed in the court system to really be able to deal with it. Coroner 4 A further reason for a seeming lack of consistency in reaching findings of suicide involves considerable differences in levels of experience, in that more practiced Coroners are often able to better manage the complexities of procedure, evidence and family management than are those with less time in the position. That said, additional experience does not necessarily translate into having the confidence to bring in a difficult finding of suicide; -in fact, often the reverse is apparent: The newer coroners are probably more likely to bring in a suicide verdict than the older ones … well I think it's because the older ones -suicide probably had more of a stigma in those days and there were some Coroners who will go to almost any lengths not to bring in a suicide

Underestimating rates of suicide
The second issue to emerge from the interviews involves the general admission by the Coroners that the Coronial inquest process acts to depress suicide rates, with this observation supported by most research in the area (Harrison et al. 2009;Walker et al. 2008 In contrast, other Coroners are aware that such wishes will often factor into their overall decision-making process. That is, they appear to consider that taking into account family wishes is a valid component of reaching an appropriate finding.
I think a lot of Coroners -me included -sometimes take a sympathetic view of the family, and perhaps, well, you know … why leave the family with the stigma of this, when we can actually make their situation better? … So, I think Coroners, to some extent, are softies, and might not necessarily bite the bullet and say, yes, this is suicide. Coroner 4 They tend to come in numbers. If you've got 10 members of the family with their eyes burning on you, and they really don't want that verdict, it is very, very hard … Coroner 4 Clearly, there is division between those Coroners for whom the job remains steadfastly administrative, and those who see their principal task as providing comfort and closure to grieving families. Indeed, advocates of the administrative approach to Coronial practice often have little time for those who seem prepared to be swayed by the influence of the family. They consider that Coroners have a clearly-defined task to accomplish, and criticise those who shy away from the tougher elements of that task.

Coroners versus statisticians
The final issue that emerged from the semi-structured interviews concerns the relationship between the Coronial suicide inquest and the production of suicide data. It is clear that Coroners feel no obligation to make their findings amenable to the production of useful suicide statistics. Most regard their task as a fundamentally administrative function concerning the management of particular kinds of death as well as helping families, where possible, deal with the passing of a loved one; however, they do not see their job as facilitating the recording of such deaths into meaningful numbers: The statisticians will try and drill down, and sometimes we'll get psychological surveys of my Those Coroners who place greater weight than others upon the non-administrative elements of their job -that is, those who emphasise a more pastoral approach to running an inquest -appear to have less concern for the difficulties faced by those coding statistical data for later interpretation: You know, I do the job as I think fit, and by trying to put families first. I think I'm as guilty as anyone sometimes of being a softy. I appreciate that it must rankle statisticians completely, but in terms of perhaps the way people can live with themselves thereafter, I think that probably is a better aim. Coroner 4 You can make a difference because one of the non-statutory functions which is not recorded anywhere but a lot of us do it, is to try and help the family in closure, without being paternalistic. It can be a cathartic exercise and to that extent I think you've justified your own existence, never mind the State's work which you do. Coroner 5 Two issues emerge from this observation. First, by adopting this approach, Coroner's become -consciously or otherwise -the principal gatekeepers of our suicide statistics.
In deciding which deaths are recorded as suicides, often for reasons above and beyond the ontology of the deaths themselves, Coroners can ultimately determine whether suicide rates are increasing or decreasing, based not upon the specifics of each case but, rather, upon their perceived responsibility to grieving families, with all the concomitant implication this may have for suicide prevention policy formulation and funding.
Continuing on from the problems and observations raised above, the second issue concerns the more important question about the role we expect Coroners to play within social governance. Are Coroners the most important cog in the administrative machine charged with recordingthe death of citizens, or are they now positioned as an appropriate part of the grieving process, providing important therapeutic interventions into the mental and emotional health of the community? One further question follows on from this issue: are these two roles mutually exclusive; or is it possible to include both within a broader understanding of the role of the Coroner within contemporary governance?

The therapeutic Coroner
The precise role of the Coronial inquest is not necessarily an easy one to define. As previously discussed, Burney (2000) has articulated the inquest's function within modern democratic processes as not only a check on State abuse of power but also as a site for new scientific truth-claims to be aired and to gain momentum. The Coroners in this study themselves voiced an array of other explanations as to its ongoing importance. For example: Part of the whole purpose of an inquest is to quell rumour. It's a very old-fashioned thing to say, but it is. Coroner 2 While this may be true, arguably the fundamental purpose of the modern inquest and, by extension, the position of the Coroner itself has now been subsumed within the general governance -governance in a Foucaultian (1977) sense -of contemporary populations.

Suicide and governance
Towards the end of the eighteenth century, the governmental process started whereby the social body was transformed from an undifferentiated mob into a workable and more readily governable population; one comprised of noticeable features and patterns as well as differentiated individuals, each with their own discernible capacities and characteristics. While this process began in a fairly modest way, it enabled disparate organs of government to sketch out a preliminary map of some of the most important contours of community life. These contours included, for example, how many people lived in particular locations, how they were employed, how they lived, and importantly for the purposes of this paper, how long they lived, and how they died (Tait 2013).
Over the ensuing two hundred years, mortality rates have proven to be one of the most important statistics within the management of populations, principally because the health of the population had rapidly become one of the central functions of the exercise of political power: that is, providing a social milieu that promised physical well-being, health, and optimal longevity. As Foucault (1984: 277)  Arguably, unless such statistical analyses measure what they claim to measurewhether dealing with suicide or any of the other problems which form the raison d'être for all programs of intervention -then they defeat the fundamental purpose of this form of governance. This leaves those Coroners more predisposed to organising their findings in part on the basis of family wishes, seemingly in an untenable position. That is, if the statistics their actions give rise to bear only a passing resemblance to any reasonable approximation of actual occurrences of suicide, perhaps that governmental responsibility should be dealt with elsewhere.
Interestingly, Marsh (2010) also adopts a Foucaultian approach in his analysis of the governmentalisation of suicide. However, not only does he address the manner in which suicide was brought into the realm of the knowable, and hence manageable, he also goes on to examine the way in which this phenomenon was re-translated into a matter for psychiatric concern, itself a new form of regulation and governance. This latter issue is of no little importance, as it may well be argued that the 'therapeutic' concern for the wellbeing of the grieving family is not simply antithetical to the management of contemporary populations, but instead represents a different governmental tactic, deployed within the same overall strategy.

Therapeutic jurisprudence
The tension evidenced among the Coroners concerning the role of the family in suicide Within this approach, the law is not simply a set of codes to be followed without reflection, much in the manner of Legal Positivism; such codes have consequences for all those caught up in the proceedings. As such, legal institutions and those charged with making them work are now deemed to have some responsibility for the mental and emotional wellbeing of all participants. King (2008: 4) is quite explicit in his call for an increasingly therapeutic approach to Coronial practice: Coroners' work is intimately connected with well-being -a concern of therapeutic jurisprudence. Part of the Coroner's role is to determine whether there are public health or safety issues arising out of the death and whether any action needs to be taken to remedy any problems, particularly those that may cause future deaths … Moreover, the dead person's family suffer grief and, depending upon circumstances of the death, significant trauma.
According to this logic, it would be insufficient for a Coroner to reach a finding within a suicide inquest without considering how this finding might impact upon those left behind by the death. Coroners would no longer be regarded, or regard themselves, as mere functionaries in the process of recording death statistics, but rather they would have a therapeutic role to play in the emotional and psychological health of their wider communities. This is not to say that the trauma of losing a loved one can never be exacerbated by being told the truth about it, but it does suggest that the Coroners' responsibilities lie beyond simply determining the cause and circumstances of death. As Freckelton (2008: 577)

Binaries of governance
The evidence suggests that, rather than simply managing the data of death, Coroners now form part of the governance of a more subtle component of the population's health and welfare: that of subjective experience. That is, particularly on the issue of suicide, they now appear to be a component of the administrative apparatus that manages the emotional wellbeing of the population. Marsh (2010) noted that suicide was brought into the realm of the statistically knowable, and from there pathologised as an unfortunate outcome of mental disorder. This is not a unique phenomenon but is instead an increasingly familiar tactic for the effective governance of subjectivity (Tait: 1993;. However, while 'mental illness' now constitutes one of the central indicators of a likely suicide, it by no means constitutes the full extent of the role played by the psydisciplines within the field of suicide determination, a fact attested to by the concern shown by Coroners for those left behind. Rose (1990: 1)  Arguably, these new forms of expertise have clustered together in what Rose (1990) refers to as a 'therapeutic community'; it may well be the case that Coroners have allocated themselves a role within that community.
From the evidence emerging from the observations at inquest and from the interviews with the Coroners, it appears that the Coroners have a significant part to play in the traditional governance of suicide as it relates to the recording of death and the management of data. However, it appears that many of the Coroners feel a social and professional obligation within the practices of emotional governance. While it is evident that these two functions do not necessarily sit easily alongside each other, it is important to avoid describing Coronial suicide inquests as some kind of relatively unsuccessful attempt at achieving a unitary governmental task: that of unfailingly accurate suicide determination. Likewise, it is also important not to construct some kind of simplistic governmental binary between the administrative and the therapeutic, where none necessarily exists.
In his book on education, Hunter (1994: xxii) notes that attempts to ascribe singular function to the modern school -that of developing fully-reasoned individuals -ignores the complex relationship between its bureaucratic components, and its long history of pastoral guidance.
There is no ideal or complete development of the person underlying the school system … the school system is a highly impure, tactically improvised institution, assembled from different spheres of life and serving a mixture of spiritual and worldly ends.
The English Coronial inquest appears to have equally complex relationships between its bureaucratic, its democratic, its scientific and, latterly, its pastoral functions, relationships that have yet to be fully, or even partially, resolved. It would consequently be overly-simplistic to place concerns over Coronial suicide determination within a dichotomous governmental problematic.

Conclusion
This study leads to three central observations. First, given the evidence assembled here, if the English inquest is any measure of the idiosyncratic and locally-organised way in which potential suicides are addressed and adjudicated upon, then comparative suicide statistics (both local and international) are likely to be inherently problematic. Without following the positivist suggestion that there can be an objective truth of suicide statistics, that we can somehow come to know, it is still possible to argue that the 'truths' produced through current statistical and administrative calculation should be subject to more effective reorganisation and refinement. Governance, after all, is a continually failing operation (Rose and Miller 1992), and while it may be impossible to be ontologically 'right', there are thousands of ways of being wrong.
Second, while the English Coroners expressed near unanimous support for the stringent standard of proof required (in spite of the statistical inaccuracies this most certainly produces), and unanimous support for the continued existence of a compulsory inquest for all potential deaths by suicide, there appears to be few advantages in Australia adopting the same protocols and procedures. The only argument that could run counter to this would involve a greater emphasis upon therapeutic models of Coronial practice, which would lean towards emphasising the benefits of suicide inquests in aiding the grieving process of bereaved families. Given the problems outlined above, and given Australia has no historical expectation of an inquest, let alone the high costs involved and the extra workload placed upon that nation's already taxed Coroners, this seems highly unlikely.
Finally, the important question arises: what is the principal role of the inquest in suicide investigations? There seems to be little agreement among the English Coroners interviewed. While most understand and accept their role within the governmental regulation of death, this often seemed secondary to their less tangible pastoral role in helping the families deal with bereavement. Still, it must be stated this is not an invalid or inappropriate role for Coroners to have adopted; such management of community emotional wellbeing constitutes an important function of governance, and Coroners are as well placed as any to participate in the process. However, the disagreement and relative confusion over their responsibilities may eventually need formal clarification, especially since, as it stands, a focus on the therapeutic components of the position appears to be impacting on the ability of some Coroners to fulfill their administrative responsibility to the full. Given the importance of suicide statistics, this may require significant clarification.