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Location and Methods of Suicide in New Zealand

TE POU The NATIONAL CENTRE of MENTAL HEALTH RESEARCH, INFORMATION and WORKFORCE DEVELOPMENT

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Locat ions and Methods of Su ic ide in New Zea land

Mr Barry Taylor

Associate Professor Sunny Collings

Social Psychiatry & Population Mental Health Research Unit

University of Otago Wellington

Published in September 2010 by Te Pou o Te Whakaaro Nui

The National Centre of Mental Health Research, Information and Workforce Development.

PO Box 108-244, Symonds Street, Auckland, New Zealand.

Web www.tepou.co.nz

Email [email protected]

ISBN 978-1-877-537-67-7

http://www.tepou.co.nz/

mailto:[email protected]

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Acknowledgements We thank the following people for their assistance:

Dr James Stanley Bio-Statistician, University of Otago, Wellington

Mr Chris Kemp Assistant Research Fellow, Social Psychiatry & Population Mental

Health Research Unit, University of Otago, Wellington

Mr Chris Lewis Information Directorate, Ministry of Health, Wellington

Mr Clifford Slade Coronial Services Unit, Ministry of Justice, Wellington

Ms Karen Vaughan National Manager, Coronial Services Unit, Ministry of Justice,

Wellington

Peer review

This report was peer reviewed by:

Dr Shyamala Nada-Raja Senior Research Fellow, Injury Prevention Research Unit,

University of Otago, Dunedin

We also acknowledge reviewers at the Ministry of Health who provided useful comments.


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Executive Summary Suicide prevention activity in New Zealand is guided by the framework set out in the New Zealand

Suicide Prevention Strategy 2006-2016 and the New Zealand Suicide Prevention Action Plan 2008-2012.

Goal 4 of the Strategy – Reduce access to the means of suicide – supports the development of policies,

strategies and regulations to reduce access to, and the lethality of, the means of suicide. This analysis was

commissioned to provide sound evidence to ensure the activities of this Goal are appropriately targeted.

The study aims were to:

1) identify changes in patterns of locations using data from 1997-1998 and 2005-2006;

2) report on emerging methods that may have been noted anecdotally but which are not

discernable in the current ICD reporting system;

3) contribute to prevention policy and programme development in respect of restriction of

access to locations and means.

Using simple descriptive methods we applied these aims to two datasets, the Ministry of Health Mortality

Data Collection 1997-1998 and 2005-2006, and the Coroners’ Files 2005-2006. The analyses looked for

any differences by gender, age and ethnicity.

Most suicides are a private and opportunistic event occurring most commonly in the deceased’s home.

The four most common methods i.e. hanging, carbon monoxide (CO) poisoning, firearms and overdosing

which accounted for 88% of all deaths were usually used at the deceased’s home. Public sites accounted

for only 22% of the suicides we reviewed.

There were no strongly emergent specific locations, location types or methods of death arising across the

observation periods. There are a small number of ‘iconic’ public sites for suicide in New Zealand but

none have newly emerged. For two of these sites it appears that it is the location rather than an associated

method that is important in the ‘iconic’ status.

Men and women across all age groups and ethnicities made similar choices of location, with their own

home being the most common. The only identified differences in location choice was that none of the

women died at their place of work. In the home men are more likely to die in a shed or garage whereas

women often choose their bedroom.

Suicides in institutions were a very small proportion of the locations. For men who die by suicide in

institutions this is more likely to be in a prison, whereas for women it was hospitals. Among men dying

in prison, Māori and European men were in equal proportion.

The proximity of the location to the opportunity to access the method, combined with impulsivity, seem to

be the key factors influencing the choice of both the location and method.

There were similar patterns in the methods of suicide across gender, age and ethnicity with hanging being

the most common method although there was a difference in the proportions using hanging, with hanging

being a much more common method for Māori and Pacific Island people than for European people. The

proportions of men and women using hanging and CO poisoning were not statistically different, however

firearms were more commonly used by men, and overdose by ingestion by women. Choice of method

appears to be influenced by what is readily accessible, with common household items often used.

In the less impulsive and more planned suicides, especially among older people, the desired method

appears to be the more defining factor in the choice of location.

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The recording of alcohol use around the time of death or presence in the body was highly variable in both

the Coroner Summary Sheets and the pathology reports. It was not reliable enough to draw more than a

strong but impressionistic inference about possible links between alcohol intoxication and some suicide

deaths.

.

Despite the data in this report being the most recent available at the time of the study, it was already out of

date at that time. There needs to be continued effort to bring the delivery of Coronial verdicts up to date to

enable more timely monitoring of potential emerging trends.

We recommend that Coroners’ summary sheets are reviewed and updated and education be undertaken

with the Police to ensure full accounts of all salient details are recorded on the Coroner’s summary sheets.

We also recommend that where any death may be due to suicide, that full alcohol and drug screening is

performed and the results recorded as part of the Coronial verdict.

Considerable effort has been made in New Zealand to reduce suicide in institutions, which in these data

contributed only 4% of all suicides. It is important that this is supported by regular staff training in suicide

prevention, risk assessment, monitoring and management. This is especially important given that most

institutional suicides are by hanging.

Suicide among older people in aged care facilities may become more common due to the changing age

structure of the population. We recommend that, where it is not already happening, staffs in aged care

facilities are trained to identify and, where appropriate, manage and monitor depression and suicide risk.

Vehicle exhaust gas is the second most common method of suicide in this analysis, attributed to 18% of

deaths in 2005-6. This method is more amenable than hanging to means restriction initiatives, therefore

we recommend that consideration of initiatives to modernise the vehicle fleet such as the installation

safety devices is prioritised. The use of other methods of carbon monoxide poisoning should be closely

monitored.

Firearms contributed only 10% of suicide deaths. Where reported, over half the firearms used were not

owned by the deceased, and it was common for the deceased to have borrowed the firearm. In several

cases, the firearm owner had felt uncomfortable about the request. Future campaigns about firearm safety,

and information given out to those gaining a firearms licence could address this by including material to

support firearm owners being cautious about their loan.

Self-poisoning was predominantly by prescription or over-the-counter medications, most commonly taken

in combinations. Paracetamol did not feature strongly and was not cited as the sole or predominant cause

of death by any Coroner. Prescribed psychotropic medications were commonly used, with antidepressants

in particular having being more commonly prescribed by GPs. How much monitoring GPs were able to

provide was not well recorded. This could benefit from further investigation, especially as it may also be

relevant to reduction of deaths by more common means. This, alongside an increased use, where

appropriate, of ‘close control’ prescriptions in primary care, may help reduce the number of people dying

by overdose of prescription medications.

Only one location could be identified as a jump site. Since the time of this study safety measures have

reduced the likelihood of deaths occurring at this site. As favoured jump sites might arise at any time, we

suggest the development of simple guidance to support agencies such as local authorities to undertake site

audits and manage such ‘hot spots’ when they emerge.

It would be challenging to identify emergent trends in suicide methods and locations in a timely way in

New Zealand at present due to the delays in relevant data gathering. The Ministry of Health has

completed a feasibility study looking at the possibility of establishing a suicide mortality review

committee. Consideration should be given to how this could overlap with the functions of existing

mortality review groups.


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The combination of existing mortality review groups, including the Child and Youth Mortality Review

Committee, does not cover suicide over the lifespan. As most suicides occur in people over the age of 25,

and (in 2007) rates were highest among those 30-39 years of age, we recommend the early development

of an approach to all-ages suicide review and monitoring.

Developing guidance for family/whānau of those at risk is challenging as vigilance is only possible after a

person has been identified as being at high risk. Nevertheless, our impression is that a significant number

of those who died, especially men, had experienced recent significant losses or life stressors, with the

most common theme being relationship breakups, domestic violence and financial failure. High levels of

emotional distress and impulsivity coupled with alcohol use appeared to be relevant in many of these. In

retrospect, early intervention to provide social support may have had the potential to avert some of these

deaths. Because most people in these situations do not die by suicide, formulating advice for

family/whānau is a challenge, and is likely to remain at the level of general community advice to actively

support one another in times of distress, and to avoid alcohol as a strategy for coping with distressing

feelings. Family/whānau should be advised to take any mention of suicide or self-harm/suicide attempt

seriously and seek appropriate help for the person. Where suicide risk is felt to be present (rather than

general emotional distress), family/whānau can be advised to take more specific measures such as

considering the safe storage of car keys, not keeping the car filled with petrol, removing ropes and/or

keeping garages and sheds locked, and securely storing LPG bottles.

From a clinical perspective it is important to attempt to delay engagement in suicidal behaviours,

especially in times of emotional turmoil. Depending on the risk profile this may involve supervision

and/or working with the person to develop alternative strategies to cope with crises, emotional turmoil and

distressing thoughts.

More consideration needs to be given to the most common method of suicide in New Zealand, hanging.

Hanging in private dwellings is a major challenge of increasing importance for suicide prevention given

that the proportion of deaths by hanging has increased.

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Contents

Acknowledgements ............................................................................... iii

Peer review ........................................................................................ iii

Executive Summary ............................................................................... iv

Contents ........................................................................................... vii

Background .......................................................................................... 9

1.1 New Zealand Suicide Prevention Strategy and Action Plan ........................................... 9

1.2 Evidence Base for Restricting Access to Locations and Methods ....................................... 9

1.3 Aims ........................................................................................................... 10

Method ............................................................................................. 11

2.1 Study Description ........................................................................................... 11

2.2 Ethics Approval & Data Agreements .................................................................... 11

2.3 Data ........................................................................................................... 11

2.4 Analysis......................................................................................................... 16

Results ............................................................................................. 18

3.1 Locations of Suicide ........................................................................................ 18

3.2 Methods of Suicide ......................................................................................... 22

3.3 Comparison between 1997-1998 & 2005-2006 ......................................................... 31

3.4 Emergent Patterns in Methods ............................................................................. 31

3.5 Witnesses and Discoverers of Suicide ................................................................... 32

3.6 The Role of Alcohol in Suicide ............................................................................ 32

Discussion ......................................................................................... 34

4.1 Summary of Main Findings ................................................................................ 34

4.2 Strengths ..................................................................................................... 34

4.3 Weaknesses .................................................................................................. 34

4.4 Implications for policy and practice .................................................................... 35

Appendix a: Social Psychiatry & Population Mental Health Research Unit .............. 41

Appendix b: Coroner Files Category Coding .................................................. 42

Appendix c: ICD Codes Mapping ................................................................ 44

References ........................................................................................ 45


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List of figures

Figure 1: Summary of data matching of Files between Coroners’ Files and Mortality Data collection ..................... 15 Figure 2: Potential points of intervention ..................................................................................................................... 39

List of tables

Table 1: Frequency of suicides by location (2005-2006) ............................................................................................. 18 Table 2: Frequency of Location by Gender, Ethnicity, Age, and Method 2005-2006# ................................................ 19 Table 3: Location by Gender, Age, and Ethnicity Aggregated (2005-2006) # ............................................................. 20 Table 4: Frequency of suicides by locations in deceased’s own place of residence (2005-2006) # .............................. 21 Table 5: Frequency of methods in own place of residence (2005-2006) * .................................................................. 21 Table 6: Summary of distribution of methods by sex (2005-2006) ............................................................................. 23 Table 7: Frequency of Method by Age and Gender ( 2005-2006)# .............................................................................. 24 Table 8: Distribution of method by age band - aggregated, (2005-2006) .................................................................... 25 Table 9: Frequency of method by ethnicity (2005-2006) ............................................................................................. 26 Table 10: Comparison of frequency of Method across ethnicity groupings - aggregated (2005-2006) ...................... 27 Table 11: Frequency of method by instrument (2005-2006) ........................................................................................ 30 Table 12: Comparison between NZHIS 1997-1998 and 2005/2006 data..................................................................... 31 Table 13: Frequency of Witnesses of the death by location (2005-2006) # .................................................................. 32 Table 14: Frequency of Discoverers of the death by location (2005-2006) # ............................................................... 33

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Background 1.1 New Zealand Suicide Prevent ion Strategy and Act ion P lan

The New Zealand Suicide Prevention Strategy 2006-2016,1 (Suicide Prevention Strategy) and its

accompanying Action Plan - New Zealand Suicide Prevention Action Plan 2008-2012,2 (Suicide

Prevention Action Plan) provides the overarching framework and work plan for suicide prevention in this

country. The development of a New Zealand evidence base for the Action Plan was the rationale for the

establishment of the Suicide Prevention Research Fund. Goal 4 of the Strategy - Reduce Access to the

Means of Suicide – supports the development of policies, strategies and regulations to reduce access to,

and the lethality of, the means of suicide. To support this goal there was a need for an analysis of suicide

locations and methods in New Zealand to ensure that means reduction activities are appropriately

prioritised and targeted. Te Pou o Te Whakaaro Nui (The National Centre of Mental Health Research,

Information and Workforce Development), which manages the Suicide Prevention Research Fund on

behalf of the Ministry of Health, developed a research brief for an analysis of the Mortality Data

Collection and the Coroners’ Files for 2005-2006. In this report we describe the methods and results of

this analysis and draw conclusions from these findings. The brief for this project did not include a

literature review. A comprehensive literature review on the evidence supporting restricting access to the

means of suicide in New Zealand was published in 2000.3

1.2 Ev idence Base for Restr i ct ing Access to Locat ions and Methods

The rationale for including the reduction of access to the means of suicide in the Suicide Prevention

Strategy is based on sound evidence. Restricting access to possible locations and means of suicide has

long been recognised as an effective strategy to reduce suicide rates. Strong international and local

research evidence (Beautrais 2000,4 Cantor et al 1996,5 Hawton6) has demonstrated that, under some

circumstances, controlling the means by which people die by suicide may reduce the risks associated with

suicidal behaviours ranging from suicide attempt to death by suicide. Interventions that have been shown

to be effective include:

‘suicide proofing’ buildings, institutions or public spaces where jumping or hanging has occurred

legislating to restrict access to firearms

restricting public access to common medications such as paracetamol, and

installing catalytic converters to prevent carbon monoxide (CO) poisoning by vehicle exhaust gas.

The most common methods of suicide and suicide attempts in New Zealand in the period 2005-2006 were

hanging, CO poisoning, jumping and firearms.7 The category of Other Methods accounted for about 8%

of all suicides. These findings are similar to the analysis of methods of suicide in a previous study 1977-

1996 by Beautrais8, suggesting that there has not been a major change in the commonest methods over the

past 30 years. These most common methods are listed as specific target areas in the Suicide Prevention

Action Plan.

1 Associate Minister of Health, 2006 The New Zealand Suicide Prevention Strategy 2006-2016, Wellington, Ministry of Health 2 Ministry of Health, 2008 New Zealand Suicide Prevention Action Plan 2008-2012 The Summary for Action, Wellington, Ministry of Health 3 Beautrais AL. 2000 Restricting Access to Means on Suicide in New Zealand: A Report Prepared for the Ministry of Health on methods of suicide in

New Zealand 1977-1996. Wellington: Ministry of Health 4 Beautrais AL. 2000 5 Cantor C et al. Access to Means of Suicide by Young Australians: A background report. Carina, Queensland: Australian Institute for Suicide

Research and Prevention 1996 6 Hawton K. Restriction of Access to Methods of Suicide as a Means of Suicide Prevention. In: Prevention and Treatment of Suicidal Behaviour –

from Science to Practice. Ed. Hawton, K. Oxford University Press 2005 pp 277-291 7 Suicide Facts 2005-2006 data. Ministry of Health, Wellington, 2007 8 Beautrais AL. 2000


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The associated actions include:

review institutional policies and procedures in relation to hanging

surveillance of jump sites, and

scope need for guidance on management of jump sites.

The means by which people die by suicide and the locations in which they choose to end their lives vary

according to an interplay of access to means and sites, individual psychological factors, and cultural and

social influences. Due to the dynamic nature of these factors, the patterns of means and location are not

distributed evenly among social groups, and are not static over time. This means that policies and

programmes to reduce access to means and manage preferred sites must be responsive to emerging

patterns. In order to develop and refine targeted intervention strategies general monitoring is needed, with

detailed examination required from time to time as concerns about potential emergent methods and

locations arise.

1.3 A ims

The purposes of this study were to:

identify any change in patterns in the locations of suicides and favoured suicide sites, e.g. jump

sites, using 1997-1998 and 2005-2006 data

report on emerging methods of suicide and determine the frequency of less common methods

that have been anecdotally reported but which are not currently picked up by the International

Classifications of Disease (ICD) codes, e.g. suffocation by plastic bag, and

contribute to intelligence to facilitate the development of policy and programme strategies to

reduce access to the locations and means of suicide, where possible.

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Method

2.1 Study Descript ion

This is primarily a quantitative descriptive study. Where appropriate narrative accounts were reviewed to

enrich and provide a context for consideration of the quantitative findings.

2.2 Ethics Approva l & Data Agreements

Ethics approval was granted by the Upper South B Regional Ethics Committee under delegation from the

Multi-Region Ethics Committee. Research agreements for data access were signed with both the Office

of the Chief Coroner and the Ministry of Health.

2.3 Data

Data sources

We used two datasets:

Ministry of Health Mortality Data Collection for the years 1997-1998 and 2005-2006, and

Coroners’ Files 2005-2006.

It had been intended to access the Child Youth Mortality Review Committee (CYMRC) database for

deaths under the age of 25. Initial discussions had indicated that this was possible. However, due to a

delay in developing guidelines for the use of the dataset by external researchers, the CYMRC was unable

to grant access to the data in time for this study.

Mortality Data Collection

The Mortality Data was supplied by the Health Information Directorate (formerly New Zealand Health

Information Service) on an Excel spreadsheet. Data on all suicides for 1997, 1998, 2005 and 2006 were

supplied. Originally it had been proposed to use 2003 and 2004 data as at the time of tender for the study

it was the most complete dataset. However by the time the data was to be accessed, the 2005 and 2006

data was available and the use of the most recent data was seen as preferable.

Coronial Files

For 2005-2006, data from the Coroners’ Files augmented that from the Mortality Data Collection. The

Coroners’ Files were read on site in a small private meeting room at the National Coronial Services Unit

at the Ministry of Justice in Wellington. Coronial staff supplied an Excel spreadsheet listing all deaths by

suicide for the years 2005 and 2006. Coroners’ Files for 1997-1998 were unavailable as they had been

archived and would have had to be ordered at considerable additional expense and time delay. Of the

1009 files listed, 1006 files were available for reading with the remaining three files being unavailable due

to being in use by Coronial staff (n=2) or being unable to be located (n=1). BT was responsible for

retrieving the files from the Coronial records room, taking them to the meeting room to be read and re-

filing in the central records. Each file was read and data coded directly onto our Access database using

the project’s notebook computer.

This process took longer than anticipated. Eighty hours (10 days) had been allocated with the task

requiring 124 hours (15.5 days). This was mainly due to inconsistencies in the presentation of the

documentation across the files and missing forms.

The Child and Youth Mortality Review Committee is a ministerial committee appointed under section 18 of the New Zealand

Public Health and Disability Act 2000 and is established by and accountable to the Minister of Health. Disclosure of information by the Committee is regulated by the Act.


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Most information could be found on the summary sheet completed by the Police Coronial Inquest Officer

for the Coroner. However in some regions this form was not provided or was only partially completed.

This meant that more time was required to gather the required information from the files.

Toxicology reports and other information such as history of recent health service use, history of self-harm,

documentation of a suicide note and living arrangements at the time of death were of varying detail where

present. Where details were not present it was not possible to interpret the absence of information, for

example, no mention of a suicide note may have meant one was present but not mentioned, or that none

was found.

After matching the two datasets (see Data Matching below), there was a further visit to the Coronial

Services Unit to examine an additional thirty files identified from the Mortality Data Collection. 1036

Coroners’ Files were included in the final analysis.

Data Storage and Security

Data from the relevant fields of each database was imported into a Microsoft Access database. Microsoft

Access was used as it can manage both quantitative and narrative data, and data can readily be exported to

other applications such as Excel or SAS for specific analyses. The electronic files were password

protected and printed copies were stored in a locked filing cabinet.

Data Coding


All deaths from the Mortality Data Collection were coded according to the ICD Codes (WHO) 1977. In

2000, the Information Directorate of the Ministry of Health changed from using the ICD-9 to the ICD-10

version of the classification. For the purposes of comparison between the 1997-1998 deaths and the 2005-

2006 deaths the ICD-9 codes, E950-E959 (suicide and self-inflicted injury) were mapped against the ICD-

10 codes X600-X849 using the table developed by the Ministry of Health (Appendix D).

Coroners’ Files

For ease of counting and analyses, the narrative information on the Coroners’ Files was coded under 6

domains (Refer Appendix C for the coding system):

1. Location of death

2. Method of death

3. Use of instrument

4. What the instrument was attached to

5. Witnessing of death

6. Discoverer of death

Location of Death

Locations were divided into 6 categories:

a. Own place of residence: the place where the deceased person was living when the death

occurred,

b. Acquaintances: death occurred at the residence of a person known to the deceased – e.g.

family member, ex-partner, friend,

c. Workplace: the workplace of the deceased person including building sites where the

deceased had been working,

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d. Public site: parks, beaches, rivers, bush land, roads, picnic rest stops, stranger’s private

property, public buildings, shopping malls, car park buildings, railway stations/lines,

bridges, apartment buildings that the deceased did not live at or know anyone living there,

e. Hotel/motel: where death occurred in the privacy of the hotel or motel room or the

deceased jumped from the hotel room they were staying in and was discovered by a staff

member, and

f. Institution: Hospitals, in-patient mental health units, rest homes, prisons, police stations.

The place of residence and acquaintances’ residence were further divided into specific areas in the house.

For all public sites, the name of the location was recorded as free text, to allow for identification of any

patterns of favoured suicide sites.

Method

The purpose of examining the Coroners’ Files was to establish the frequency and pattern of less common

methods that the ICD codes do not specifically capture. Therefore a modified coding system was devised.

The methods were divided into 13 groups: hanging, CO poisoning, firearms, overdose, jumping,

stabbing/cutting, suffocation, drowning, train, self-immolation, vehicle, poisoning and electrocution.

This coding, while closely aligned to the ICD codes, splits some ICD categories into more specific

method groups. It separates hanging from suffocation and the poisoning categories are separated into two

groups - overdose and poisoning. Overdose refers to the use of pharmaceutical products whereas

poisoning refers to other ingested poisons including chemicals.

Use of Instrument

This category provided more detailed information about the method with attention on the frequency of

particular instruments used with different methods, e.g. vacuum cleaner pipe for CO poisoning from car

exhaust, rope for hanging, and plastic bag for suffocation. It also included details on how a moving object

was used or the way the person engaged with a moving object, e.g. drove car into bridge, lay in front of

train, jumped in front of car, jumped from bridge.

Instrument Attached

This provided details on the object to which the instrument was attached. This mainly pertained to

hangings where there were a variety of objects that the person hung from, e.g. exposed rafters, trees, door

frames, wardrobe clothes rails. It also covered what parts of the body were aimed at in relation to

firearms and or cutting, e.g. shotgun to mouth, knife to wrist.

Death witnessed

This category was divided into three groups and identified whether the death was witnessed by others,

whether people were present at the location but did not witness the death, or whether the person was alone

at the time of the death.

Discoverer

This identified who discovered the suicide. The location of a suicide often determines the type of people

likely to discover the body or witness the death, whether it is a family member or a member of the public

‘passing by’.


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Data matching

To ensure accurate alignment of the quantitative and qualitative data, our two databases (from the

Mortality Data Collection and from the Coroners’ Files) were merged and a data matching exercise

undertaken. As commonly occurs when information from multiple databases is being combined, some

data was missing from one but present in the other. Where there was a difference, the data sourced from

the Mortality Data Collection was used as the reference, as this information originates from the Birth

Deaths and Marriage records.

After importing the two databases into a second Access database an automated matching by name and

date of birth was created using an Access programme tool. Initially the matching had been done using the

Coroner File ID number but this approach was very incomplete with only 629 files (629/1037 = 61%)

being matched. Using the name and date of birth resulted in 847 deaths (82%) being matched.

A further 103 files were matched manually. The most common causes for the non-match were differences

in the spelling of names, use of aliases, different order of forenames and minor differences in birth dates.

These two processes matched 950 Coroners’ Files to the 1037 Mortality Data files. Unmatched files were

referred back to the respective dataset custodians for possible explanations. There were names that were

in the Mortality Data Collection and not in the Coroners’ Files (49 names) and vice-versa (19 names).

One reason for this non-match was the different criteria used by the Mortality Data Collection and the

Coroner’s database to determine in which year a death is counted. For the Mortality Data Collection the

year of inclusion is based on the date of registration of the death and for the Coroner’s Court the death is

counted in year the death occurred. Therefore for 2005, the Mortality Data Collection included deaths

that occurred in previous years but were not registered until 2005 (3 deaths) and the 2006 data did not

include deaths that occurred in 2006 but were not registered until 2007 (6 deaths). In eight cases there

was a difference between the two databases in the recording of the verdict with the Mortality Data

Collection having non-suicide causes of death with one death having an explicit note stating that the

Coroner's Finding did not make a statement on intent. Information Directorate staff stated that unless the

Coroner specifically indicates a death as intentional self-harm, that death cannot be recorded as a suicide,

so this file was excluded from the analysis.

A final matching was undertaken and there was a 94% match (972/1037 files) between the datasets for the

two sources.

After the matching there was a manual checking between the ICD code in the Mortality Data Collection

and the Method code allocated in the Coroners’ Files to ensure consistency of coding between the data

from the two sources in relation to methods. There was a 98% (954/972 files) alignment between the two

databases. Where there was a discrepancy, the Coroner’s file was taken as the more accurate code based

on the more detailed information provided in these files.

Missing Files

Of the 49 files not matched from the Coroners’ Database, 29 files were unable to be viewed as they had

not yet been sent to Wellington for storage by the district offices (8 files) or could not be found on the

Coroner’s database (21 files). The balance of 20 were located following searching the Coroner’s filing

room and were matched manually.

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Figure 1: Summary of data matching of Files between Coroners’ Files and Mortality Data collection

Matched back to

Initial Matching: Matched 847

Non – matched 190

Manual Matching: + 103 files Matched 950

Non – matched 87

Final Matching: + 22 files Matched 972

Non-matched* 65

* Breakdown of non-matched files:

Excluded from Mortality Data Collection 26

Unable to be located from Coroners’ Files 29

Found in Coroners’ Files but not matched 10

Total unmatched files 65

Coroners’ Files

N=1036


N=1037


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2 .4 Ana lys i s

Approach to use of statistical testing

In an analysis such as this that is exploratory and not strongly hypothesis driven, it is possible to conduct

multiple statistical tests. However, this increases the likelihood of finding chance associations. Our

testing was restricted to associations supported by broader evidence of social inequalities in suicide rates

and patterns. This is consistent with the overall aim of the Suicide Prevention Action Plan to reduce

social inequalities as well as reduce overall rates. We have not adjusted for multiple comparisons, as it

has been argued that routine adjustment introduces more problems to the interpretation of findings than it

solves. For instance, its use increases the Type II error rate, exactly which tests to include are not clear,

and its use does not assist in the assessment of evidence to be found in the data, providing a ‘correct

answer to an irrelevant question.’9 We have reported exact p values to enable readers to make

adjustments as they see fit, and we have reported all non-significant results.

Location of suicide

The Mortality Data Collection was limited in the information it could provide on the locations of suicide.

The Coroner Files provided more in-depth detail on locations regarding both the actual physical location

and the specifics of the location such as the room within the house or the type of park. The analysis of

location was restricted to the 2005-2006 deaths and no comparison was made with the 1997-1998 data in

the Mortality Data Collection as these Coroner Files were not retrieved. Due to the numbers in certain

types of locations being low and for the purpose of statistical analysis, the locations were aggregated up to

6 main categories. The full list of locations is listed in Appendix C.

For the 972 deaths in the matched dataset for 2005-2006, we carried out the following descriptive

analyses:

1. Summary frequencies of all deaths by location for the two years combined. Initially the

deaths were broken down to each year to see if there were any significant differences but as

there was no difference (2005: 492 deaths / 2006: 480 deaths) and due to the low numbers for

most locations and methods it was decided to report only on the two years combined.

2. With data from both years combined, frequencies of death by each location as coded above,

distributed by 10 year age bands, sex and ethnicity (European, Māori, Pacific Island, Asian

and Other). The Chi square test was used to determine any differences in the distributions by

sex, age and ethnicity. For statistical testing, age was aggregated to 20 year age bands and

ethnicity was aggregated to three categories (European, Māori and Other).

3. When the location of death was a public site, it was matched to the home address to ascertain

if local sites were used or if people had travelled to publicly known places for suicide, e.g.

jump sites. Specific locations that appeared on more than two occasions were also identified

to ascertain if there were any apparent emerging multiple use of specific locations or types of

locations. Narrative summaries of this information were constructed, with an opinion (based

on judgement) as to whether the location appears to be becoming more frequently used, and

whether it should be subject to more specific ongoing monitoring.

9 Pernerger T. What’s wrong with Bonferroni adjustments? British Medical Journal 1998; 316 (7139): 1236-1238

17

Method of suicide

Frequency of Methods

For the 972 deaths in the matched dataset for 2005-2006, we undertook the following descriptive

analyses. The rationale for these was the same as for the analyses of locations:

1. Summary frequencies of all deaths by method of death for the two years combined.

2. With data from both years combined, frequencies of death by each method as coded

above, distributed by 10 year age bands, sex and ethnicity (European, Māori, Pacific

Island, Asian and Other). Differences in the distributions by sex, age and ethnicity were

determined as previously described for locations. Age was aggregated to 20 year age

bands and ethnicity was aggregated to three categories (European, Māori and Other).

Comparison with 1997-1998 Data

In order to understand whether methods have changed over time, the method frequencies were compared

with the equivalent data from the Mortality Data Collection for 1997-1998. These years were selected as

they immediately follow the change in ethnicity classification in New Zealand, and comparisons with data

prior to this would be difficult to interpret. As already mentioned, due to time and funding constraints, the

comparison between the two periods was restricted to the Mortality Data Collection.

As the purpose of the comparison was to get a snapshot of any possible changes in the distribution of

methods based on the ICD codes, we included all deaths in the Mortality Data Collection: 1997-1998

(1141 files), 2005-2006 (1037 files). This was a discrete analysis and therefore differs from the main

matched dataset, the main difference being the separation of some of the methods as grouped in the ICD

codes.

Emergent Methods

Potentially emerging methods were investigated by inspecting the Coroners’ Files which proved to be

more useful than the ‘Other Methods’ and associated ‘Clinical Notes’ fields in the Mortality Data

Collection. The focus of the investigation was on uncommon methods that have been anecdotally

reported such as suffocation by plastic bag and charcoal burning, as well as emergent methods that have

not received publicity, and may not be picked up in the ICD codes.

Frequencies for age, sex and ethnicity groupings are reported however the numbers are too small to

conduct meaningful statistical tests for differences between groups. Narrative summaries of the

information are provided, with a recommendation (based on judgement) as to whether the method appears

to be becoming more frequently used, and whether it should be subject to more specific ongoing

monitoring.


18

Results 3.1 Locat ions of Suic ide

Most of those who die by suicide do so in a location they are familiar with, at or close to their home.

Table 1 shows that most deaths (69%) occurred in the deceased’s place of residence. When combined

with an acquaintance’s property or their workplace, 75% of deaths occurred in a familiar place.

Acquaintance’s properties belonged to a family member (n=19), ex-partner (n=11) or friend (n=7).

Public sites including hotels or motels accounted for approximately 22% of all locations. While public

sites were the second most common location, it was still a private event with the majority of deaths (66%)

occurring in isolated locations such as forestry roads, riverbanks and beaches, parks and picnic stops,

sides of road, industrial sites, and rural private property.

Fewer than 3% of deaths occurred in health (n=14) or corrections (n=11) institutions with just over half of

institutional deaths (56%) occurring in health facilities. Deaths in health facilities were only counted for

that location if the death occurred at the location. Where a person died in hospital subsequent to an

attempt at another location, then the death was coded at the location where the attempt occurred.

Table 1: Frequency of suicides by location (2005-2006)

Location N %

Own place of Residence 667 68.6

Public 210 21.6

Acquaintances 41 4.2

Institutions 25 2.6

Workplace 21 2.2

Hotel/Motel 8 0.8

Total 972 100

Sex

Table 2 shows that for locations there were similar patterns for males and females with their own place of

residence and public sites being the two most common locations. For males using an acquaintance’s

property, 45% were properties of family members and 30% were ex-partners. For females, friends’ and

family members’ properties combined accounted for 37.5% each and 25% for ex-partners.

While a small number of males used their workplace (3%) as a location for suicide this was not a choice

made by any females (n=0). Although numbers were too small to test for statistically demonstrable

differences, a slightly greater percentage of females (4%) died in institutions than males (2%) as was the

case in hotels with females (1.5%) and males (0.7%).

When institutions were separated out into prisons and health facilities, females mainly died in health

facilities (90%) compared to males who mainly died in prisons (66%). For males dying in institutions

there was an approximately even split between European (53%) and Māori (47%) with a similar pattern

for females: European (60%), Māori (40%). In prisons it was an even 50/50 split between European and

Māori males.

19

Location and Method

The person’s own place of residence was the location used most for the four most common methods:

hanging, CO poisoning, firearms and overdosing, with public sites being the second most used location

for each of these methods (Table 2). The location is partly influenced by the method. Methods such as

driving a vehicle into or off an object, trains and drowning by their nature all occurred in public sites as

did almost all jumpings (Table 2). However none of these methods are common and they account

cumulatively for only 6.4% of all deaths (Table 6).

Table 2: Frequency of Location by Gender, Ethnicity, Age, and Method 2005-2006#

# Shows the proportions by row

*All row totals equal 100%

Residence

(%)

Public

(%)

Acquaintance

(%)

Institution

(%)

Workplace

(%)

Hotel/

Motel

(%)

Row

total*

Gender Male 485 (67) 161 (22) 33 (5) 15 (2) 21 (3.3) 5 (0.7) 720

Female 182 (72) 49 (19) 8 (3.5) 10 (4) 0 3 (1.5) 252

Age(years) 0-14 5 (83) 1 (17) 0 0 0 0 6

15-24 160 (72) 46 (21) 8 (3) 7 (3) 2 (1) 0 223

25-34 126 (65) 45 (23) 9 (4.5) 7 (3.5) 7 (3.5) 1(0.5) 195

35-44 117 (60) 51 (26) 11 (6) 5 (2.5) 7 (3.5) 4 (2) 195

45-54 107 (71) 27 (18) 8 (5.5) 2 (1.5) 4 (2.5) 2 (1.5) 150

55-64 83 (78) 20 (18) 3 (3) 0 1 (1) 0 107

65-74 35 (68) 12 (24) 2 (4) 1 (2) 0 1 (2) 51

75-84 21 (78) 5 (18) 0 1 (4) 0 0 27

85+ 13 (72) 3 (17) 0 2 (11) 0 0 18

Ethnicity European 486 (69) 157 (22) 25 (4) 14 (2) 16 (2.1) 7 (0.9) 705

Māori 137 (69) 34 (17) 14 (7) 11 (6) 2 (1) 0 198

Pacific Is 32 (76) 7 (17) 1 (2) 0 2 (5) 0 42

Asian 12 (48) 10 (40) 1 (4) 0 1 (4) 1 (4) 25

Other 0 2 (100) 0 0 0 0 2

Method Hanging 382 (77) 58 (12) 19 (3.6) 20 (4) 16 (3) 2 (0.4) 497

CO Poisoning 126 (67) 53 (29) 2 (1) 2 (1) 4 (2) 0 187

Firearms 63 (67) 15 (16) 14 (15) 0 1 (1) 1 (1) 94

Overdose 57 (75) 12 (16) 4 (5) 1 (1) 0 2 (3) 76

Jumping 2 (7) 24 (89) 0 0 0 1 (4) 27

Stabbing/

Cutting

10 (50) 6 (30) 2 (5) 2 (8) 0 0 20

Suffocation 18 (90) 0 0 0 0 2 (25) 20

Drowning 0 15 (100) 0 0 0 0 15

Train 0 13 (100) 0 0 0 0 13

Self-

immolation

3 (37) 5 (63) 0 0 0 0 8

Vehicle 0 7 (100) 0 0 0 0 7

Poisoning 5 (71) 2 (29) 0 0 0 0 7

Electrocution 1 (100) 0 0 0 0 0 1

Total N (%) 667 (69) 210 (22) 41 (4) 25 (2.2) 21 (2) 8 (0.8) 972


20

Age

For all age groupings, the deceased’s own place of residence (Table 3) was the most common place in

which the suicide occurred with this location accounting for approximately 70% of suicides in each age

group. The lowest percentage was in the 25-44 year age band (62%) which had a higher proportion in the

second most common location – public sites. This difference in proportion for own place of residence

was significant (p=0.006) but there was no significance in the difference in proportions for public sites.

For older people, suicide in institutions was entirely due to those dying by suicide in aged care facilities,

which if it had been coded as an own place of residence would have increased the proportion for place of

residence by a further 4%.

Ethnicity

The deceased’s own place of residence (Table 3) was the most common place of suicide across all ethnic

groupings, accounting for approximately two thirds of deaths in each group. While having the lowest

percentage for death at own place of residence (64%), the combined group of ‘Other’ (Pacific Islander,

Asian, Other) had the highest proportion at public sites (29%). Institutions accounted for 6% of locations

for Māori compared to 2% for European, with no people of Pacific Island, Asian or other ethnicities dying

in institutions. The distribution of deaths in institutions by ethnicity was the only difference by ethnicity

to be statistically significant (p=0.007).

Table 3: Location by Gender, Age, and Ethnicity Aggregated (2005-2006) #

Residence Public Acquaint

ance

Institution Workplace Hotel/Motel Row Total##

Gender Male 485 (67) 161 (22) 33 (5) 15 (2) 21 (3.3) 5 (0.7) 720

N (%) Female 182 (72) 49 (19) 8 (3.5) 10 (4) 0 3 (1.5) 252

Value 2.049 0.9376 0.9169 2.647 7.512 Fisher Exact

p-value 0.15 0.33 0.34 0.10 0.006 0.69

Age in <24 165 (72) 47(21) 8 (3.1) 7 (3) 2 (0.9) 0 229

years (%) 25-44 243 (62) 101 (26) 20 (5) 12 (3) 14 (4) * 390

45-64 190(74) 49 (19) 11 (4) 2 (1) 5 (2) * 257

65+ 69 (72) 21(22) 2 (2) 4 (4) 0 * 96

Chi 12.31 4.862 2.182 4.886 4.867 -

Df 3 3 3 3 3 -

p-value 0.006 0.18 0.53 0.18 0.08 -

Ethnicity

N(%)

European (%) 486 (69) 164 (23) 25 (4) 14 (2) 16 (2) * 705

Māori 137 (69) 34 (17) 14 (7) 11 (6) 2 (1) 0 198

Other 44(64) 20 (29) 2 (3) 0 3 (4) * 69

Chi 0.8172 5.132 5.073 9.822 2.841 -

Df 2 2 2 2 2 -

p-value 0.66 0.07 0.07 0.007 0.24 -

# Shows the percentages by row

## All row totals equal 100%

Combined with public due to low number in cell

21

Places within home

With the deceased’s own place of residence being the main location for suicide, further investigation was

done (Table 4) to determine whether there were any patterns in where the person died within the property.

For both males and females the garage (52%:39%) was the most common place followed by the bedroom

(18%:33%).

Table 4: Frequency of suicides by locations in deceased’s own place of residence (2005-2006) #

Locations within home Male (%) Female (%) Total (%)

Garage / Shed 255 (52) 71 (39) 326 (49)

Bedrooms 88 (18) 61 (33) 149 (22)

Yard 85 (18) 23 (13) 108 (16)

Communal 57 (12) 27 (15) 84 (13)

Total (%) 485 (100) 182 (100) 667 (100)

# Shows the percentages by column

The locations within the property appeared to some extent to be determined by the method used (Table 5).

Garages and sheds usually had more hanging points such as exposed rafters compared to other places in

the house and as would be expected were the main site for CO poisoning by car exhaust fumes (82%).

Suffocation (78%) and overdoses (74%) occurred mainly inside the house with often the person found in

their bedroom lying on their bed. In yards hanging from trees (65%) and using a firearm (15%) were the

most common methods followed by CO poisoning by exhaust fumes in a sealed car (14%).

Table 5: Frequency of methods in own place of residence (2005-2006) #

Location within

home

Garage/

Shed (%)

Bedroom (%) Yard (%) Communal/

Other (%)

Total (%)

Hanging 207 (63) 61 (41) 70 (65) 44 (52) 382 (57)

CO Poisoning 103 (31) 5 (3) 15 (14) 3 (4) 126 (19)

Firearms 13 (4.1) 21 (14) 16 (14.7) 13 (15) 63 (9)

Overdose 0 42 (28) 0 15 (18) 57 (8)

Suffocation 0 14 (9) 1 (0.9) 3 (4) 18 (4)

Stabbing/

Cutting

1 (0.3) 2 (1) 3 (2.7) 4 (5) 10 (1.5)

Poisoning 1 (0.3) 3 (3) 0 1 (1) 5 (0.7)

Self-immolation 1 (0.3) 0 1 (0.9) 1 (1) 3 (0.5)

Jumping 0 0 2 (1.8) 0 2 (0.2)

Electrocution 0 1 (1) 0 0 1 (0.1)

Train 0 0 0 0 0

Drowning 0 0 0 0 0

Vehicle 0 0 0 0 0

Total (%) 326 (100) 149 (100) 108 (100) 84 (100) 667 (100)

# Shows the percentages by column


22

Multiple use of location

Using a criterion of five or more deaths, we identified no multiple uses of specific locations. When the

criterion was reduced to three or more deaths, three generic locations were identified but no single case

used a place identical to any other. These generic location types were: Huka Falls in Taupo (n=3),

Waimakariri River near Christchurch (n=3) and Lawyers Head in Dunedin (n=3). Nelson had one site

where there had been 2 deaths in the time period. All four of these locations were known locally as

suicide sites. In the case of two locations, Huka Falls and Waimakariri River, while the same location,

different methods were used. Knowledge of the location as a ‘suicide site’ is probably as significant as the

method that can be accessed by using that location, e.g. a place to jump from.

One of the commonly known ‘iconic’ places for suicide, Grafton Bridge, did not feature among these

locations highlighting the efficacy of interventions such as the erection of bridge barriers.10

In relation to Lawyers Head a local study11 has shown that subsequent to public works in the area that

stopped public traffic access to the site, there had been no deaths at this location. However there was a

death soon after a local newspaper article on the decrease in deaths and a subsequent series of letters to

the editor, including one which offered an alternative about how to access the location. There has been

lobbying of local authorities to permanently keep the road closed.

A high rise apartment block in Auckland was the only property identified for more than one unrelated

death, with two deaths occurring within two months. There was no evidence in the police records that the

deceased were personally known to each other.

The seven incidents where there was a double suicide, i.e. two people taking their lives at the same time at

the same location were not included in the count for multiple uses of specific locations. There was one

further incident when a person used the same method at the same location within 24 hours of the partner’s

suicide but as this was in a private residence it was also not included.

3.2 Methods o f Suic ide

Table 6 shows that of the thirteen categories for methods, four accounted for 88% of all deaths with

hanging being the most common. These four methods; hanging, CO poisoning, firearms and overdose are

those that the public most commonly associate with suicide acts. The remainder of the methods each

accounted for around 1 or 2% with the combined rarer methods of electrocution, poisoning other than

overdose, self-immolation and the crashing of a vehicle accounting for only 2.3% of all deaths.

10 Beautrais, Annette L et al. Removing bridge barriers stimulates suicides: an unfortunate natural experiment. Australian and New Zealand

Journal of Psychiatry 2009; 43 (6): 495 - 497 11 Skegg, Keren and Herbison, Peter. Effect of restricting access to a suicide jumping site. Australian and New Zealand Journal of Psychiatry

2009; 43 (6): 498 - 502

23

Table 6: Summary of distribution of methods by sex (2005-2006)

Method Females % of

deaths

Males % of

deaths

Total % of all

deaths Χ2 Value p-

Value Hanging 120 48 377 52 497 51 1.68 0.19

CO Poisoning 41 17 146 20 187 19 1.93 0.16

Firearms 7 3 87 12 94 10 18.5 <0.005

Overdose 41 16 35 5 76 8 33.71 <0.005

Jumping 11 4 16 2 27 2.7 3.174 0.07

Stabbing/Cutting 3 1 17 2 20 2 Fisher exact 0.4

Suffocation 11 4 9 2 20 2 8.988 0.003

Drowning 8 3 7 1 15 1.5 5.959 0.01

Train 5 2 8 1 13 1.5 Fisher exact 0.46

Self-immolation 2 0.8 6 1 8 0.8 Fisher exact >0.99

Poisoning 2 0.8 5 0.8 7 0.7 Fisher exact >0.99

Vehicle 1 0.4 6 1 7 0.7 Fisher exact 0.84

Electrocution 0 - 1 0.2 1 0.1 Fisher exact >0.99

Total 252 100 720 100 972 100

Sex

When broken down by sex (Table 6), there were similar patterns in the proportions for most methods with

two exceptions: overdose, where a higher proportion of females (16%) used this method compared to

males (5%) and firearms, with males (12%) using this method more than females (3%). This reflects the

long standing pattern in the distribution of these methods by sex.

Combining gender with age (Table 7) revealed that across different age bands, there were important

similarities between men and women. Contrary to popular thinking, hanging was the most common

method for all women under the age of 44, not only the youngest women. It was the only method used by

young women under 15 and 31% of all women who hung themselves were 15-24, the largest women’s

age group to use this method. No women over 75 used hanging.

When ranked in order from most common to least common, the most common methods for older women

(65+) were suffocation (n=7), CO poisoning (n=6) and drowning (n=6) whereas for older men the most

common methods were hanging (n=20), CO poisoning (n=16) and firearms (n=10). This pattern was also

consistent across all age bands for men except for those aged over 85 years.


24

Table 7: Frequency of Method by Age and Gender (2005-2006)# # Shows the proportions by column

Method Age Total (%)

0-14 (%) 15-24 (%) 25-34 (%) 35-44 (%) 45-54 (%) 55-64 (%) 65-74 (%) 75-84 (%) 85+ (%)

F M F M F M F M F M F M F M F M F M

Hanging Total 6 (100) 168 (75) 109 (56) 89 (46) 57 (38) 45 (42) 19 (36) 1 (3) 3 (17) 497 (51)

4 2 37 131 26 83 27 62 10 47 13 32 3 16 1 3

CO Poisoning Total 0 20 (9) 40 (21) 45 (23) 37 (25) 23 (21) 10 (20) 10 (38.5) 2 (11) 187 (19)

3 17 10 30 9 36 9 28 4 19 2 8 3 7 1 1

Firearms Total 0 15 (6) 12 (6) 18 (9) 17 (12) 20 (18) 5 (10) 5 (19.5) 2 (11) 94 (10)

2 13 2 10 18 2 15 20 5 1 4 2

Overdose Total 0 4 (2) 11 (5.5) 22 (11) 25 (18) 6 (6) 5 (10) 1 (3) 2 (11) 76 (8.5)

3 1 5 6 14 8 11 14 2 4 5 1 2

Jumping Total 0 5 (2.5) 9 (4.5) 3 (1.5) 2 (1) 3 (3) 4 (8) 0 1 (5.5) 27 (2.7)

5 3 6 3 1 1 3 3 1 1

Stabbing/

Cutting

Total 0 1 (0.5 4 (2) 6 (3.5) 4 (2) 2 (2) 2 (4) 1 (3) 0 20 (2)

1 4 2 4 1 3 2 2 1

Suffocation Total 0 2 (1) 2 (1) 1 (0.5) 1 (0.5) 3 (3) 2 (4) 4 (15) 5 (28) 20 (2)

1 1 1 1 1 1 2 1 1 1 4 2 3

Drowning Total 0 0 2 (1) 1 (0.5) 3 (1.5) 2 (2) 1 (2) 4 (15) 2 (11) 15 (1.5)

1 1 1 2 1 2 1 4 2

Train Total 0 4 (2) 2 (1) 2 (1) 1 (0.5) 1 (1) 2 (4) 0 1 (5.5) 13 (1)

4 1 1 2 1 1 1 1 1

Self-immolation Total 0 1 (0.5) 1 (0.5) 4 (2) 1 (0.5) 0 1 (2) 0 0 8 (0.8)

1 1 4 1 1

Poisoning Total 0 1 (0.5) 1 (0.5) 2 (1) 2 (1) 1 (1) 0 0 0 7 (0.7)

1 1 1 1 2 1

Vehicle Total 0 2 (1) 2 (1) 1 (0.5) 0 1 (1) 0 1 (3) 0 7 (0.7)

2 1 1 1 1 1

Electrocution Total 0 0 0 1 (0.5) 0 0 0 0 0 1 (0.1)

1

Total N (%) 6 (100) 223 (100) 195 (100) 195 (100) 150 (100) 107 (100) 51 (100) 27 (100) 18 (100) 972 (100)

25

For women aged 15–24 and 25–34, hanging, CO poisoning and overdose were the most common

methods. Among the 35–44s hanging was still the most common method (n=27) but overdose (n=14)

replaced CO poisoning (n=9) as the second common method. For women 45-54 overdose (n=11) was the

most common method, followed by hanging (n=10) and CO poisoning (n=9).

Apart from hanging, the more ‘violent’ methods of suicide; firearms, stabbing/cutting, self-immolation,

lying or jumping in front of a train, crashing a vehicle into an object or into the sea, electrocution, and

self-poisoning using chemicals were used more by men than women. While women did use these

methods, they were ranked towards the bottom of the list (Table 6).

Age

For the comparison of the proportion of each method across the age bands (Table 8), the original age

bands were aggregated into four bands and the four least common methods were combined into a category

called ‘Other Methods’. Even with this aggregation only half the methods had sufficient numbers to

provide any meaningful analysis. When comparing across age bands, the differences in the proportions

for hanging, CO poisoning, firearms and overdose were all shown to be statistically significant.

Hanging was the most common method across all age bands but was more common in the younger than in

the older population. This method accounted for 76% of deaths for the under 25 group and just over half

(51%) for 25-44 year olds, but was below a quarter of deaths (24%) in the 65+ age group. CO poisoning

was the second most common method in all age bands and accounted for about a quarter of deaths in each

band for those over 25 and 9% for those under 25. Suffocation ranked the fourth most common method in

the 65+ group whereas it ranked much lower in all other age groups.

Table 8: Distribution of method by age band - aggregated, (2005-2006)

* Not tested due to small cell sizes

Ethnicity

Table 9 provides a summary of the distribution of methods across the five ethnic groupings. Unlike

gender and age there were methods which were not used by all ethnic groupings. This was possibly due

to small numbers: for the ethnic group ‘Other’ where n=3, and for the method of electrocution as there

was only one death. For suffocation (n=20) all those who died were European. Among Māori, drowning

and poisoning were the other two methods that were not used. Overdose, drowning, vehicle and

poisoning were not used by Pacific Islanders.

Method <25

(%)

25-44

(%)

45-64

(%)

65+

(%)

Total

(%)

χ df p- value

Hanging (%) 174 (76) 198 (51) 102 (40) 23 (24) 497 (51) 98.45 3 <0.0001

CO Poisoning (%) 20 (9) 85 (22) 60 (23) 22 (23) 187 (19) 21.53 3 <0.0001

Firearms (%) 15 (7) 30 (8) 37 (14) 12 (13) 94 (10) 11.75 3 0.008

Overdose (%) 4 (1.5) 33 (8.4) 31 (12) 8 (9) 76 (8) 18.39 3 <0.0001

Jumping (%) 5 (2) 12 (3) 5 (2) 5 (5) 27 (3) 3.188 3 0.36

Stabbing/Cutting (%) 1 (0.5) 10 (2) 6 (2.3) 3 (3) 20 (2) * * *

Suffocation (%) 2 (1) 3 (0.8) 4 (1.8) 11 (11) 20 (2) * * *

Drowning (%) 0 3 (0.8) 5 (2) 7 (7) 15 (1.5) * * *

Train (%) 4 (1.5) 4 (1) 2 (0.9) 3 (3) 13 (1) * * *

Other Methods(%) 4 (1.5) 12 (3) 5 (2) 2 (2) 23 (2.5) * * *

Total (%) 229 (100) 390 (100) 257 (100) 96 (100) 972 (100)


26

The absence of poisoning as a method by Pacific Islanders is interesting given it is a very common

method in the Pacific Islands,12 especially poisoning by pesticide. This perhaps gives weight to the

thinking10 that the method used is not only influenced by choice but also by what is accessible at the time

of crisis.

Table 9: Frequency of method by ethnicity (2005-2006) Method European

(%)

Māori

(%)

Pacific Island

(%)

Asian

(%)

Other

(%)

Total

(%)

Hanging (%) 302 (43) 152 (76) 31 (74) 12 (48) 0 497 (51)

CO Poisoning (%) 164 (23) 17 (9) 5 (12) 1 (4) 0 187 (19)

Firearms (%) 80 (11) 12 (6) 2 (5) 0 0 94 (10)

Overdose (%) 66 (9) 6 (3) 0 4 (16) 0 76 (8)

Jumping (%) 21 (3) 3 (1.5) 2 (5) 1 (4) 0 27 (3)

Stabbing/Cutting (%) 14 (2) 4 (2.5) 1 (2) 1 (4) 0 20 (2)

Suffocation (%) 20 (3) 0 0 0 0 20 (2)

Drowning (%) 13 (2) 0 0 1 (4) 1 (50) 15 (1.5)

Train (%) 9 (2) 1 (0.5) 1 (2) 2 (8) 0 13 (1)

Self-immolation (%) 6 (0.8) 0 0 1 (4) 1 (50) 8 (0.9)

Poisoning (%) 6 (0.8) 0 0 1 (4) 0 7 (0.7)

Vehicle (%) 3 (0.3) 3 (1.5) 0 1 (4) 0 7 (0.7)

Electrocution (%) 1 (0.1) 0 0 0 0 1 (0.2)

Total N (%) 705 (100) 198 (100) 42(100) 25 (100) 2 (100) 972 (100)

When comparing the distribution of methods within an ethnic grouping (Table 10) the ranking of the

methods from most to least common were similar, however there were differences in the proportions of

methods within each group. Hanging was the most common method across all ethnicities but accounted

for a greater proportion of deaths for Māori (76%) and Other (61%) than for European (43%). When

Other was separated into specific ethnic groups, 72% of Pacific Islander suicides were by hanging.

As for age, for the purpose of statistical analysis, the ethnicity groupings were aggregated into three

categories with Pacific Island, Asian and Other combined into one group called Other. Even with this

aggregation only half of the methods had sufficient numbers to allow meaningful analysis. The four least

common methods were combined into a category called ‘Other methods’. The difference in the

proportion of deaths across ethnicities was statistically significant for hanging, CO poisoning, firearms

and overdose.

12 De Leo, D. Milner, A. Xiangdong, W., Suicidal behaviour in the Western Pacific Region: Characteristics & Trends. Suicide and Life-

Threatening Behaviour, 2009; 39 (1): 72 - 81

27

Table 10: Comparison of frequency of Method across ethnicity groupings - aggregated (2005-2006)

* Not tested due to small cell sizes

Hanging

Hanging was the most common method of suicide with 51% of all deaths being by this method. For

males, 52% of deaths were by hanging and for females 48%. It was represented across all age groups. It

was more common for younger people with 34% of hangings being in the 15–24 age band. When

combined with the under 15s and the 25-34 age band, those under 35 accounted for 57% of suicide by

hanging. For the under 15s all deaths were by hanging. Just as there were many instruments used for

hanging so were there places to hang making it one of the most challenging methods to restrict access or

to suicide proof environments. Just over half used exposed beams or rafters (54%), followed by trees

(15%), door and windows (11%), outdoor fixtures such as fences, pergolas, clotheslines (8%), railings and

other fixtures (6%), wardrobes (5%) and bridges (1%).

Logistic regression (SAS v 9.13, SAS Institute, North Carolina) was used to investigate the likelihood of

the suicide method being hanging compared to any other method: this was possible due to the number of

hanging deaths. A multiple variable model included age (as a continuous variable), sex, and ethnicity as

predictors. This model allowed for testing whether the effects of different factors are independent of each

other, or whether (for instance) the effects of ethnicity in a univariate model are confounded by

differences in the age structure of people dying by suicide in the different ethnic groups.

Sex was not a significant predictor of likelihood of death being by hanging (odds ratio for females relative

to males = .823, 95% confidence interval 0.603, 1.123); Māori were more likely to use hanging than

another method, relative to the New Zealand European group (OR = 3.05, 95% CI = 2.09, 4.46); while the

apparently higher proportion of hanging in the Other ethnicity group relative to New Zealand European

was not statistically reliable (OR = 1.69, 95% CI 0.997, 2.88). Age was strongly related to likelihood of

method selection being hanging: older individuals were less likely to use hanging than younger

individuals (OR per 5 year increase in age = 0.849, 95% CI = 0.813, 0.886).

Carbon Monoxide (CO) poisoning

The second most common method was CO poisoning; predominantly car exhaust fumes (97%). This was

usually done by attaching an instrument to the exhaust pipe and inserting it in the car (n=165).

Method: European (%) Māori

(%)

Other

(%)

Total (%) Chi df p-

value

Hanging (%) 302 (43) 152 (76) 43 (62) 497 (51) 74.95 2 <0.001

CO Poisoning (%) 164 (23) 17 (9) 6 (9) 187 (19) 26.74 2 <0.001

Firearms (%) 80 (11) 12 (6) 2 (3) 94 (10) 8.846 2 0.01

Overdose (%) 66 (9) 6 (3) 4 (6) 76 (8) 9.019 2 0.01

Jumping (%) 21 (3) 3 (1.5) 3 (4) 27 (3) 1.904 2 0.39

Stabbing/Cutting (%) 14 (2) 4 (2.5) 2 (3) 20 (2) 0.2615 2 0.88

Suffocation (%) 20 (3) 0 0 20 (2) * * *

Drowning (%) 13 (2) 0 2 (3) 15 (1.5) * * *

Train (%) 9 (2) 1 (0.5) 3 (4) 13 (1) * * *

Other (%) 16 (2) 3 (1.5) 4 (6) 23 (2.5) * * *

Total N (%) 705 (100) 198 (100) 69 (100) 972 (100)


28

All the instruments used to attach to the exhaust pipe were common household items such as hoses,

vacuum cleaner pipes, piping and tubes. For males 20% used this method and for females 17%. Apart

from the under 15 age band all age groups used this method with 46% being in the 25 – 44 age band.

It was the second most common method across ethnic groups but more commonly used by Europeans

(23%) compared to the other groups (Māori 9%, Pacific Island 12%, Asian 4%)

Firearms

The use of a firearm was one of the few methods where there was a statistically significant difference in

the proportion of use by gender with 12% of males using firearms and only 3% of females. Europeans

used this method more (11%) compared to Māori (6%) and Pacific Islander (5%). The method was

represented in all age groups except the under 15 age band with 14% of the 45-64 age band using firearms

compared to under 25s where only 7% used firearms. The most common firearm was rifles (n=55),

followed by shotguns (n=23) then pistols (n=3). It was interesting to note the use of nail guns (n=6)

although it is not possible to determine if this is an emerging pattern. Most firearms were fired at the head

(n=66) or the chest although for both parts of the body it is likely to be higher as it was not specified in 21

deaths.

Overdose

Overdose, usually by prescribed medication, was the other method where there was a statistically

significant difference in the proportion of use by gender with 16% of females overdosing and only 5% of

males. Overdose was the second most common method for Asian people (16%) whereas it was the fourth

commonest method for Europeans (9%) and Māori (3%). The method was represented in all age groups

except the under 15 age band with 12% of the 45-64 age band overdosing compared to under 25s where

only 1.5% died by overdose.

Jumping

Jumping by its nature tends to occur in a public place. Even the deaths that took place at own place of

residence (n=3) were located in apartment blocks. Cliffs (n=9) were the most common place to jump

from, followed by buildings (n=8) including car parks (n=3). A third of all who jumped (n=9), jumped

into water, usually the sea. Of the eight who jumped from a bridge, five were from motorway

overbridges, all being located in Auckland, although no bridge was identified more than once. Jumping

accounted for 4% of deaths for females and 2% for males. Jumping was the fourth most common method

in the under 25 age band (2%) whereas it was the fifth most common method for the other age groupings.

For Pacific Islanders (5%), jumping was the fourth most common method whereas it was the fifth most

common method for Asian (4%) and European (3%) and the sixth most common for Māori (1.5%).

Stabbing/Cutting

Despite being a common method of attempted suicide, stabbing or cutting is not a common method for

completed suicides with twenty deaths over the two years. For Asians, 4% of deaths were by stabbing or

cutting and it was their fifth most common method. For other ethnic groupings it made up 2% of deaths

for European and Pacific Islander and 2.5% for Māori. All age-groups except the under 15 and 85+ age

bands used stabbing and cutting although the numbers are very small ranging from 0.5% of deaths for

under 25s to 3% of deaths for those 65+. Stabbing or cutting accounted for 2% of deaths for males (n=

17) and 1% for females (n=3).

29

Suffocation

While suffocations accounted for 2% of all deaths overall, it accounted for 4% of all female deaths and

2% for males. It was used more by older people accounting for 11% of deaths for those in the 65+ age

band whereas it only accounted for about 1% in all the age groupings. All those who died of suffocation

were of European ethnicity.

Drowning

For those who drowned, eleven (73%) drowned in the sea, with the remainder drowning in a river (20%)

or a creek (7%). Drowning was 4% of deaths for Asians and 2% for Europeans and was one of the two

methods used by those from ethnic grouping of Other. It was more common in older people with

drowning being 7% of deaths in the 65+ age band and was not a method used by those under 25. For

females it was 3% of deaths and 1% for males.

Trains

This is a rare but significant method due to the unavoidable trauma to the driver. Of the 13 deaths by

train, nine people lay or sat in front of the approaching train and most deaths (n=9) occurred on a railway

line away from a railway station. Trains accounted for 8% of deaths for Asians whereas for European and

Pacific Islander it accounted for 2% and 0.5% for Māori. This method was represented in most age

groups except the under 15s and 75-84 age bands. The proportion of deaths varied from 3% in the 65+

age band to 0.9% in the 45–64 age band. For females it was 2% of deaths and 1% for males.

Self-immolation

Self-immolation, i.e. setting oneself on fire, accounted for 8 suicides (0.8% of all deaths), six men and two

women with no difference in the proportion of deaths for each gender. The numbers were evenly split

across the two years so there seems to be no increase. Five doused themselves in an accelerant while

three set fire to vehicles which they were sitting in. Self-immolation was the second method used by the

ethnic grouping of Other and is a method that is more commonly used in the person’s country of origin.

Vehicles

Six people drove a vehicle into the sea (n=3), a bridge (n=2), or a tree (n=1). The remaining death

involving a vehicle was a person jumping in front of a truck. Six out of the seven deaths were males and

the ethnicity breakdown was five Europeans, one Māori and one Asian. Five of the people were in the 15-

44 age group with the remaining two being over 55.

Other Methods

Poisoning other than overdose by drugs accounted for seven deaths with five using some chemical and

two using a medical gas (these two deaths were connected). It was not a method used by younger or older

people with 58% in the 35-54 age band. They were predominantly European (86%) and five out the seven

were males. There was one death by electrocution.

Instrument

The instrument used in the suicide was determined by the chosen method. Table 11 highlights that the

most common instruments used are accessible to most people and could be found in any household and

garage. For hanging, rope (60%) was the most common instrument followed by clothing (13%) and

electrical and computer cables (11%).


30

Accessibility to the method is a critical factor as is shown in institutions where the most common method

used was hanging and the two instruments used for this method were clothing and bed sheets, these being

the most accessible in such locations.

Table 11: Frequency of method by instrument (2005-2006)

Instrument

Ha

ng

ing

CO

Po

iso

nin

g

Fir

earm

s

Ov

erd

ose

Ju

mp

ing

Sta

bb

ing

/ C

utt

ing

Su

ffo

cati

on

Dro

wn

ing

Veh

icle

Tra

ins

Po

iso

nin

g

Sel

f-im

mo

lati

on

Rope 305 - - - - - - - - - - -

Clothing 66 - - - - - - - - - - -

Electrical Cables 55 - - - - - - - - - - -

Straps Leashes Chains 49 - - - - - - - - - - -

Bed sheets 19 - - - - - - - - - - -

Hose 1 79 - - - - - - - - - -

Vacuum Hose - 50 - - - - - - - - - -

Tube / Pipe 2 30 - - - - - - - - - -

Lay in front of - 17 - - - - - - - 9 - -

Brazier / Charcoal - 5 - - - - - - - - - -

LPG Bottle - 3 - - - - - - - - - -

Petrol Generator - 1 - - - - - - - - - -

Rifle - - 55 - - - - - - - - -

Shotgun - - 23 - - - - - - - - -

Nail Gun - - 6 - - - - - - - - -

Pistol - - 3 - - - - - - - - -

Medication - - - 74 - - - - - - - -

Illicit Drugs - - - 2 - - - - - - - -

Cliff - - - - 9 - - - - - - -

Bridge - - - - 8 - - - 2 - - -

Building - - - - 4 - - - - - - -

Balcony/Porch/

Verandah

- - - - 3 - - - - - - -

Car Park - - - - 3 - - - - - - -

Knife - - - - - 13 - - - - - -

Scissors - - - - - 1 - - - - - -

Razor Blade - - - - - 4 - - - - - -

Stanley Knife - - - - - 1 - - - - - -

Plastic bag - - - - - - 20 - - - - -

Sea - - - - - - - 11 3 - - -

River - - - - - - - 3 - - - -

Creek - - - - - - - 1 - - - -

Tree - - - - - - - - 1 - - -

Jumped in front of - - - - - - - - 1 4 - -

Chemicals - - - - - - - - - - 7 -

Fire - 1 - - - - - - - - - 8

Unspecified - - 7 - - 1 - - - - - -

Total 497 187 94 76 27 20 20 15 7 13 7 8

31

3 .3 Comparison between 1997 -1998 & 2005-2006

Comparison between 1997-1998 and 2005-2006 (Table 12) suggests that there is no major increase in the

proportions of any method except for hanging which has increased from 42% to 52%. For self-poisoning

by inhalation there has been a decrease in the proportion over the two time periods from 25% to 18%.

This may be due to the increase in the use of hanging with the changes in proportions for both these

methods being statistically significant.

Table 12: Comparison between NZHIS 1997-1998 and 2005/2006 data

Method 1997-1998 (%) 2005-2006 (%) Total % Value P-value

Hanging, strangulation and suffocation 482 (42) 539 (52) 1021 (47) 20.67 <0.005

Self-poisoning - inhalation 290 (25) 195 (18) 485 (22) 13.72 <0.005

Overdose & self-poisoning 124 (11) 102 (10) 226 (10) 0.6217 0.43

Firearms 128 (11) 92 (9) 220 (10) 3.294 0.070

Jumping from a high place 27 (2.5) 26 (2.8) 53 (2.6) 0.04542 0.83

Drowning and submersion 27 (2.5) 22 (2.5) 49 (2.1) 0.1481 .70

Stabbing/Cutting 22 (2) 26 (2.5) 48 (2) 0.8453 0.36

Jumping or lying before moving object 15 (1.5) 17 (1.6) 32 (1.5) 0.3957 0.53

Crashing of motor vehicle 6 (0.7) 5 (0.4) 11 (0.7) 0.02064 0.89

Fire and inhalation 12 (1) 8 (0.7) 20 (1.2) 0.469 0.49

Other Specified Means 7 (0.7) 3 (0.3) 10 (0.7) Fisher Exact 0.43

Unspecified means 0 2 (0.2) 2 (0.1) Fisher Exact 0.45

Sequelae of intentional self-harm 1 (0.1) 0 1 (0.1) Fisher Exact >0.99

Total 1141 (100) 1037 (100) 2178 (100)

3.4 Emergent Patterns in Methods

In this analysis, particular attention was on the identification of any emerging patterns in methods that

may not be highlighted in the ICD codes. Overall there were no new emerging patterns identified in the

study. For the examples cited in the study brief the following patterns were found:

Plastic bags over the head

All twenty suffocations were by placing a plastic bag over the head with 3 people also taking medication.

Many of those choosing suffocation had a chronic or terminal illness (n=7) or mental illness (n=5) and

over half (n=11) were aged over 65 years. While noting that this method is advocated by many euthanasia

organisations, it is not possible to say if the choice of method was influenced by information available on

euthanasia related websites or publications although one file mentioned the person was an advocate of

euthanasia and had wanted to die before the illness progressed. Several police summary sheets (n=5) also

noted that euthanasia material was found in the residence near the body. It was not possible to identify

any longer term trends by comparing with the 1997-1998 data as suffocation is combined with hanging

and strangulation in the ICD codes.


32

Charcoal and LPG Gas

Eight people died of gas or smoke inhalation in a sealed space (garages and bedrooms). Charcoal related

products accounted for 50% of the deaths (n=4): charcoal barbecues (n=2), charcoal bricks (n=1),

Carbonettes (n=1). Three people used LPG gas cylinders and one person used a small petrol generator.

Seven out of the eight deaths were males. In terms of ethnicity, European accounted for 88% of the

deaths (n=7) and 12% Asian (n=1). There does not seem to be an emerging pattern of use of charcoal

related products.

3.5 Witnesses and Discoverers of Suic ide

The majority (79%) of people who suicide, do so alone with no witnesses to the death (Table 13). This

applied across all locations even for those who died in a public place (84%). For 18% of deaths, there

were people present at the location but they did not witness the death. Only 3% of deaths had people

witness the act and this was mainly due the deaths occurring in a public place (70%) with a very public

act, e.g. jumping in front of train or jumping off a building.

Table 13: Frequency of Witnesses of the death by location (2005-2006) #

# Shows the proportions by column

The majority (69%) of those who discovered the dead body (Table 14) were known to the deceased with

the most common group being partners (21%). Family members when combined accounted for 28% of

discoverers: parents (12%), other family members (11%) and children (5%). Passers-by accounted for

18% of discoverers making them the second largest group and as could be expected predominantly

discovered the people in public locations (77%). Police and emergency services discovered 10% of

deaths.

3.6 The Ro le of A lcohol in Suic ide

Due to the dis-inhibiting effects of alcohol we were interested to note the extent to which alcohol was

implicated in these deaths. Unfortunately the Coronial Files and pathology reports did not systematically

indicate whether or not the ingestion of alcohol in the hours prior to the suicidal act, or the presence of

alcohol in the body was actively considered. That is, where no mention was made of alcohol, it was not

possible to tell whether it was not present or whether it was not considered. Alcohol use in the hours

before death was mentioned in the ‘Cause/circumstances’ part of the verdict in 18 deaths, and in the notes

on context in 15 deaths. In a further 14 deaths it was mentioned in relation to ‘addiction’ or ‘alcoholism’.

In total, alcohol was mentioned in the Coroners’ notes in relation to 47/972 (4.8%) deaths.

Locations Residence

(%)

Public

(%)

Acquaintance

(%)

Institution

(%)

Workplace

(%)

Hotel/

Motel (%)

Total (%)

Alone 526 (79) 176 (84) 28 (68) 8 (53) 18 (86) 8 (100) 764 (79)

Present but not

witness

132 (20) 10 (5) 11 (27) 17 (47) 3 (14) 0 173 (18)

Witnessed 8 (0.9) 24 (11) 2 (5) 0 0 0 34 (3.9)

Not Specified 1 (0.1) 0 0 0 0 0 1

(0.1)

Total (%) 667 (100) 210 (100) 41

(100)

25

(100)

21

(100)

8

(100)

972

33

Table 14: Frequency of Discoverers of the death by location (2005-2006) #

Locations Residence

(%)

Public

(%)

Acquaintance

(%)

Institution

(%)

Workplace

(%)

Hotel/

Motel

(%)

Total

(%)

Partners 197 (30) 6 (3) 3 (7) 0 1 (4.5) 0 207 (21)

Passers- by 4 (0.6) 161

(77)

3 (7) 0 3 (15) 1 (12.5) 172 (18)

Parents 115 (17) 0 6 (15) 0 1 (4.5) 0 122 (13)

Other Family 87 (14) 5 (2) 11 (27) 0 3 (15) 0 106 (12)

Police /

Emergency Services

49 (7) 28

(13.5)

7 (17) 1 (4) 2 (10) 1 (12.5) 88 (9)

Friend 71 (11) 5 (2) 8 (20) 0 0 0 84 (8)

Child 49 (7) 1 (0.5) 1 (2) 0 0 1 (12.5) 52 (5)

Neighbour 40 (6) 1 (0.5) 2 (5) 0 0 0 43 (4)

Paid Staff 9 (1) 2 (1) 0 23 (92) 1 (4.5) 5 (62.5) 40 (4)

Workmate/Employer 15 (2) 0 0 0 9 (42) 0 24 (2.5)

Flatmate 22 (3) 1 (0.5) 0 0 1 (4.5) 0 24 (2.5)

Acquaintance/Landlord 7 (1) 0 0 1 (4) 0 0 8 (0.8)

Not Specified 2 (0.4) 0 0 0 0 0 2 (0.2)

Total (%) 667 (100) 210

(100)

41 (100) 25 (100) 21 (100) 8 (100) 972 (100)

# Shows the proportions by column


34

Discussion 4.1 Summary of Main Findings

This review of suicide deaths over two year periods eight years apart did not reveal any strongly emergent

location types or methods of death. There are few ‘iconic’ public sites for suicide in New Zealand but

none have newly emerged. Most suicides are a private and opportunistic event occurring most commonly

in the deceased’s home, although deaths at public sites are also mainly in concealed or inaccessible

locations. Proximity of the location to the opportunity to access the method, combined with impulsivity,

seem to be the key factors influencing the choice of both the location and methods. Choice of method

appears to be influenced by what is readily accessible, with common household items often used. In the

less impulsive but more planned suicides, especially among older people, the desired method appears to

be the defining factor in the choice of location. Both location and method varied by sex, age and ethnicity.

4.2 Strengths

A particular strength of this study is the use of Coronial records for such a large number of deaths. This

enabled a focus on detailed aspects of methods such as hanging and also consideration of the relationship

between location and method, with location commonly at least partly determining method. The detailed

examination of locations provided insights into the challenges for effective policy in this area due to the

private and solitary nature of suicidal acts.

4 .3 Weaknesses

There are three main limitations to this study. Firstly, our findings are limited to descriptive observation

because we did not do a time trends analysis. This would have required a larger dataset over many more

years, and was outside the scope of the contract. Lack of a time trends analysis means we are unable to

comment on emerging trends in the statistical sense.

Secondly, the extent of the detail obtained from the Coroners’ Files was highly variable, mainly due to the

brevity of the information provided in some of the Coroner Summary Sheets. There was a variation not

only in the detail provided but in some Coroner districts the standard form was not used. This highlights a

key issue for improvement in the reporting of suicide in New Zealand. Variation in pathology reports was

also an issue. The information from pathology reports was most relevant when the cause of death was

clearly overdose or poisoning. As part of the study it had been hoped to be able to identify possible

patterns of the most common substances used in suicides, but this was more difficult than expected. Often

a mixture of substances had been consumed or the overdose was one of multiple methods used in the

suicide, making it difficult to identify the actual single cause of death. While substances may have also

been ingested, the Coroner may have pronounced another cause of death.

Thirdly, we did not examine deaths where the Coroner had recorded an open verdict or the issue of intent

was otherwise unclear, as in some deaths recorded as accidental. This was also outside the scope of this

contract. However, the lack of information on these additional deaths is unlikely to alter our findings in

major ways. For 2005/2006 only seven deaths were recorded as open verdicts. Furthermore, it is likely

that only a small proportion of deaths recorded as accidental during the period of interest might be

potentially misclassified.

As a general comment we note that the data in this report are already out of date despite being the most

recent available at the time of analysis. This points to the importance of more up-to-date monitoring for

trends in locations and methods. The Coroners’ Summary Sheet should be reviewed and updated where

necessary to ensure that information on locations, methods and full context of deaths can be easily

recorded. Importantly, education should be undertaken with the police on the importance of completing

all details of the Coroners’ Summary Sheet.

35

4.4 Impl icat ions for pol i cy and pract ice

Our findings indicate that the identified areas of action in the Suicide Prevention Action Plan reflect the

current policy and programme needs in terms of restricting access to the locations and means of suicide.

Based on this study we recommend that there is no need to amend or review the current work plan or the

timeline for the implementation of Goal 4 activities. Our focus is therefore on how the Goal 4 Areas of

Action could be strengthened or expanded or where particular emphasis should be given.

Review policies and procedures for institutions

As identified in the Suicide Prevention Action Plan the potential to reduce suicide rates by hanging is

limited in most circumstances due to the ready access to the means and places for hanging. While

institutions constituted only 4% of locations where hangings occurred, hanging was the most common

method (80%) used in an institutional setting.

The principles identified in the Suicide Prevention Action Plan for the prevention of hanging in

institutions are supported by the findings of the Coroners in the 20 suicides by hanging that occurred in

New Zealand institutions over the two year period. Much has already been done in institutions to provide

suicide safe areas, and this needs to be supported by ensuring appropriate levels of staff knowledge and

skills related to suicide prevention. For example, suicide prevention could be covered in regular staff

training programmes. Topics could include risk assessment and the management and monitoring of at risk

clients, using approaches that are appropriate for the nature of the institution.

When considering suicides in institutional settings, our attention was drawn to the aged care facilities as a

location for suicide in older persons. Eight people over 65 died from overdoses, which although not a

common method for this age group as a whole, was the most common method among those dying in aged

care facilities. With an increasingly aging population and the increase in demand for aged care facilities,

the occurrence of suicide in these institutions should be monitored. Clinicians and other workers often

show a greater tolerance of suicide by older people and depression and suicidality in this age group is

frequently unrecognised or under diagnosed.13 In this context it is important that staff in aged care

facilities have access to appropriate training on:

a. the identification and management of depression and suicide risk, and

b. when it is appropriate to monitor the medication of older people identified as being depressed or

at risk of suicide.

Vehicle Exhaust Gas

Carbon monoxide (CO) poisoning is the second most common method of suicide with vehicle exhaust gas

making up 97% of such deaths. As with hanging, strategies to reduce suicide rates by vehicle exhaust gas

are limited but given the numbers who use this method, any initiatives to incorporate changes in the

vehicle fleet such as the installation of catalytic converters and other safety devices in older cars, should

be a high priority in the Ministry of Health work plan, as this may achieve reductions in the numbers of

suicides by vehicle exhaust gas.

While it was not possible to identify the use of charcoal products and LPG bottles as an emerging trend in

CO related deaths, the use of both these methods is worthy of monitoring. There is potential for these

methods to become a substitute for vehicle exhaust gas given that they do not require access to a vehicle

and can be utilised in a greater range of locations. This was evident in the data which showed that sealed

rooms, especially bedrooms, were a common location for these methods.

13 Conwell, Y, Suicide in later life: A Review and recommendations for prevention. Suicide and life-threatening behaviour, 2001, 31

(supplement), 32-47


36

Both are easily accessible household items. While there was no evidence that it was a method being used

by younger age groups, the abovementioned reasons could make this a more accessible method for this

age group especially if there is publicity or promotion of such methods on suicide related websites. It

would be useful for studies or monitoring of such websites to take into account what methods are being

discussed or promoted.

Safe custody of firearms

Suicides by firearms, while being the third most common method, constitute only a small percentage of

total deaths (10%). This is partly due to lower firearm ownership in this country compared to countries

like the United States where it has been shown that regions with the highest firearm ownership rates also

had the highest suicide rates and the use of firearms as a method was much higher.14 From a policy

perspective New Zealand already has a relatively stringent set of firearm regulations in the Arms Act 1983

and the 1992 Amendment Act that incorporates most of the strategies for restricting access to firearms

recommended in the international literature15.

The continued promotion of personal responsibilities of gun ownership, including secure storage of guns

and ammunitions is a useful programmatic initiative. There are two observations from the study of the

Coroners’ Files that we believe should be considered in the development of any publicity campaigns.

Firstly, where reported, over half the firearms used by the deceased were owned by someone else, usually

someone within the extended family and police often noted that guns had been securely stored. However,

it should be noted that due to the variance in the reporting in the Coroners’ Files it was not possible to

establish the extent to which a) the firearms and ammunition were safely secured and b) whether the

firearm used was owned by the deceased.

Secondly, while some of the deceased knew about the storage of the firearms and the ammunition and had

taken the firearm without the owner’s knowledge, it was more common for the deceased to ask the owner

for the gun. Owners when interviewed after the death, often mentioned that the reasons given by the

deceased for needing the use of the gun did not seem to ‘stack up’ and while some had been already

concerned about the welfare or emotional state of the person most had not considered that the firearm

would be used for suicide. For those who had a ‘suspicion’ that the person could be wanting to use the

firearm to end his or her life, they had not felt confident to intervene by denying the loan of the firearm,

asking if the person was suicidal or to notifying others or police about their concern. These issues should

be addressed in any future publicity campaigns, along with messages about the importance of not lending

firearms and taking into account recent life stressors or emotional state when considering a request to

borrow a firearm.

Self-poisoning

The most common form of self-poisoning was the overdose of either prescription or non-prescription

medications. In most cases, the deceased did not use just one medication but a combination of several

drugs, sometimes in relatively small amounts but with cumulative toxicity. While there has been much

written about the use of paracetamol, especially in attempted suicides, it was not a drug that featured

strongly in this study and was not cited by Coroners as the sole or main cause of death.

Once again due to the incompleteness of the information in the Coroners’ Files it was not possible to

establish the usage or prescribing patterns of prescription medications so it is difficult to form strong

conclusions about novel strategies for reducing rates of suicide by self-poisoning. However, we made

several general observations that are worthy of further study.

14 Kposowa, A, & McElvain, J. Gender, place and method of suicide. Social Psychiatry and Psychiatric Epidemiology 2006; 41:435-443 15 Beautrais AL. 2000

37

Many of the prescribed medications were anti-psychotic or anti-depressant medications prescribed as part

of a specific treatment regime. It was most common for anti-psychotic medications to have been

prescribed or at least monitored by a psychiatrist or mental health professional in secondary or tertiary

mental health services. For anti-depressants, GPs were a more common prescriber and it often appeared

that this was the sole treatment for depression and that other therapeutic modalities such as talking

therapies were not being utilised.

In terms of access to means this raises the question of consideration of the amount of drugs that are

prescribed at any one time and the on-going monitoring of the clinical state of people being treated with

medication. Both overseas and in New Zealand there have been proposals16 to restrict the number of

tablets which may be prescribed or dispensed, especially for people who have been identified as having

some suicide risk. There is a high degree of clinical awareness of the need to prescribe the least toxic

medication to those who may be at risk of suicide.

For those receiving mental health care in community settings the practice of using ‘close control’

prescriptions, where patients are given smaller amounts of medication prescribed at one time, is available

to mental health professionals. Other strategies available are daily supervised dispensing of medications

by the mental health professional or the client presenting at a pharmacy for the medication. The uptake of

this practice by mental health professionals and the advantages and disadvantages of such practices are

worth further study.

We also note the work that is being undertaken by pharmacists and District Health Boards on prescription

synchronisation and optimisation and see the potential for these processes to be adapted in relation to the

management of prescribing, dispensing and utilisation of medications by those who are at risk of suicide,

especially those who are being prescribed anti-depressants in a primary care setting. Pharmacists may be

in a position to contribute to the monitoring of prescriptions for people who have a mental illness.

Education work should be undertaken with the major supermarket chains and pharmacists about the

placement and advertising of paracetamol products in supermarkets.

Surveillance and Management of Jump sites

We identified only one location, Lawyers Head in Dunedin, that could be identified as a jump site in New

Zealand. As already mentioned there have already been measures taken to restrict access to the location

which appear to be very successful in halting suicides from this site. While restricting access to jump

sites or the erection of barriers at these sites have been shown to be effective,17,18,19 the low number of

deaths by jumping and identified jump sites presents a challenge for implementing any targeted

programmes, especially providing justification to agencies such as local authorities for the cost of

implementing such interventions. For example, while there was not one single location identified, we

note that all jumping from motorway overhead bridges occurred in the Auckland region and in the first

instance any initiatives to address motorway over-bridges should be undertaken in Auckland with

discussions to be held with the appropriate agencies about developing a process to audit and monitor with

the view to implementing a suicide proofing programme.

16 Beautrais A.L. Restricting Access to Means on Suicide in New Zealand: A Report Prepared for the Ministry of Health on methods of suicide in New Zealand 1977-1996. Wellington: Ministry of Health 2000 17 Ministry of Health, 2008 New Zealand Suicide Prevention Action Plan 2008-2012 The Evidence for Action, Wellington, Ministry of Health 18 Beautrais, A.L. (2000). Restricting access to means on suicide in New Zealand: A report prepared for the Ministry of Health on methods of suicide. New Zealand 1977-1996. Wellington: Ministry of Health. 19 Beautrais,A.L., Gibb, S.J., Fergusson, D.M., Horwood, L.J., & Larkin, G.L. (2006). Guidance on action to be taken at suicide hotspots.

London: NIMHE.


38

In considering the potential auditing of jump sites, we recognised the need for guidance for agencies on

how to undertake such a process. We recommend that an educational resource on identifying and

managing suicide hot spots be developed for agencies and local authorities as has been done overseas.20

Restriction of access to jump sites and other kinds of hotspots requires careful consideration, as it may not

always succeed and success can be difficult to measure.21 Guidance therefore has the potential to ensure

that this approach is used and monitored skilfully. Such a resource could also be helpful for public

building owners and property developers. The resource could include criteria to consider in auditing

potential jump sites with recommendations on suicide proofing strategies.

Consider feasibility of establishing a suicide mortality review committee

While a study such as this is useful in providing a description of the locations and methods of suicide

utilised in New Zealand, the delays in data gathering in this country makes it difficult to monitor emerging

patterns or locations and to provide an expedient response to such trends. We would support the review

of existing mortality review committees with a view to including suicide at all ages in an extended remit

for one of them, or preferably, establishment of a distinct suicide mortality review committee. A major

role of such a committee would be the monitoring and regular reporting of emerging patterns in methods

of suicide and the identification of suicide hot spots as well as possible suicide clusters. This committee

could also systematically consider and report on the role of alcohol and other drugs in suicide, and, if

relevant, contribute to the work of other agencies developing policy around alcohol regulation and

availability in New Zealand. One of the authors (SC) is a member of the Wellington Regional Youth

Mortality Review Committee, which examines all deaths among those aged under 25 years in the region.

The review process enables systematic consideration of all details relevant to a death, allowing for the

reporting back of issues including those with agencies who may have been involved in care and support,

social contextual matters and service access problems. Feedback can then be provided as appropriate so

that systemic and other problems may be addressed. Given the recent improvements to the Coronial

service in relation to suicide, it would be important to work alongside the Coronial process and add further

value to this.

Promote guidance to family/whanau of those at risk

While totally suicide proofing a place of residence is not possible, when discussing restricting access to

means it is important to think broadly. Our reading of the Coroners’ Files suggests that the major

emphasis of any advice needs to be on ensuring that the person’s whereabouts is known and they are not

left alone for long periods. Regular supportive face to face contact is important – this might be at least

several times per day. The Ministry of Health advice on guidance to family/whanau 22 is still current, and

should include: restricting or preventing access to weapons including air rifles and ramset guns, knives

including craft knives, preventing easy access to transport (e.g removing vehicle keys), leaving petrol

tanks partly empty, accounting for all medications including over-the-counter products and keeping them

locked away, returning unused medications to a pharmacy, locking away poisons, LPG bottles, ropes and

cords and hoses or asking someone else to store them. Alcohol should be kept only in small quantities if at

all.

A number of cases highlighted that even when people were present they did not pick up on the suicidality

of the person. Because suicide is statistically rare it is difficult to predict with any certainty. However

people may be more vulnerable in times of high stress and crisis such as death and loss, domestic

violence, financial failure, legal proceedings, worsening mental or chronic physical illness. Vigilance by

others at such times is important, and any talking about suicide or other concerning behaviours needs to be

taken seriously.

20 National Institute of Mental Health in England, Guidance on Action to Be Taken at Suicide Hotspots, 2006, London, NIMHE

21 Gunnell D & Miller M. Strategies to prevent suicides. 2010. BMJ 341:157. 22 NZ Ministry of Health. The assessment and management of people at risk of suicide. 2003. The New Zealand Guidelines Group and Ministry of Health. Wellington.

39

Advice like this is usually provided only after a person has been identified as high risk, following a

serious overt threat of suicide or a suicide attempt and being seen by a mental health professional or

presenting to an Emergency Department. However many who killed themselves were not identified in the

Coroners’ files as having been suicidal or depressed despite experiencing significant or overwhelming

stresses. This was especially so for a number of males who, just prior to their death, were highly

emotionally distressed and had been using alcohol. As noted, alcohol intoxication and the presence of

alcohol in the body was not recorded in the Coroners’ Files in a standardised way, which makes it

impossible to draw conclusive findings on a possible link between alcohol ingestion and suicide and we

noted it being recorded as part of the cause of death. Given that recent alcohol consumption is present in

up to 50% of those presenting at Emergency Departments for intentional self-harm in New Zealand and

internationally,23,24,25 we think the mentioning of alcohol in the Coroners’ files we inspected is likely to be

a significant under-report. We suspect alcohol to be relevant in an important proportion of suicide deaths,

although this remains to be demonstrated unequivocally. Impulsivity may have been a factor in some

deaths, with the suicide occurring in the hours or days after a trigger event such as a domestic dispute. In

addition, for many there was no record of recent consultation with any health or helping professional,

although this was not recorded systematically.

These suicides that appear to occur ‘out of the blue’ present a major challenge for prevention. Early

intervention may be of similar importance to restricting access to means for some people who have

experienced significant life events that may be a trigger for depression or significant sadness and loss that

leads to despair or futility. Figure 2 shows the suicide pathway that may occur for some of these people

and indicates points of potential intervention.

Figure 2: Potential points of intervention

Face to face contact at any of these points provides an opportunity for people at risk to be supported in

seeking help. It may also reduce social isolation which is known to be associated with suicide risk.

Family/whanau should not hesitate to ask for additional help if they are concerned.

Because of the dis-inhibiting effects of alcohol, consideration should be given to the potential positive

impact on suicide rates of population strategies aimed at the reduction in alcohol consumption.

23 Collings S, Kuehl S, Atkinson J et al. Unpublished data from the NZ Multilevel Intervention for Suicide Prevention (MISP) study. 2009-2012. 24 De Munck S, Portsky G, van Heeringen K. 2009. Epidemiological trends on attempted suicide in adolescents and young adults between 1996 and 2004. Crisis: Journal of Crisis Intervention and Suicide 30(3):115-9. 25 Hawton K, Bergen H, Casey D & Simkin S. 2008. General hospital presentations of hanging over a 28-year period: case-control study. British Journal of Psychiatry 193, 503-4.

Suicidal

ideation/

plan

Impulse Death Psycho-

social

precursors /

precipitating

factors

Alcohol

Potential Points for Intervention

Figure 3

Access to

means


40

Advice to Clinicians on Access to Means in Risk Assessment

Risk assessment documentation usually includes questions about access to means. That this needs to

consider a broad range of methods should be highlighted in risk assessment training for clinicians, as well

as in any reviews of risk assessment documentation.

The study also highlights that access to means is just one small yet important part of the identification of

risk and the absence of access to the methods cannot be considered as an indicator of the absence of risk

for suicide. The removal of means or the suicide proofing of an environment is particularly challenging

especially when clinicians are assessing if it is safe to discharge the person back into the community.

Once again clinicians need to consider a variety of factors and not just the absence of means. It is our

opinion that given these difficulties a clinician’s assessment and management may be better focused on

delaying the opportunity to engage in suicidal behaviours. This may be especially relevant in a crisis

period when the person is still emotionally distressed, when keeping the person under supervision until the

crisis has subsided, and supporting the person to develop some distress tolerance skills may have more

impact.

Clinicians and mental health services should be encouraged to review their suicide risk assessment

guidelines so that they extend their focus across the full range of methods.

Further, best practice guidance on the treatment of mental illness should include and emphasise the

importance of:

a. prescribing less toxic medications to individuals at risk of suicide, and

b. the use of ‘close control’ prescriptions, where patients are given smaller amounts of medication

prescribed at one time.

Further strategies which would support this outcome, such as consultation with pharmacists and education

with major supermarket chains have been discussed in Self-poisoning above.

Discoverers of Suicide

The location of the suicide often determined people who were likely to discover the body. As most deaths

were in homes discoverers of suicide were often family members or people who were known to the

deceased. Deaths in public locations often meant that discoverers were ‘passers-by.’ While the broader

ramifications of the impact of discovering has on a discoverer are beyond the scope of this study, this

information was included to highlight that interventions on location may have social benefits beyond the

prevention of suicide. A restriction on access to locations, especially public sites, contributes to the

prevention of potential trauma from witnessing a death.

41

Appendix a: Social Psychiatry & Population Mental Health Research Unit

The Social Psychiatry and Population Mental Health Research Unit was formed in 2007, is directed by

Associate Professor Sunny Collings, and is based at the University of Otago Wellington.

The Social Psychiatry and Population Mental Health Research Unit’s mission is to contribute to

knowledge, policy and services by conducting research in topics related to mental health and illness in

populations, with a focus on social inequalities and other contextual factors.

Research training is a core part of the Unit’s activities with a strong commitment to enhancing the mental

health and suicide research capacity in New Zealand. The Unit has a mixture of Masters and PhD

students so there is a collegial group with mutual interests to provide a rich learning environment.

In addition to its research, the Unit also makes a strong contribution to policy and provides consultancy

services to Government departments, District Health Boards and to non-government organisations.


42

Appendix b: Coroner Files Category Coding Locations Instrument Instrument cont. Attachment Cont.

Own Place of Residence (OPR) Hanging Vehicle / Trains Window/Window frame

OPR Bedroom Animal Leash Building

OPR Lounge Bag Strap Jumped in front CO poisoning

OPR Bathroom Bed sheet Sat/lay in front Car

OPR Garage Belt/Cords Sea Exhaust pipe

OPR Yard Chain Tree Sealed spaced

OPR Shed Clothing

OPR Hallway Cord Overdose Stabbing / Cutting

OPR Home office Electrical/Computer

Cable Illicit Drugs Chest

Extension Cord Medication Femoral artery

Residence of acquaintance Hose Stomach

ACQ Bedroom Nylon strap Poisoning Throat

ACQ Lounge Rope Chemical Wrists

ACQ Bathroom Scarf

ACQ Garage Seat Belt Drowning Self-immolation

ACQ Yard Shoe Laces Creek Car

Tow rope River Self

Public Site Tube Sea

Apartment building Truck tie down Firearms

Beach Suffocation Head

Bridge CO poisoning Plastic bag over head Chest

Park Brazier / BBQ /

Carbonettes

Plastic Bag +

Medication

Private property Hose Discoverer of death

Public Building LPG bottle Self-immolation Father

Railway Station Petrol Generator Fire Mother

Railway Line Pipe Friend

School Plastic Bag + CO

poisoning Attachment Partner

University Sat/lay in front Hanging Sibling

University hostel Tube

Balcony / Porch /

Verandah Child

Vacuum hose Bed end Emergency Services

Hotel/Motel Bridge Police

Firearms Clothesline Extended family

Workplace Nail Gun Curtain rail Work mate

Pistol Door handle Neighbour

Institution Rifle Fence Passer by

Hospital Shotgun Pergola Acquaintance

In patient Mental Health Piping Flatmate

Police Cell Jumping Rafter Health professional

Prison Balcony / Porch /

Verandah Rail Not specified

43

Locations Instrument Instrument cont. Attachment Cont.

Rest home Bridge Roof beam thru manhole

Building Shelving Witnessed death

Car Park Shower rail Alone

Cliff Staircase railing Others Present & witness

Swings

Other present but not

witness

Stabbing / Cutting Tilt door runner Not known

Knife Tree branch

Razor Blade Truck

Scissors Wall Bracket

Stanley Knife Wardrobe Clothes Rail


44

Appendix c: ICD Codes Mapping ICD – 9 ICD-10

Code Description Code Description

E950 Suicide and self-inflicted poisoning by solid

or liquid substances

X60

X61

X62

X63

X64

X68

X69

Intentional self-poisoning by and exposure to non opioid

analgesics, antipyretics and antirheumatics

Intentional self-poisoning by and exposure to antiepileptic,

sedative-hypnotic, anti parkinsonism and psychotropic

drugs, not elsewhere classified

Intentional self-poisoning by and exposure to narcotics and

psychodysleptics [hallucinogens], not elsewhere classified

Intentional self-poisoning by and exposure to other drugs

acting on the autonomic nervous system

Intentional self-poisoning by and exposure to other and

unspecified drugs, medicaments and biological substances

Intentional self-poisoning by and exposure to pesticides

Intentional self-poisoning by and exposure to other and

unspecified chemicals and noxious substances

E951 Suicide and self-inflicted poisoning by

gases in domestic use

X66

X67

Intentional self-poisoning by and exposure to organic

solvents and halogenated hydrocarbons and their vapours

Intentional self-poisoning by and exposure to other gases

and vapours

E952 Suicide and self-inflicted poisoning by other

gases and vapours

X67 Intentional self-poisoning by and exposure to other gases

and vapours

E953 Suicide and self-inflicted injury by hanging

strangulation and suffocation

X70 Intentional self-harm by hanging, strangulation and

suffocation

E954 Suicide and self-inflicted injury by

submersion (drowning)

X71 Intentional self-harm by drowning and submersion

E955 Suicide and self-inflicted injury by firearms

air guns and explosives

X72

X73

X74

Intentional self-harm by handgun discharge

Intentional self-harm by rifle, shotgun and larger firearm

discharge

Intentional self-harm by other and unspecified firearm

discharge

E956 Suicide and self-inflicted injury by cutting

and piercing instrument

X78 Intentional self-harm by sharp object

E957 Suicide and self-inflicted injuries by

jumping from high place

X80 Intentional self-harm by jumping from a high place

E958 Suicide and self-inflicted injury by other

and unspecified means

X76

X81

X82

X83

X84

Intentional self-harm by smoke, fire and flames

Intentional self-harm by jumping or lying before moving

object

Intentional self-harm by crashing of motor vehicle

Intentional self-harm by other specified means

Intentional self-harm by unspecified means

E959 Late effects of self-inflicted injury Y87 Sequelae of intentional self-harm

45

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