In the coroner's chair – substance misuse and suicide in young people: have we got the focus...

Copyright © 2007 John Wiley & Sons, Ltd 17: 197–203 (2007)DOI: 10.1002/cbm

EditorialIn the coroner’s chair – substance misuse and suicide in young people: have we got the focus right?

Criminal Behaviour and Mental Health17: 197–203 (2007)Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/cbm.670

IAN SMITH1 AND ILANA B. CROME2*, 1HM Coroner, District of Stoke-on-Trent and North Staffordshire, UK; 2Keele University Medical School, Stoke-on-Trent, UK

Background

Throughout England and Wales, it is a requirement that when any person dies, that death is formally registered. In most cases this is achieved by a registered medical practitioner issuing a medical certifi cate as to the cause of death. If the doctor cannot issue such a certifi cate, or if there is reason to believe that the death may have resulted from ‘unnatural causes’, then the death is referred to the coroner in whose jurisdiction the death occurred. Many of the deaths referred to the coroner are subsequently deemed to be from natural causes, following post mortem examination. However, if the coroner has reasonable grounds for believ-ing that the death is ‘violent or unnatural’ he or she is required, by law, to conduct an inquest (HM Government, 1988). Any death of a person in prison, even from natural causes, will require an inquest. The coroner will notify the Registrar of Deaths of the fi ndings, though it should be noted that, with the exception of deaths involving criminal proceedings at the Crown Court, the Registrar’s death certifi cate is not issued until the inquest proceedings have been concluded. A coroner is an independent judicial offi cer, who is legally and/or medically quali-fi ed and who is of not less than fi ve years’ standing (HM Government, 1988). He or she is appointed and paid by the local authority and works from offi ces sup-plied or supported by the authority, but is not controlled by the authority and cannot be dismissed by its offi cers. There are just over 100 different coroners’ jurisdictions or districts in England and Wales. Most coroners are still part time, although posts are becoming full time in most jurisdictions and the total number of coroners is slowly reducing as amalgamations take place. The Stoke-on-Trent and North Staffordshire jurisdiction has a full-time coroner.

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The Stoke-on-Trent and North Staffordshire coroner’s jurisdiction is very mixed, including both the deprived inner-city areas of some parts of Stoke-on-Trent and the more rural and sometimes, but not always, more affl uent areas of North Staffordshire. No two coroners’ jurisdictions are the same, and the number of cases reported to the North Staffordshire coroner is higher than the national average, due to two principal factors. First, the University Hospital of North Staffordshire, which is one of the largest hospitals in the country, takes patients with chronic and acute disease and trauma from all over the West Midlands region, resulting in an inevitably high death rate. Second, the generally very poor state of health of certain sectors of the local population produces a wide range of serious medical complications. This high death rate is a longstanding feature of the area covered.

Drug-related deaths

How signifi cant are substance misuse deaths for the North Staffordshire coroner? The population of this jurisdiction represents approximately 1% of the population of England and Wales. In 2005, deaths in North Staffordshire represented 1.72% of all deaths referred to coroners in England and Wales, and the inquests repre-sented 1.63% of all inquests. The annual reports for drug abuse deaths in the North Staffordshire area are, as a whole, about average for the country, without showing some of the problems experienced in, for example, London, Brighton, Liverpool or even the Channel Isles (Ghodse et al., 2006).

Inevitably the fi gures change slightly from year to year, but certain patterns appear to emerge (see Table 1). Men die more commonly than women from drug-related problems. The fi gures for the period 2001–2005 indicate an average of just over eight deaths per annum in the under-30 age group, with a peak of 13 in 2002 and only six in 2005. Preliminary fi gures for 2006 indicate only two deaths in that age group which, if confi rmed, will be a signifi cant reduction. The striking thing about the fi ndings (apart from the 2002 peak) is that deaths from drug abuse, which invariably involve heroin in all age groups, typically and increas-ingly take place in the older age groups. Only six of the 23 drug abuse related deaths in 2005 were of persons under 30 years old, and just two under 25.

Are the resources being directed in the right way?

Nothing in what follows diminishes the importance of any death from drug abuse in the young. It is also important to remember that, for every drug-related death, there are many more whose lives, and the lives of those around them, are being wrecked by drugs. Nevertheless, such deaths must be viewed in context. While, as noted, the average number of drug-related deaths is just over eight per annum in the under-30 age group, the average number of deaths per annum in the same

Substance misuse and suicide in young people


199

Tabl

e 1:

HM

Cor

oner

’s D

istr

ict

for

Stok

e-on

-Tre

nt a

nd N

orth

Sta

fford

shir

e

Year

Tota

lde

aths

refe

rred

to

coro

ner

Tota

lin

ques

tshe

ld

Dru

gab

use

deat

hs:

mal

e

Dru

gab

use

deat

hs:

fem

ale

Tota

lnu

mbe

rof

dru

gab

use

deat

hs

Dru

gab

use

deat

hsin

tho

seag

edun

der

30*

Suic

ide

inqu

ests

:m

ale

Suic

ide

inqu

ests

:fe

mal

e

Tota

lnu

mbe

rof

sui

cide

inqu

ests

Suic

ide

inqu

ests

in

thos

e ag

ed

unde

r 30

2001

3709

371

92

11 8

(H

6)26

733

Not

qua

ntifi

ed20

0237

4335

115

318

13 (

H12

)35

742

Not

qua

ntifi

ed20

0341

2440

115

217

8 (

H6)

215

26N

ot q

uant

ifi ed

2004

4058

511

173

20 8

(H

8)19

322

220

0540

2947

818

523

6 (

H8)

206

261

2006

3676

485

––

6 2

(H

1)20

222

1

*Fig

ure

in b

rack

ets

deno

tes

num

ber

of d

eath

s w

here

her

oin

was

impl

icat

ed i

n th

e ca

use

of d

eath

.

Smith, Crome


200

age group over the same period from road collisions in the North Staffordshire area alone was 15: one is statistically much more likely to die in a car than as a result of drug abuse, though drugs, and alcohol, may help achieve that end (Staffordshire Police, personal communication).

Suicides

The offi cial verdict at inquest in these cases is that ‘the deceased killed himself’, to which the words ‘whilst the balance of his mind was disturbed’ may be added. A person may self-harm and die but evidence of intent has to be present and proven beyond reasonable doubt. This can be diffi cult in some drug overdose cases (was it suicide or a cry for help?), so an open verdict may be recorded. Perhaps a more accurate and more socially acceptable verdict for suicide cases might be that ‘the deceased died as a result of self-harm’, removing the need to prove the intention to kill, but in a hangover from the days when suicide was a criminal offence it remains necessary for such a verdict to be established beyond reasonable doubt, and intent continues to be central to the verdict. Overall the numbers for North Staffordshire are down slightly on the fi gures for the 1990s, when over 20 suicides occurred per annum, even reaching into the low 40s in some years. The suicide verdicts for the years 2004–2006 reveal that in 2004 there were 22 such deaths (males 19, females 3), in 2005 there were 26 (males 20, females 6) and in 2006 there were 22 (males 20, females 2). Of these 70 cases only four were in the under-30 age group and there were six in the over-70 age group (including one 92-year-old). The overwhelming conclusion is that the most vulnerable group consists of men aged between 40 and 60. Again, here, the younger age groups are not so vulnerable.

What about alcohol?

We have a very strange attitude towards alcohol. In most sectors of the commu-nity in England and Wales alcohol is totally socially acceptable, drinking laws liberal and access to alcohol easy. Methodists, Muslims and members of one or two other religious groups profess to be teetotal but for many Christians alcohol is at the centre of their main religious ceremony – the communion wine. On the other hand, we shy away in horror from the unkempt alcoholics who can frequent our town centres, but we toast the monarch with wine or spirits. We recoil at the loud and drunken behaviour of young men and women who drink to excess. The production and consumption of all types of alcohol is nonetheless a very large part of our economy.

Until 1984, when there was a change in the Coroners’ Rules, ‘chronic alcohol-ism’ was a cause for inquest: it was regarded as an unnatural cause of death and equated with ‘addiction to drugs’. Since then, it has been considered to be a



201

‘natural cause’, unless there is evidence of death from, for example, acute alco-holic poisoning or aspiration of stomach contents due to high alcohol levels. Is there any real difference between the abuse of alcohol and illicit drugs? Surely the effects of alcohol can be as devastating on the individual and society, if not more so because of the numbers involved, as can those of heroin? One obvious difference is that of legal status; another is that of social mores and acceptability.

It is diffi cult to be too precise about how many deaths each year are due to the effects of alcohol. Because chronic alcoholism, liver cirrhosis and so on are regarded as natural causes and do not have to be reported to the coroner, one might guess that many such deaths will go straight to the Registrar of Deaths and bypass the coroner’s offi ce altogether. During 2005 all deaths reported to the North Staffordshire coroner having a clear link with alcohol, whether as a part of a drug-related death, a fall downstairs whilst drunk, a road traffi c accident, or just plain simple liver cirrhosis, were identifi ed as part of a study. In the current climate, even such research as this will undoubtedly under-record these deaths. However, despite the fact that the majority of alcohol-related deaths are now regarded as deaths from natural causes, many such deaths are still referred to the coroner (possibly a hangover from the previous system) and, as shown below, alcohol was a feature in a very substantial number of deaths.

The overall total number of alcohol-related deaths in 2005 was 117, which included 73 non-inquest cases. Thus, had chronic alcoholism still been a cause for inquest, the inquest load in North Staffordshire would have gone up by an extra 15%, to about 550. Forty-four deaths involving alcohol were the subject of inquest because they were not from natural causes. However, among the so-called natural causes, there were some shocking cases, including a young man of 29 with pancreatitis due to excessive drinking and a 32-year-old with alcoholic cir-rhosis. Most alcohol-related deaths were in the middle age ranges, with a particu-larly worrying number of separated or divorced women in their 40s and 50s, but there were younger people too. These fi gures are substantiated by national sta-tistics (Department of Health et al., 2007; Offi ce for National Statistics, 2007).

Stoke has the highest rate of hospital admissions specifi c to alcohol, mortality from liver disease and alcohol-related mortality in the West Midlands. All these indices are well above the English average. Nationally, the alcohol-related death rates for men in all age groups increased between 1991 and 2005. The alcohol-related death rate in the UK increased from 4144 in 1991 to 8386 in 2005. The biggest increase was in men aged 35–54, which more than doubled from 13.4 to 29.9 deaths per 100,000. However, the highest alcohol-related death rates in each year were for men aged 55–74. In 2005 the rate in this age group was 43.4 per 100,000. Similarly, the death rate for women aged 35– 54 nearly doubled between 1991 and 2005, from 7.2 to 14.2 per 100,000, a larger increase than the rate for women in any other age group. The highest rates in each year were again found in the 55–74 age group. In 2005 there were 19.2 alcohol-related deaths per 100,000

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202

population for women in this age group. In the 15–34 age group the alcohol-related death rate rose from 1991 to 2005: in young males it almost doubled (from 116 to 192 per annum, or 1.3 to 2.4 per 100,000 population), while in young females it increased from 63 in 1991 to 93 in 2005 (0.7 to 1.1 per 100,000) (Offi ce for National Statistics, 2007).

Viewed from this perspective the prevailing concerns regarding the high prevalence of binge drinking in young people may well be justifi ed: What sort of societal problems are we storing up? Deaths from illicit drug misuse, especially in the young, are unlikely to escape the coroner’s attention, but most from alcohol probably will.

Are the right systems in place?

Coronial fi les and systems are not set up to process data to produce trends. Coroners have neither the remit nor the resources to study social, or indeed any other, trends, apart from those provided for the Ministry of Justice (formerly for the Department of Constitutional Affairs, and before that for the Home Offi ce) at the end of each year. While there is a lot of information, it is generally case-specifi c, contained within the fi le and can only be extracted manually case by case. Successive governments have not tackled the problems facing coroners, presumably because of the costs involved. Coroners’ offi ces are under-resourced. Many coroners believe that every single death should be referred to the coroners’ service and that, by combining the coroners’ service with the death registration service, it should be possible, given better computer systems, to identify given features, provide further and better information for the public and help coroners understand what is happening locally. Under this system, too, the serial killer Harold Shipman might have been identifi ed much sooner.

Note

This editorial is based on the presentation given by Ian S. Smith, HM Coroner for Stoke-on-Trent and North Staffordshire, at the Annual Lock Conference on Friday 20th April 2007.

References

Department of Health, Home Offi ce, Department for Education and Skills, Department for Culture, Media and Sport (2007) Safe. Sensible. Social. The Next Steps in the National Alcohol Strategy. London: Department of Health.

Ghodse H, Corkery J, Oyefeso A, Schifano F, Thomy, T, Annan J (2006) Drug Related Deaths in the UK National Programme on Substance Abuse Deaths. London: International Centre for Drug Policy.



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HM Government (1988) Coroners Act 1988. http://www.opsi.gov.uk/ACTS/acts1988/Ukpga_19880013_en_1.htm [27 July 2007]

Offi ce for National Statistics (2007) Alcohol-related Deaths: Rates Rise Since 1990s. http://www.statistics.gov.uk/cci/nugget.asp?id=1091 [4 July 2007]

Address correspondence to: Prof. Ilana B. Crome, Academic Psychiatry Unit, Keele University Medical School (Harplands Campus), Harplands Hospital, Hilton Road, Harpfi elds, Stoke-on-Trent, Staffs, ST4 6TH, UK. Email: [email protected]

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