Minutes of Central Statistics Office (CSO) Liaison Group on Suicide Mortality Statistics held on June 23^rd 2016 in the CSO Offices, Rathmines, Dublin.

In attendance:   Eileen Williamson and Ella Arensman  (NSRF), Suzi Lyons (Health Research Board), Deirdre O’Reilly (Irish Prison Service representing the Department of Justice), Anna Wallace (Department of Health ), Bernadette Smith (GRO),  Sara Parsons (Garda Commissioner’s Office),Paul M. Crowley, James Barrett, Carol Anne Hennessy (CSO).

Apologies:  Colm Desmond (Department of Health), Ciaran Austin (Console), Myra Cullinane (Cork City Coroner) Gerry Raleigh (National Office for Suicide Prevention).

Agenda item No 1 - Welcome and Introductions

Eileen Williamson welcomed everyone to the meeting, made the relevant introductions and conveyed the apologies of the non-attendants to the meeting.

Agenda item No 2 - Agree Minutes of Previous Meeting of the 14^th January, 2016 and Matters Arising

Minutes agreed. 

Actions arising from meeting of the 14^th January, 2016.

• The CSO is to carry out a more detailed analysis of the forms 104 issued and received for 2013. This Report is prepared and will be presented under Agenda item No 3 of meeting of 23^rd June.
• The CSO is to contact Department of Justice to get a blank form C71 and see the information requested on this form and enquire if this information can be made available to the CSO.  Copy of form C71 received by the CSO.
• The GRO to request that the Coroners group add 2 additional questions to their form.  In Coroner’s opinion was the death (a) a suicide or (b) not a suicide.   The Coroners are reviewing their form.  The Coroners Annual General Meeting is held in September of each year.  The liaison group on mortality statistics agreed that the CSO will send a formal letter on their behalf to the Chairperson of the Coroners and request that these 2 additional questions be included in their revised form.
• The CSO to investigate further if the Pulse data is a useful source of information.  As the information collected by C71 form wouldn’t be a suitable substitute for the Form 104, then this action is not necessary.
• The NSRF (Eileen Williamson) is to apply to become an Officer of Statistics to carry out further analysis on deaths given an open verdict in 2013.  The CSO is continuing to process this application and will be signed off on in due course.
• Sandra Walsh (Department of Health) is to revert to Paul Crowley regarding a representative from the CSO in the Connecting for Life group.  Action completed.

Agenda item No 3 – Report on the Form 104 Exercise

The CSO presented report on their analysis of Forms 104 in relation to unnatural deaths that occurred in 2013.  The report (i) outlined the number of Forms 104 that had been issued by and that were returned to the CSO (II) established how well the forms were completed by the Gardaí and (III) evaluated any gaps in the information returned.  In addition, details were presented of the number of cases where the tentative underlying cause of death had been changed totally or slightly as a result of information received from the Form 104.   The CSO stressed the value of the information that is received on the Form 104 and as a result of its analysis made recommendations to the group.  These are:

• A reminder letter is to issue in all cases where a Form 104 is not returned from 01\01\2016.  The reminder letter is to issue after 3 months from the date of issue of the original form.
• A letter is to be drafted and issued to all Superintendents outlining the importance of the Form 104 in the determination of the most accurate underlying cause of death.
• Contact is to be made with the head of training in Templemore requesting a meeting to discuss (a) the importance of the completion of the Form 104 to meet CSO needs and (b) advise on or provide training on the completion of the Form 104 as part of the Gardaí training program for recruits.

A hard copy of the report was distributed to all present and an electronic copy of report will be attached to the Minutes.

The Cork City Coroner’s comments regarding the current Form 104 were discussed and it was agreed that any review process would require the Coroners presence and input.

Sara Parsons of the Department of Justice will check if there is a directive for the Gardaí to return the completed Form 104 and she will revert to me in due course.  If there is a directive then it could be re-issued in order to encourage return of these forms across the country.

Agenda item No 4 – Suicide Cluster Exercise

As there is a general belief that deaths from suicide are under-counted, the CSO suggested that they carry out an exercise that involves looking at deaths from suicide that may form part of a geographical cluster.  Suicide deaths in excess of 3 are regarded as a cluster.   These deaths would be looked at individually to establish what was the underlying cause of death that was attributed by the mortality coder and if a Form 104 was issued\received.   The NSRF identified 2 such clusters i.e. Mayfield\Glanmire (22 deaths over a 2 year period circa 2009) and North Cork in 2011.  The NSRF will forward names and addresses of these particular suicide deaths, identified by the NSRF as being part of these 2 clusters, to the CSO for examination.

Agenda item No 5 –Late Registration of Suicide Deaths

The CSO circulated a hard copy of excel spreadsheet showing the additional number of suicide deaths that were registered late for the years 2000 et seq.  These figures can be added to the already published figures for each year to get the most accurate data for each year.  The late registered deaths can be added to in the future when the late registered data for 2014 at the end of the year.  The CSO intends making these figures available on the CSO Statbank facility so that these figures can be added to the published suicide deaths based on occurrence (i.e. the year the death occurred).

The NSRF requested that CSO look at the late registered deaths to see if particular counties are involved in the late registration of these deaths.

Agenda item No 6 – A Study of Untimely Sudden Deaths and People who Took their Lives while in the Care of the Donegal Mental Health Service – Study by the NSRF 2016.

The NSRF provided a hard copy of the report for the attendees, gave the background to and general outcomes of the report and hoped that this study could be replicated across the country.

Agenda item No 7 – Accidents and Undetermined Deaths: Re-evaluation of Nationwide Samples from the Scandinavian Countries – Paper by Tollefsen and Colleagues 2016.

The NSRF provided hard copies of this paper to the attendees for their perusal.

Actions Arising from the Meeting:

• Sara Parsons to revert to the CSO to with information of whether a directive exists to get Gardaí to return Form 104.
• CSO is to contact the Head of Training in Templemore to arrange meeting re training on completion of Form 104.  Done
• CSO to issue reminders within 3 months of the issue of the original Form 104.  Done
• A letter is to be drafted and issued to all superintendents outlining the importance of the Form 104 to the determination of the most accurate underlying cause of death.  Done
• Electronic version of the Form 104 to be circulated to members of the group.  Done
• CSO to write to Chairperson of the Coroners Group to request inclusion of 2 new questions on the Coroners form that is being reviewed (i.e. In the Coroner’s opinion was the death (a) a suicide or (b) not a suicide). Done
• The NSRF to provide the CSO with the names and addresses of ‘cluster’ suicides in both the Mayfield\Glanmire and North Cork areas.
• CSO to put table of late registered suicide deaths on Statbank 
• CSO to carry out further analysis on the geographical location of the late registered deaths.  Done

AOB

Next Meeting to be held by mid-October.

Carol Anne Hennessy

24^th June, 2016.