7. Narrative verdicts in England and Wales

Annually, there are around 30,000 coroner’s inquests held in England and Wales that conclude with a verdict. Around 90% of these inquests conclude with a 'short form' verdict such as accident, misadventure, natural causes, suicide or homicide. Narrative verdicts can be used by a coroner or jury instead of a short form verdict to express their conclusions as to the cause of death following an inquest.

A narrative verdict can be given in a range of different circumstances, and for a variety of causes of death. Table 2 shows that almost half of all narrative verdicts in England and Wales in 2011 were where the underlying cause of death was some type of disease, most commonly a circulatory disease or a type of cancer (a neoplasm). For example, a narrative verdict is sometimes given if the deceased died from mesothelioma (an industrial disease which is often associated with exposure to asbestos in the workplace), but the source of the asbestos exposure could not be determined. Other examples of narrative verdicts include instances where the deceased may have suffered an accidental fall as a result of an underlying health condition, or where the deceased died whilst having medical treatment for an underlying health condition.

Table 2. Number of narrative verdicts: by underlying cause of death, England and Wales, 2011 Underlying cause of death Hard-to-code narrative verdict Other type of narrative verdict All narrative verdicts All causes 1,814 1,152 2,966 Diseases 816 603 1,419 Neoplasms 149 151 300 Circulatory 173 152 325 Respiratory 91 44 135 Digestive system 84 90 174 Other disease or condition 319 166 485 External causes 998 549 1,547 Transport accidents 153 15 168 Other accidents 802 229 1,031 Intentional self-harm 0 117 117 Undetermined intent 0 153 153 Other external cause 43 35 78 Source: Office for National Statistics Notes: 1. Underlying cause of death was defined using the International Classification of Diseases, Tenth Revision (ICD–10) codes shown in Box 1 below 2. Figures include deaths of non-residents 3. Figures are for deaths registered in 2011 4. Narrative verdicts are a factual record of how, and in what circumstances the death occurred. They are sometimes returned where the cause of death does not easily fit any of the standard verdicts. Hard-to-code narrative verdicts are those where no indication of the deceased's intent has been given by the certifier, which makes it difficult for ONS to assign an underlying cause of death. A more in depth explanation can be found in the the statistical bulletin Download this table Table 2. Number of narrative verdicts: by underlying cause of death, England and Wales, 2011 .xls

Just over half of all narrative verdicts in England and Wales in 2011 resulted from injury or poisoning (that is, as an ‘external’ cause of death), rather than a disease. Some of these narrative verdicts clearly state the intent (for example, accidental) and mechanism (for example, hanging, poisoning) of death. However, in some cases the coroner does not indicate whether the fatal injury was accidental or if there was deliberate intent to self-harm. These latter deaths are defined by ONS as ‘hard-to-code’.

ONS applies the rules of coding cause of death such that where no indication of intent has been given by the certifier, deaths from injury or poisoning must be coded as accidents. Therefore, unsurprisingly, Table 2 shows that about 40% of narrative verdicts are assigned an accidental cause of death.

An examination of a sample of hard-to-code narrative verdicts that ONS had coded as accidents (based on ICD coding rules) in 2011, found that between 40 and 50% of the deaths were where people had fallen in their home or in a care setting. There was no suggestion that these deaths were anything other than an accident. The remaining deaths had a variety of causes including poisonings and hangings. While many of these other deaths are likely to be accidents, suicide researchers are concerned that cause coding rules force ONS to code some probable suicides as accidents (Gunnell et al, 2011), meaning that official suicide figures may be an underestimate. These concerns have grown in recent years, as the number of narrative verdicts has increased.

Table 3. Hard-to-code narrative verdicts and all narrative verdicts (for 2011 only) as a percentage of all inquest verdicts: England, regions in England, and Wales, 2006 to 2011 Percentage Hard-to-code narrative verdict All narrative verdicts 2006 2007 2008 2009 2010 2011 2011 England 6 8 9 10 12 6 10 North East 4 6 6 7 8 2 4 North West 5 8 11 13 15 6 11 Yorkshire and The Humber 7 9 8 10 10 9 13 East Midlands 4 6 6 8 11 5 10 West Midlands 15 17 17 16 20 8 12 East of England 5 7 8 13 13 10 15 London 5 6 8 8 8 6 9 South East 5 6 7 6 8 5 8 South West 4 6 7 8 8 5 7 Wales 3 7 9 8 8 4 8 Source: Office for National Statistics Notes: 1. Narrative verdicts are a factual record of how, and in what circumstances the death occurred. They are sometimes returned where the cause of death does not easily fit any of the standard verdicts. Hard-to-code narrative verdicts are those where no indication of the deceased's intent has been given by the certifier, which makes it difficult for ONS to assign an underlying cause of death. A more in depth explanation can be found in the the statistical bulletin 2. Figures are for persons usually resident in each area, based on boundaries as of August 2012 3. Figures are for deaths registered in each calendar year 4. Percentages are calculated as the number of hard-to-code narrative verdicts as a percentage of all inquest verdicts. Figures are also provided for all narrative verdicts for 2011 only, as prior to 2011, ONS were only able to identify hard-to-code narrative verdicts in our mortality database Download this table Table 3. Hard-to-code narrative verdicts and all narrative verdicts (for 2011 only) as a percentage of all inquest verdicts: England, regions in England, and Wales, 2006 to 2011 .xls

Between 2001 and 2010 there were large year-on-year increases in the number of narrative verdicts returned by coroners in England and Wales (Reference Table 13). In England, there were almost double the number of narrative verdicts in 2010 (3,170) than there were in 2006 (1,592). In Wales, the number increased almost three-fold over the same period from 52 in 2006 to 147 in 2010. This trend is supported by figures from the Ministry of Justice showing that the number of unclassified verdicts (including narrative verdicts) in England and Wales increased from 2,406 in 2006 to 4,180 in 2010.

Moreover, there is considerable variation in the use of narrative verdicts between coroners. Until 2011 the region with the highest proportion of narrative verdicts (out of all inquests that returned a verdict) was the West Midlands. In 2010 around 20% of inquests in the West Midlands resulted in a hard-to-code narrative verdict compared with only 8% in the following regions: South West, North East, South East, London and Wales. This regional variation led to concerns that if the use of narrative verdicts continued to increase, it could affect the reliability of ONS suicide statistics – especially at a sub-national level.

To help improve the accuracy of suicide statistics, in January 2011 additional guidance was given to the ONS coding team in order to improve the coding of narrative verdicts. ONS also provided advice to coroners on the types of narrative verdicts that are hard to code, elements of which the Local Government Committee of the Coroners Advisory Group incorporated into an advice note issued in October 2011. This advice note is unlikely to have had a big impact on suicide statistics in 2011, as most of the deaths would have been registered before the note was issued. ONS will continue to monitor the impact in the future.

Prior to 2011, ONS could only identify hard-to-code narrative verdicts within our mortality database, so figures for the years 2001 to 2010 reported in Reference Table 13 (587 Kb Excel sheet) do not show the total number of narrative verdicts. In 2011 ONS made improvements to enable the identification of all narrative verdicts. Reference Table 13 (587 Kb Excel sheet) shows that in 2011 the total number of narrative verdicts fell by 12% in England (2,796 narrative verdicts), but increased by 5% in Wales (155 narrative verdicts). However, Ministry of Justice figures suggest that the number of unclassified verdicts (including narratives) increased by 5% in England and Wales between 2010 and 2011 (from 4,180 to 4,400). This is likely to be due to differences in the ONS definition of a narrative verdict and the MoJ definition of an unclassified verdict, as there is no fixed definition of a narrative verdict.

Between 2010 and 2011 the number of hard-to-code narrative verdicts decreased by 46% in England and by 49% in Wales. Every region in England showed a decrease in the number of hard-to-code narrative verdicts. The largest decrease was in the North East, which saw a 71% fall; and the smallest decrease was in Yorkshire and the Humber, which only saw a 5% fall.

Hence, the additional guidance given to ONS coders and coroners appears to have significantly reduced the number of hard-to-code narrative verdicts, thus improving the reliability of ONS suicide statistics.