TECHNICAL NOTE 1 ABS CODING OF SUICIDE DEATHS


BACKGROUND

1 Users of suicide data have raised concerns regarding the number of deaths identified as suicides in ABS causes of death data for a number of years. As a response to these concerns, the ABS has undertaken a number of investigations and made a number of changes to both coding, quality assurance and dissemination practices. A summary of the changes introduced are listed below:

• publication of Information Paper: External Cause of Death Data Quality (cat. no. 3317.0.55.001) in April 2007 in order to assist users in interpreting ABS external causes data.
• publication of Information Paper: ABS Causes of Death Statistics: Concepts, Sources and Methods (cat. no. 3317.0.55.002) in March 2008
• all coroner certified deaths registered after 1 January 2007 will be subject to a revision process. This is a change from previous years where all ABS processing of causes of death data for a particular reference period was finalised approximately 13 months after the end of the reference period. Where insufficient information was available to code a cause of death (e.g. a coroner certified death was yet to be finalised by the Coroner), less specific ICD codes were assigned as required by the ICD coding rules. The revision process will enable the use of additional information relating to coroner certified deaths as it becomes available over time resulting in increased specificity of the assigned ICD-10 codes.
• improved quality assurance processes particularly aimed at assessing and improving the quality of suicide coding
• revised coding instructions for ABS coders in coding suicides to ensure greater consistency in coding outcomes between individual coders

ICD 10 CODING RULES FOR INTENTIONAL SELF HARM

2 International coding rules are used to assign codes from the International Classification of Diseases and Health Related Problems, 10th Revision (ICD-10). The coronial determination of intent is especially important for statistics on suicide deaths because information on intent is necessary to complete the coding under ICD-10 coding rules.

3 The coding rules for ICD-10 give no additional notes or definitions at the beginning of the Intentional self-harm categories (X60-X84) that provide the coder with an indication of when an intentional self-harm code should be assigned. The only guidance is an inclusion note for suicide. Additionally, no reference is made in Volume 2 of ICD-10 of the assignment of intentional self-harm codes. The coding index defaults external causes to "accidental" unless qualified with further description.

4 Previous versions of ICD-10 clearly provided an indication for coders in the use of the undetermined intent categories via a Note at the beginning of the Y10-Y34 categories. The note indicates that these codes can only be assigned "where available information is insufficient for the medical or legal authority to make a distinction between accident, self harm and assault ". The 2007 version of ICD-10 has altered the instructions for undetermined intent categories to : "This section covers events where available information is insufficient to enable a medical or legal authority to make a distinction between accident, self-harm and assault. It includes self-inflicted injuries, but not poisoning, when not specified whether accidental or with intent to harm (X40-X49). Follow legal rulings when available."


HISTORICAL ABS PRACTICE

5 In order to classify a death as suicide (intentional self-harm) the ICD-10 interpretation used by the ABS requires that specific documentation from a medical or legal authority be available regarding both the self-inflicted nature and suicidal intent of the incident. If this information is not available then the death must be classified as accidental. The interpretation of what constituted a "medical or legal authority" has been inconsistently applied by the ABS over a number of years.

6 The first interpretation used by ABS coders was that only a coronial determination of "suicide" met the criteria for coding of a particular death as suicide. This interpretation then meant that a case needed to be closed by the coroner and that the coroner had made a formal determination of suicide in order to code a suicide as such. However, the interpretation used by the ABS resulted in some suicide deaths being "missed" due to the fact that coroners may be reluctant to determine suicidal intent (particularly in children and young people). In some cases, no statement of intent will be made by a coroner. The reasons may include legislative or regulatory barriers, sympathy with the feelings of the family, or sensitivity to the cultural practices and religious beliefs of the family. For some mechanisms of death where it may be very difficult to determine suicidal intent (e.g. single vehicle accidents, drownings), the burden of proof required for the coroner to establish that the death was suicide may make a finding of suicide less likely. In addition, if the coronial case had not been finalised by definition there is no coronial determination. In this case ABS coders would determine what information was available on the National Coronial Information System (i.e. police, autopsy or toxicology reports) and would determine an intent from the available information.

7 The second interpretation used by ABS coders was that a "medical or legal authority" included not only a coroners determination but also police, autopsy and pathology reports. This resulted in the coder using a wider range of information in which to code the death record. This interpretation resulted in less deaths being "missed" as suicide deaths, however as there was no further guidance given to coders, this resulted in inconsistent coding due to differing interpretations of what is acceptable evidence of a suicide in police, autopsy and pathology reports..


ABS SUICIDE CODING PRACTICE FOR 2007

8 For processing of deaths registered from 1 January 2007, revised instructions for ABS coders were developed in order to ensure consistency in the coding of suicide deaths and compliance with the revised notes for coding to the undetermined intent categories. At the time that the ABS ceases processing, each coroners record on the NCIS will have a status of "open" or "closed" (See Technical Note: Coroner Certified Deaths, for further information on coroner certified deaths). The NCIS case status impacts on how deaths are coded with regard to suicides.With the introduction of a revisions process for all deaths registered from 1 January 2007, records with a case status of "open" will be recoded when the coronial process is finalised and the status changes to "closed". Below is a summary of the suicide coding process used by the ABS.


SUICIDE CODING OF CLOSED CASES ON NCIS


SUICIDE CODING OF OPEN CASES ON NCIS