Ambiguous Cases

Classifications of deaths vary regionally (see also Chapter 6). Some jurisdictions, for example, require a suicide note in order to render a verdict of suicide, yet fewer than half of all suicide victims leave a note. Russian roulette deaths are called suicides in some jurisdictions but accidents in others (Keck et al., 1998). Religious traditions, life insurance policies, or actual legal sanctions may motivate underreports of suicide. Some jurisdictions tend to call any deaths with prominent intoxication an accident. All of these differences interfere in cross-site comparisons (Brent et al., 1987; McCarthy and Walsh, 1975).

The verdict of “undetermined” (also known as “open verdict” in the United Kingdom) harbors many unreported suicides, with estimates ranging from 50–100 percent of all undetermined cases being true suicides (Brent et al., 1987; Cavanagh et al., 1999; Holding and Barraclough, 1975; 1978; Ovenstone, 1973). Undetermined verdicts appear to be more likely if the victim is older, died by poisoning, and is female, perhaps because this profile may not fit the archetypal suicide completer (Ohberg and Lönnqvist, 1998; Ovenstone, 1973). Studies suggest that the official suicide rate underestimates the true rate by about 30 percent, but that time trends are unaffected by classification errors (Brent et al., 1987; Gist and Welch, 1989; Sainsbury and Jenkins, 1982).

There are other types of ambiguous cases that may be misclassified as accidents or homicides. For instance, some controversy exists about the degree to which vehicular deaths might be due to suicide (Jenkins and Sainsbury, 1980; Phillips and Ruth, 1993; Schmidt et al., 1977). “Victim precipitated suicides,” often in the context of “suicide by cop,” (Mohandie and Meloy, 2000; Wolfgang, 1958) are difficult to determine definitively, but may contribute to the underestimation of suicide. The availability of routine toxicology, physical evidence, autopsy, and psychological data can influence the classification of suicide. Larger jurisdictions may be able to investigate most comprehensively, making inter-jurisdiction comparisons unreliable (Nelson et al., 1978). Differential investigation by ethnic group and differences in willingness to share information with an investigator can also distort the picture of suicide.

Training and Background of Coroner/Medical Examiner

There are marked differences in the training and background of the persons who by law certify a death as a suicide among states within the United States (O’Carroll, 1989) and internationally (see also Chapter 6). In the United States, the qualifications range from simply having an interest in the job (e.g., Indiana) to specialized training in forensic pathology (e.g.,



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