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<p>The Government recognises that quality information on the circumstances leading to self-harm and suicide, including issues relating to gambling addiction, can support better interventions. Coroners may be made aware of information about the motivation or contributory factors in a suicide. However, it is likely that any such information collected by coroners would not necessarily be complete or consistent, and therefore not always useful for delivering these interventions.</p><p>Expecting coroners routinely to assess the motivation for individual suicides would take the coronial role fundamentally beyond its legal parameters, which are to determine who died, and how, when and where they died. Coroners are not permitted, by law, to appear to determine any question of civil or criminal liability against another person.</p><p>However, in addition to the inquest conclusion, coroners have a statutory duty to make a Prevention of Future Deaths (PFD) report to a person where an investigation gives rise to a concern that future deaths will occur, and the coroner considers that action should be taken to reduce that risk. PFD reports are about learning and improvements to public health, welfare and safety and could, for example, raise concerns relating to gambling addiction where the circumstances of the individual case give rise to a concern. To promote learning, any PFD report and the responses to it must be sent to the Chief Coroner, who may publish them on the judiciary website.</p> |