Determining manner of death: statistical modelling of coronial decisions

Lack of standardised procedures and the varied expertise of decision-makers can make manner of death determination in ambiguous cases equivocal in its own right. The aim of the present study was to identify factors influencing coronial manner of death determinations in cases of equivocal death. Twenty-nine equivocal cases were randomly selected from the files of an experienced British county coroner. The coroner had determined these cases to be accidental deaths (n = 10), open findings (n = 8) or suicides (n = 11). Case files were individually reviewed and the information contained within each was identified for subsequent analysis. The structure of the data was examined using multidimensional scalogram analysis (MSA). Overall, MSA conducted on the data revealed cases fell within three geometric regions (accidental death, open finding and suicide), thus indicating a moderate systematic basis for manner of death determinations by this coroner. However, within the three MSA regions seven cases were identified where the coroner's manner of death determination differed from MSA manner of death region suggested by the case data. These discrepant cases are discussed in detail, with specific reference to the influence of subjective case variables on manner of death determinations.