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<p>The information recorded by the coroner in the Record of Inquest is dependent on
the circumstances of the individual case and is at the coroner’s discretion as an
independent judicial office holder in the exercise of their statutory functions. The
register is completed by the Registrar using the coroner’s certificate after inquest,
and will record the medical cause of death and the conclusion of the inquest. A death
certificate contains the same information as the register entry.</p><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.
However, whilst coroners may be made aware of information about the motivation or
contributory factors in a suicide, it cannot be guaranteed that consistent and comprehensive
information on a deceased person’s background will be made available to the coroner
in every case.</p><p>In addition, expecting coroners to routinely 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.</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 an individual case give rise to a concern. To promote learning,
all PFD reports and the responses to them must be provided to the Chief Coroner, and
most are published on the judiciary website.</p>
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