Mapping coronial discretion in suicide death investigation

This article examines coronial investigations into the suicide deaths of people voluntarily admitted to a psychiatric facility. It focuses on this context of suicide – death following or during voluntary mental health treatment – to unpack how discretionary coronial decision-making around suicide developed in the historical governmentality of death. The evolution of the coronial role following suicide is also situated in broader policy changes around mental health that narrowed the mandated focus of coroners as the mental health sector expanded beyond asylum walls, reordering mandatory scrutiny along the lines of patient status as opposed to institutional site. Considering this history, the article traces how contemporary discretionary coronial decision-making around suicide can therefore disassociate a death from questions of institutional treatment. The article argues that thinking ‘institutionally’ about psychiatric facilities, whether private or public, as ‘sites of state confinement’ directs attention to how these sites operate as investigatory vacuums, and how the limited coronial acknowledgement of these institutional sites of ‘care and control’ supports individualistic views of suicide. By identifying a gap in understanding the social and legal impact of this dimension of discretionary coronial work in Australia, the article contributes to literature on coronial decision-making following suicide.