Former Chief Coroner Neil MacLean said the number of recorded suicides in New Zealand should be taken "with a large grain of salt".We want to blame - their fault, his or her fault, or this issue or that issue. None of that is really helping because it isn't getting to the heart of the issue.
"Some people could fall through the gaps because just relying on raw suicide numbers isn't giving us the true number," he said.
Judge MacLean said each case was judged on whether the evidence proved the person deliberately intended to take their life.
"That would include making a determination that it wasn't just an accident or indulging in risky behaviour without thinking of the consequences," he said.
I'm going to talk about that and some ideas for solutions over the next couple of posts.