He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction recommended that the process by which suicides are investigated by coroners should be reviewed in consultation with whānau and families to ensure the most responsive and supportive system is in place. This recommendation was included in Every Life Matters – He Tapu te Oranga o ia Tangata: Suicide Prevention Strategy 2019–2029 and Suicide Prevention Action Plan 2019–2024 for Aotearoa New Zealand.
The Suicide Prevention Office within Manatū Hauora commissioned KPMG to undertake this review with a Design Group comprised of people bereaved by suicide to provide a view on what a system that validates the impact of suicide and supports healing looks like. In line with this, the report reflects the views and perspectives of the Design Group. It does not necessarily represent the views of Manatū Hauora or wider government, and the recommendations do not necessarily take into account constitutional arrangements or legislative frameworks.
The report describes 18 recommended changes to current investigative processes for suspected self-inflicted deaths, which include improvements and enhancements to existing investigative processes, as well as changes to systems and processes.