Decision-Making in Youth Suicide Manner-of-Death Determinations: A National Mixed-Methods Study

Accurate classification of suicide deaths is essential for understanding and preventing suicide, yet misclassification remains a longstanding public health challenge. Medical examiners and coroners (ME/Cs), who certify cause and manner of death in the United States, operate within diverse institutional, legal, and cultural contexts that influence their determinations. These challenges are magnified for children and adolescents, whose deaths often involve ambiguous intent, limited psychiatric history, and complex social circumstances. Misclassification undermines national suicide surveillance, obscures the true burden of youth suicide, and limits the effectiveness of prevention and policy efforts. Despite their central role in mortality surveillance, little empirical research has examined how ME/Cs make youth suicide determinations or how institutional and contextual factors shape these decisions.

This study addresses this critical gap through a sequential explanatory mixed-methods design integrating a national survey with in-depth qualitative interviews. The overall objective is to identify, characterize, and contextualize how ME/Cs determine suicide as the manner of death in youth. Specifically, we aim to: (1) assess current practices, criteria, and sources of information used by ME/Cs in determining suicide as the manner of death for youth aged 5-17 and (2) use qualitative inquiry to explore perceived challenges, training needs, and recommendations for improving consistency and accuracy in youth suicide determinations.

Aim 1 involves designing, testing, and administering a national survey to all active ME/Cs (approximately 2,000 nationwide) using a two-phase approach (electronic and mail) to ensure the target sample size is met. The survey will assess investigative practices, evidence sources, and decision-making criteria used in youth suicide determinations. Analyses will examine how professional characteristics (e.g., role, years of experience) and jurisdictional contexts (e.g., urbanicity) influence knowledge, attitudes, and classification accuracy. We hypothesis that ME/Cs with greater medical training, more experience, and those serving urban jurisdictions will demonstrate greater knowledge, confidence, and accuracy in manner-of-death determinations.

Aim 2 builds on survey findings through qualitative inquiry with a purposive subsample (approximately 24) of ME/Cs representing variation in role and classification performance. Semi-structured interviews will explore perceived challenges, contextual pressures, and training needs related to youth suicide determinations. We will use reflexive thematic analysis to identify themes, elucidating how ME/Cs integrate evidence, institutional norms, and professional judgment when classifying ambiguous deaths. Integration of quantitative and qualitative findings will generate empirically grounded recommendations to improve consistency, accuracy, and transparency in medicolegal death investigation practices.This is the first study to examine national variability in youth suicide classification, identify modifiable barriers to accurate determination, and develop actionable recommendations for policy and training. Findings will inform the creation of standardized, evidence-based guidelines and specialized training modules for ME/Cs, ultimately strengthening national surveillance data and informing more effective suicide prevention practices. Future directions include developing a standardized youth suicide classification protocol, developing ME/C training interventions, and partnering with national stakeholders to translate findings into policy. This study provides the foundation for research focused on improving the accuracy of suicide mortality data and advancing public health strategies to reduce youth suicide in the United States.