Special Projects Fund

Project Title

Learning from Loss: Improving Suicide Fatality Reviews for Effective Prevention Activities

Grant Amount


Priority Area

Special Projects Fund

Date Awarded

March 20, 2019







Annually, an estimated 1,700 New Yorkers die by suicide, and 539,000 have suicidal thoughts.

These numbers may even underestimate the actual number of suicides in New York State because of limitations in the current system for suicide death reporting. Without the presence of a suicide note or a well-documented history of suicide attempts, coroners and medical examiners (CMEs) are unlikely to declare a death a suicide, especially in the case of an overdose death. Such misclassifications can impede the development of effective prevention strategies. In 2019, NYHealth awarded the Suicide Prevention Center of New York (SPCNY) a grant to improve the current system for suicide death reporting and prevention initiatives.

Under this grant, SPCNY replicated an Oregon pilot that trained CMEs to more accurately classify suicide deaths and transfer the information into the State’s Violent Death Reporting System. In Oregon, the new system made it easier to identify risk factors, allowing the State to work with community organizations and medical providers to better develop targeted interventions and treatments. SPCNY’s project replicated the Oregon pilot in four New York counties that had large numbers of annual suicides: Suffolk, Westchester, Onondaga, and Saratoga. SPCNY developed, tested, and refined the suicide fatality review process and death investigation data collection tool, then trained a review team of CMEs and medicolegal death investigators on the new system. The new system provided a more complete picture of the circumstances surrounding suicides to inform prevention initiatives at the State and local levels. SPCNY presented on this model at the annual New York State Suicide Prevention Conference, held educational webinars, and created a train-the-trainer program so that the model could expand across New York State.