Reforming the coroner's service

A review of the coroner's service in England and Wales and Northern Ireland was published in June 2003.¹ This was followed on 14 July by the Shipman inquiry report of Dame Janet Smith, which dealt with the role of coroners.² Dame Janet Smith also commented on the review. The coroner is central to death investigation in the English legal system, and implementation of these proposals will result in major changes. The current system is fragmented, legalistic, and inadequately funded. The coroner was exported to many Commonwealth countries. In the United States and Canada, many states and provinces have abolished the coroner's system, replacing it with a medical examiner's system. Other systems have been modernised, notably in Ontario, Canada, and Victoria, Australia.

Both the review and the judicial inquiry recommend a full time service. The review recommends that all coroners should be legally qualified (some are currently medically qualified) with a reduction to 60 full time jurisdictions. Overall responsibility for the coroner's system will be vested in a national “coronial council.” Medical input into the coroner's system is currently lacking, and such input is proposed by the creation of a statutory medical assessor, with a post in each coronial jurisdiction. The statutory medical assessor will have responsibility for the supervision of the death certification system and audit of the death certification process.

The Shipman inquiry proposes greater medical input. The inquiry rightly recognises that many of the decisions taken by the coroner, or frequently the coroner's officer, are medical. The inquiry therefore proposes 60 medical coroners in district offices, along with regional medical coroners and a chief medical coroner. There would only be legally qualified judicial coroners in 10 regional offices with a chief judicial coroner. The medical coroner would have the responsibility for the medical investigation. Where there is a need for a wider investigation the judicial coroner would supervise and would conduct inquests where appropriate. Properly trained coroner's investigators, headed by a chief investigator, would replace the current system of coroner's officers.

Both the review and inquiry recommend replacing the current system of death certification and cremation certificates with one unified process. The review gives the statutory medical assessor responsibility for organising a second, independent doctor to review a death. The inquiry proposes that the coroner's system should conduct the second review of all death certificates, with the coroner's investigator initially providing this role and the medical coroner supervising the process. The inquiry proposes random and targeted checks with fuller investigation of selected deaths.

Public inquests have been criticised, often being considered intrusive or perfunctory. However, the public inquest does provide a public review of controversial deaths. This is particularly important where the death involved law enforcement agencies or where someone has been deprived of their liberty. Both the review and inquiry see a reduction in mandatory inquests, with other inquests being discretionary.

Postmortem rates would fall under both the newly proposed systems. The review recommends more formal contractual relations with pathologists. The inquiry suggests that a special health authority could provide pathology services, including both forensic pathologists and histopathologists doing coronial work. Postmortem examinations should meet approved standards, with greater use of toxicology. The review calls for audit of coronial pathology and for the work to form part of a pathologist's appraisal.

The inquiry supports the proposals made by the Home Office's review of forensic pathology services for regional centres of excellence.³ It also supports the close association of forensic medicine and the coroner's service as exists in Victoria, Australia, a situation that has existed in Sheffield for three decades but which has not been replicated elsewhere in the United Kingdom. The Victorian Institute of Forensic Medicine (www.vifm.org) also coordinates the Australian National Coroner's information system, an internet based data system detailing coronial findings, which will be a major resource in injury prevention. Such information sharing should be a feature of any new system.

The review proposes that the new service should be based in the Lord Chancellor's Department. Dame Janet, who reported after the proposed abolition of the office of lord chancellor, proposes that the new service should be a body working at “arm's length” from the government, associated with both the new Department of Constitutional Affairs and the Department of Health. This would provide independence, but the service would still be accountable to parliament.

Of the two proposals, it seems to us that Dame Janet's provides the most comprehensive system. Her proposal would provide for greater integration of the services required in death investigation, with medical issues left to those with appropriate medical training; such posts are likely to attract more experienced and motivated staff. The new system will require funding, but the status quo is not acceptable. Proper death investigation protects the public. It cannot be neglected any longer.