Bereaved people will have greater rights to participate in inquests, and coroners will deliver fuller verdicts emphasising the failures that contributed to deaths, under a package of reforms proposed for the 800 year old coroners system in England, Wales, and Northern Ireland.
The two year independent review, which was commissioned by the Home Office, also recommends a much tighter system of certifying deaths to prevent a recurrence of the Harold Shipman affair, in which the Greater Manchester murdered 215 patients over 23 years.
The 122 changes are aimed at bringing the 12th century office of coroner into the 21st century. Tom Luce, former head of social care policy at the Department of Health and head of the review team, said: "It is important that this forgotten service is updated and given the correct tools to ensure that it can be the professional and specialised service that bereaved families rightly expect it to be."
He added: "Quite a lot of families said the scope of the inquest is too constrained, and they [inquests] do not go far enough into the circumstantial causes of the death. They do not look far enough into the activities of, for example, the hospital or prison.
"Widening of the boundaries of inquests within reasonable limits should become the norm, so the families are not left feeling that there was this process that did not get to the heart of things."
Home Office minister Paul Goggins said: "The coroner system has long laboured under outdated legal provisions which were never designed to meet the demands of today's society. It is essential that we build an effective, supportive, and transparent system that commands public confidence." He said the government would publish a response after the second report of the judicial inquiry into the Shipman affair, which is due later this summer.
Under the changes, all existing coroners would have to reapply for their jobs. The present 136 coroner districts in England and Wales would be replaced by 60 areas broadly linked with police authorities.
At present most coroners are solicitors (some combining the coroner's job with legal practice), and a few are doctors. The review recommends that all coroners should work full time and have at least five years' practice as a solicitor or barrister. Doctor coroners would be phased out, although those now in office would be able to reapply, with their experience as coroners replacing time in legal practice.
There would be a national coroner service for England and Wales and another for Northern Ireland, each headed by a chief coroner, who would be a judge. The most complex inquests could be presided over by a High Court or circuit judge.
Each coroner will work with a doctor as a statutory medical assessor. The doctor will supervise and audit the death certification process, handle cases needing medical investigation, and create links between the coroner's office and public health and safety networks.
The review says that one critical defect in the current system is the separation of the death certification and coroners' processes. No public authority is responsible for seeing that deaths are properly certified and that deaths that ought to be investigated by the coroner are reported for investigation. There is little to stop an unscrupulous doctor from "certifying his way out of trouble."
There is also "persuasive evidence suggesting that the coroner service is not identifying some suicides, drug related deaths and deaths to which adverse reactions to prescribed drugs may have contributed," it adds.
Currently, when a body is to be cremated a second doctor must sign the death certificate. This second doctor can be a colleague of the doctor who treated the patient. Under the reforms an independent second doctor drawn from a panel kept by the statutory medical assessor would look at medical records and prescriptions and certify the cause of death for both burials and cremations.