Reform of investigation of deaths

The UK government has recently published a draft bill for reform of the investigation of deaths in England and Wales by the coroner system.¹ A coroner is an independent judicial officer and must be a barrister, solicitor, or, currently, a medical practitioner of not less than five years' standing (the last qualification is abolished in the draft bill). This proposed legislation heralds many changes, several with implications for doctors (box). These are all sensible evolutionary changes that will lead to a more consistent, effective, and better managed service. There are several problems, however, that the draft bill does not tackle.

The draft bill fails to cover important recommendations made by a government review of death certification and investigation,² by the Shipman Inquiry (which followed the murder of more than 200 patients by general practitioner Harold Shipman),³ and by the UK Home Office.⁴ Moreover, it does not give detailed instructions on the categories of deaths that should be investigated. Section 1 of the bill simply requires a senior coroner to investigate if she or he suspects that a death was violent or unnatural, if the cause of death is unknown, or the death occurred in custody. The bill does not discuss the format of certificates for notifying death and for authorising cremation and does not take up a previous proposal for a unified system of certification for burials and cremation because this might delay funerals.⁵

Reform of investigation of deaths in England and Wales

The draft bill will lead to:

• Fewer coroners

• A greater proportion of full time coroners

• A chief coroner who reports to the lord chancellor, oversees training and performance of coroners, and hears appeals against their decisions

• A coronial advisory council to give advice to the chief coroner and lord chancellor on the operation and administration of the coroner system.

The draft bill also:

• Clarifies coroners' powers to retain human tissues and organs

• Gives coroners substantial new powers to enter and search premises, including powers to seize paper and electronic records

• Clarifies when a jury should be present at an inquest and reduces the numbers of jurors required

• Gives powers to the lord chancellor to make regulations about investigations and rules for inquests

• Creates the post of “coroner for treasure”

• Proposes a charter for bereaved people who come into contact with the coroner's system, setting out rights to information, participation, and appeal.

Another proposal not followed through was to appoint medical examiners to conduct medical investigations of natural deaths, approve death certificates, and promote proper certification practice among doctors. The draft bill does provide, however, for enabling each coroner to buy in medical support, and for the creation of the new post of chief medical adviser to the chief coroner. The vision (of the government's review and Shipman Inquiry) of a coronial service that receives reports of all deaths in England and Wales, oversees certification in all cases, conducts investigations, and prepares reports to inform public health will not be achieved.

This means that doctors will still bear the considerable responsibility of completing certificates for death and cremation. New certification procedures may be introduced eventually, but for now doctors will have to adhere strictly to guidance on completing these forms to minimise the weaknesses of the current systems.⁶,⁷

The first paragraph of the foreword to the draft bill states that investigations and inquests “will give an official finding of the facts, and can identify lessons for preventing future deaths.” This will sometimes be true, and a senior coroner “who believes that action should be taken to prevent the recurrence of” similar fatalities may report the matter “to a person who may have power to take such action, and to the Chief Coroner” (section 12(2)). But in the main text of the draft bill the aim of investigations and inquests is stated simply as to find “who the deceased was, and when, where and by what means he came by his death” (section 10(1)). Senior coroners and juries will be prohibited from expressing opinions on any other matters. The absence in the draft bill of any more explicit aim to prevent death or injury, arguably the major policy basis for a modern coroner's system, is a lost opportunity for public health.

Another important lost opportunity relates to forensic pathology. A dynamic coroner system serving the community well is a partnership between law and medicine, especially the small subspecialty of forensic pathology. A coroner's bill is the obvious place to outline the structure, powers, and processes for this subspecialty, which currently has no coherent framework to sustain and nourish it. Section 26 of the draft bill authorises a senior coroner responsible for investigating a death to request “a registered medical practitioner to make a post mortem examination of the body” but does not specify that the practitioner should even be a pathologist, let alone a forensic pathologist.

The words of Sir Henry Harvey Littlejohn, professor of forensic medicine and dean at the University of Edinburgh and chief police surgeon of Edinburgh, spoken in the first learned address to the newly formed Medico-Legal Society in London in 1902, come to mind: “It would be ludicrous if it were not such a serious matter to reflect that in this advanced age and in an enlightened and humane country the law still permits any medical practitioner to be summoned to make a post mortem examination, without any regard to his knowledge, his previous experience or his capacity to fill the duty thus imposed on him.”⁸ We hope that the Lord Chancellor will remedy this through regulations or guidance (section 65).