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CORONERS' SOCIETY OF ENGLAND & WALES - PRESS STATEMENT ON THE FUNDAMENTAL REVIEW OF DEATH CERTIFICATION AND INVESTIGATION, JUNE 2003

PRESS STATEMENT EMBARGOED UNTIL 10.00 AM WEDNESDAY 4TH JUNE 2003

CORONERS' SOCIETY SAYS REFORM TO CORONIAL SERVICES IS OVERDUE

The Coroners' Society of England and Wales contributed enthusiastically to the two year review conducted by the Home Office Review team under the chairmanship of Tom Luce, who today published its Report. While it has not yet had time to consider thoroughly all the 122 recommendations contained in the Review, the Society welcomes the fact that its members' contributions have clearly been taken into account by the Review team, and is pleased to see that many of its recommendations appear, namely:

• the discretion to avoid public inquests if neither the family of the deceased nor their community need it;
• better targeting of post mortem resources; better training for medical students, doctors and all involved in inquests;
• recognition of the important role played by Coroner's Officers and proper arrangements for their provision, training and support;
• the establishment of a small Coroner Service Inspectorate to monitor standards and the quality of interaction with bereaved families;
• opportunity for coroners to order greater privacy about causes of death and publication of material to protect grieving families, or to order greater publicity if the family opt for more openness;
• Regional Co-Coordinating Coroners - the Society suggested this to achieve more structure and uniformity of approach, believing that greater regionalism is a necessary part of modernisation;
• extension of protocols to provide higher uniform standards and best practice;
• the Society called for deaths by suicide not to be routinely inquested in public to preserve the privacy of the bereaved relatives.

The Society is interested in the proposal for the establishment of a new Coronial Council as an independent statutory body designed to oversee the public interest and family aspects, and able to give statutory guidance on the types of deaths which should be reported to coroners. It believes that this could promote consistent standards of service, but only if proper resources are made available. While the Review recommends better family access to and input of information through the system, the Society believes this will only be workable if sufficient additional people and resources are provided and will require sensitive handling.

The Society has reservations about the workability of some of the other proposals and generally about whether adequate resources will be allocated for their implementation.

• the Society is concerned if all families are entitled to meet the coroners conducting inquests into relatives' deaths. While this could be welcomed in cases such as cot death, with the number of cases investigated by the reduced number of coroners available they may not have sufficient time. In multi-party cases it can also lead to accusations of bias in favour of one group;
• the Society welcomes the reduction of retirement age to 65 from 70 but hopes that recruitment will be accelerated to ensure adequate numbers of experienced coroners are available to service demand;
• the Society endorses the need for mandatory training for all coroners but is concerned that this will not be achieved without proper funding;
• if Circuit Judges are to be used in more complex cases the Society would require reassurance about the adequacy of their training to help them to adapt to the non-adversarial structure of inquests which is radically different;
• it hopes that resources will be made available to ensure that the improvements rightly demanded and expected by those communities affected by the Alder Hey, Bristol and other reports will be found without delay;
• while it has long been the concern of many that autopsies following the deaths of children and babies should only be performed by paediatric pathologists, there are currently insufficient qualified practitioners to fulfil the need;
• while the Society welcomes the proposal that all pathologists should be regularly appraised, it again is concerned that resources must be provided to support this;
• The Society itself put forward detailed mechanisms for the introduction of Medical Assessors to meet the same needs. However in the form and numbers here proposed it doubts whether the post could be staffed retaining the vital independence from clinicians without losing doctors from the already-pressured National Health Service;
• it hopes fervently that this Report will receive the attention and implementation that its predecessor reports - the Wright Report (1931) and the Broderick Report (1971) never received.

Victor Round, HM Coroner for Worcester and Secretary of the Coroners' Society's Review Committee said today,

"While we are pleased to see many of our recommendations appear in this report, we remain genuinely concerned that without serious commitment to finding proper resources and implementing reforms soon, the changes for which members of the public and the coroners who serve them have been calling will simply not happen.

"In the meantime, we will continue to carry out our duties as required by the current law while at the same time developing with the Government the new and better service envisaged in the Report. We have long argued for a well resourced, efficient and effective death investigation service with the necessary powers and authorities and one which is responsive to the individual needs of families and all those others affected by death. Our hope is that the Government will now address those needs without delay and we hope to work closely with the Home Office, the Lord Chancellor's Department, the Department of Health and any others involved in this reform programme. While the reforms are taking place, coroners, their officers and staff have still to run and maintain the present system and to ensure that the concerns and interests of all those now suffering bereavement are addressed as sympathetically as the present systems and resources permit."

ENDS

Notes to editors: The Coroners' Society was founded in 1846 and has as its members all the coroners, deputy coroners and assistant coroners holding office. There have been a number of formal and informal contributions made by the Society, as well as by individual coroners, who have also provided the Review with detailed notes and submissions, made and received visits to and from Review Members, and completed detailed responses to consultation papers and comparative questionnaires and time studies.

• Every year, some 204,000 deaths (approximately 34% of all those occurring in England and Wales) are referred to a coroner. Most are concluded without an inquest although approximately one in nine (24,000 each year) is the subject of an inquest.
• The actions and decisions of coroners, as with others administering justice, are subject to the overview of the High Court. This offers a well-recognised avenue for testing the actions and decisions of a coroner. Each year, the High Court entertains 12-15 judicial reviews in this way, of which some (but not all) are allowed, resulting in the coroner having to rehear the case, take some other particular action or make a particular decision.
• An inquest is an inquiry. As such there are no parties, and the "set piece" battles which are the norm in adversarial courts and which apply across the rest of the English judicial system, have no place in the coroner's court. All those with a recognised proper interest (i.e., those with a familial or financial relationship or interest or those whose conduct may be called into question) should be striving to find the answers to simple but limited questions, e.g. who it is that has died and how, when and where the death came about and the details required to register the death. Other than on these matters the coroner's court is unable (indeed, it is forbidden) to make any pronouncement or finding.
• Some come to the coroner's court seeking a particular conclusion or defending a particular position. In many cases, they may be unaware of the limitations of the court and may have had their expectations unnecessarily raised. Inevitably, they may feel disappointed when the inquest is concluded and their expectations are not satisfied.
• Coroners are public officials, who are answerable through the English judicial system of which they are part. The Society and its members do not normally participate in debates on radio or television.
• It is not possible for any spokesman or coroner, whether or not directly involved in a particular case, to retain the judicial independence which is required of him or her and, at the same time, to be seen to enter into a debate centred upon the facts of particular cases without, thereby, being seen to be commenting upon such cases.

Over recent years, the Society has -

• published Practice Notes for Coroners;
• provided assistance, advice and professional help to individual coroners in their course of their duties;
• held regular meetings with departments of H.M. Government and various professional and other organisations to address matters of mutual interest and concern;
• made substantial contributions and submissions to various public and/or judicial inquiries, including the House of Commons Select Committee on Health (re: Adverse Effects of Medical Procedures), Bristol Royal Infirmary Inquiry, BSE Inquiry, Marchioness Inquiry, the original Shipman Inquiry (under Lord Laming) and Shipman Inquiry (under Dame Janet Smith) [still continuing]
• submitted papers to the (2000) Home Office Review of Death Certification; and
• submitted detailed suggestions and papers to the (2001) Home Office Fundamental Review of the Coroner System and Death Certification, as announced in the House of Commons on 30 January 2001.

More information from: Victor Round, Coroners' Society on 01562 887795 or at e-mail: crowner@freeuk.com Or from Sue Stapely, Quiller Consultants on 020 7233 9444 or at e-mail stapely@quillerconsult.co.uk Or on the Home Office website at http://www.homeoffice.gov.uk/justice/legalprocess/coroners

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Last modified:  Monday, 09-Aug-2004 08:53:21 BST by: Malcolm Bishop