Coroner service - urgent reform needed?
An iPM listener emailed to say her family's been waiting almost two years for an inquest after their daughter died in a car accident in August 2006.
So, we've decided to take a closer look at inquests and the coroner system.
According to the Coroner's Act 1988, when someone dies 'a violent or unnatural death' or 'a sudden death of which the cause is unknown', the death has to be reported to the coroner and there has to be an inquest to identify the person and to answer the questions 'how, when and where' the person died and if there are to be no criminal proceedings. (Inquest Information Pack)
There are around 20,000 inquests in the UK each year, about 2,000 of which require a jury.
Currently, there is no national coroner service, the coroner and their courts are all managed locally.
There is no time period within which an inquest must take place. And there is no
formal complaint system.
A draft Coroner Reform Bill was proposed in 2006, but hasn't yet made it through Parliament as it's been delayed twice.
You can read the latest update on The Ministry of Justice website.
Have you had any dealings with the coroner service? Have you attended the inquest of a loved one? Who would you like to hear from on this? All comments welcome.
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Comments
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Many years ago I was a magistrates' clerk. JP's had virtually carte blanche in sentencing and general procedure. Now by Home Office dictat JP's are highly constrained and unable to use common sense to any degree. The Magistrate's Courts were all independant - and perhaps too inconsistant as a result.
My concern for a "review" of Coroner's Courts would be that the seemingly onward march of state control to reduce the free speech of responsible Coroners will be curtailed. Improve the throughput of cases by all means. That involves investment (oops! sorry I swore).
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I am the Medical Referee to a local Crematorium; that is, mine is the final authority required for the body of a deceased person to be cremated. I have to be sure that the cause of death has been properly recorded and registered, and that there is no discernable reason why a body needs to be retained for further examination. At least two other doctors are required to complete detailed questionnaires about the deceased person's medical condition prior to death, and to certify the cause of death; the first doctor may be newly qualified, although the second must have been qualified for five years, and there must be no professional or personal relationship between the two doctors.
In 1993, one of the few things I think David Blunkett got right during his tenure of the Home Office, was to publish a paper on the future of death certification, in which he basically argued that ALL deaths [not just the more difficult few, as at present] should be certified by the Coroner's service, and that all Coroners should have a medical team to scrutinise all death certificates, and investigate those which were not straight forward; only one senior doctor having clinical care of the patient prior to death should give the [more detailed] death certificate, and the Medical Referee would be replaced by a Medical Examiner working with each Coroner.
Superbly sensible suggestions - postponed YET AGAIN by this inept Government!
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revdrpaul @2.
Let's play the law of averages. What's the chances of another GP murdering 200 of his patients? Will it cost money? Will the public put two and two together to make four?
A child is murdered. Recomendations are made. No actions are taken until the third child dies and then only in a form of macarbre postcode lottery for abused children.
So for a ME for Coroners we need two more mass murdering GPs to get the ball rolling.
I would like to think that if we lived in a democracy this kind of lazy government might happen less often but in this case I am not so sure it would make much difference.
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[To the moderator: when I wrote a letter to my local paper with my observations below of the behaviour of Advocates, I was told it was too risky to be published. As I was only reporting what I saw and experienced I did not think this would be a problem - especially as they are free to say all kinds of things about bereaved people eg being over-emotional etc. Please consider what Ihave writen carefully as I do not wish to be sued for defamation - they have money, I don't!)
Having helped a lot of people in a major train crash I decided to attend the Inquest as I had never been to one before. I ended up attending nearly every day of the 4 weeks as I felt it was so important for the bereaved to have a witness to what they went through. I also realised how important it was for survivors and their families to receive daily reports of proceedings as most were unable to attend either for reasons of distance, work or psychlogical inability to do so. (There is no written transcrpt of the proceedings.) Thinking back I still feel shocked by what I saw and heard. The manner in which the bereaved are treated by the system and powerful Advocates, especially those who challenge and become powerful, was unbelievable. I witnessed the raised eyebrows and what I would only describe as smirks of some of the legal people whenever a bereaved person spoke and one was seen texting in spite of the ban on mobiles in the court. At the end of the 4 weeks one bereaved person told me that only one of the Legal Representatives had the humanity to come up to him and wish them well.
The whole system appeared to me to be biased against the bereaved - in this case because a fragmented rail industry with so many different agencies meant that each agency had their own two legal representatives and resources behind them. One of the bereaved families managed to obtain Legal Aid as an exceptional case but another represented themselves - just imagine the strain they were put under. This meant that whenever the Coroner asked the Advocates for advice on various points about procedure the Advocate for the bereaved family was vastly outnumbered by the 10 or so Advocates for the industry.
Another point that really came home to me is that without a fatality then mere survivors, some of whom still suffer from their injuries, trauma & loss of income, would have had no means of finding out facts or having challenging questions asked. The fact that the Inquest is 'not for them' and not their business' was brought home quite starkly. Public enquiries are rarely granted and usually only after long campaigning so the Inquest is the only source of information. I think for major incidents there needs to be a different system (perhas a half way house between Inquest and Public Enquiry if that were possible) with specially trained coroners who can deal with multiple traumatically bereaved people (who in some cases are survivors themselves). They need to be very brave people to challenge powerful institutions. I have watched with interest and admiration the Oxford Deputy Coroner who stuck his neck out and dared to challenge powerful agenices when dealing with military deaths.
The recent Government decision not to grant Legal Aid to bereaved familie also leaves bereaved families feeling a great sense of injustice.
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