HM Coroner
Derek Winter
City of Sunderland
Thoughts for Today
• The Coroner and Justice Bill 2009
• Corporate Manslaughter and Corporate
Homicide Act 2007
• The Road Safety Act 2006
• The future of Forensic Pathology?
Handouts
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The Work of the Coroner
When Sudden Death Occurs
Understanding CMCHA 2007
A Guide to CMCHA 2007
Circular 2008/03 Road Safety Act 2006
Draft Charter for Bereaved people who come
into contact with a reformed Coroner System
• Coroner Reform Bulletin (2) April 2009
• What to do after a death
• R-v-Evans[2009] EWCA Crim 650
“The Coroner frequents more public houses
than any man alive. The smell of sawdust,
beer, tobacco-smoke and spirits is
inseparable in his vocation from death in its
most awful shapes”
Charles Dickens
Bleak House ch11
2007
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504,300 deaths in England Wales
234,500 referred to the Coroner (46%)
110,400 subject to PM (47%)
30,800 Inquests (13%)
2946 traffic fatalities
750 homicides (75% male)
3000 suicide verdicts (80% male)
Coroner Service
Funded by LA (s27 indemnity)
104 Coroners (Deputies & Assistant Deputies)
Police Coroners Officers (Police Staff)
Corporate Manslaughter Basics
• An Organisation will be guilty if the way in which
its activities are managed or organised (at a
senior level) causes a death and amounts to a
gross (far below) breach of a duty of care to
the deceased
CMCHA 2007 Section 8 (3)
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The Jury may also consider the ….
Attitudes
Policies
Systems
Accepted Practices
….that were likely to have encouraged the
breach or produced a tolerance of it
Practicalities
• Investigate Sudden and Unexplained Death
• Refer to the Police prior to or during Inquest for
Gross Negligence Manslaughter and now
Corporate Manslaughter to consider
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Employers
Local Authority
Doctors
Pharmacists
(NB Govt estimates were for 10/12 prosecutions pa)
Problems
• Do we need a forensic autopsy in more/all
cases?
• 2nd PM?
• Police/CPS views?
• Delay
• Family never get a chance to be heard
Expectations
• Inquests are not:
• A dry run for a civil hearing to determine liability
• To adjudicate complaints
Inquests determine who the deceased was
when and where they died and how they came
about death BUT……
Pressures
• Confusion with Neglect v Negligence
• Neglect is a gross failure to provide basic
nourishment/medical treatment (Jameson)
• Unlawful Killing Verdict has to be beyond
reasonable doubt
• Cannot apportion blame (r42 CR84)
• No self incrimination (r22 CR84)
More Pressures
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Ordinary PM (£90)
Independent PM (£300)
HO Forensic PM (£2500)
“defence” PM ?
Police resources
Disclosure/Statements/Policies/Experts
Delays
Scope of the Inquest/Jury?
And More!
• Who is a manager at a senior level in a medical
death?
• Appointment/supervision/training/review of staff
• Procedures-review and audit
• Volume of NHS instructions to Trusts
• Causation
• Emergency response versus medical treatment
• Longer case-delays with routine work
• Reluctance to provide full reports for fear of
disclosing criminal liability.
• Conflicts of interest
• More lawyers
• Rule 43 reports
The Road Safety Act 2006
s20 Causing death by Careless or inconsiderate driving:
“A person who causes the death of another person by driving a
mechanically propelled vehicle on a road or other public place
without due care and attention, or without reasonable consideration
for other persons using the road or place, is guilty of an offence."
s21 Causing death by driving: unlicensed,disqualified or uninsured drivers
Mandatory adjournment under s16 Coroners Act 1988 (both for Magistrates and
Crown Court)
Inquest may be resumed after the criminal proceedings are concluded if in the
Coroners opinion there “is sufficient cause to do so”
Re-trial? Sentencing issues-further evidence-family to be heard
Chief Medical Officer Guidance
• 1998 “All those who have information which could help Coroners
inquiries should disclose it voluntarily and not only when requested”
• 2008 “NHS organisations should aim to assist Coroners by providing
prompt access to information that may be relevant to an Inquest.
Where an organisation takes the decision to withhold information
from an inquiry, this should be clearly documented with an
explanation of the considerations that are believed to outweigh the
public interest that would be served by disclosure”
• Coroners will not be playing “hide and seek” with NHS organisations
and will look very seriously at contempt of Court and/or attempting to
pervert the course of justice
The Coroners and Justice Bill
2009
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Chief Coroner (High Court Judge)
Leadership
Training and Guidance
Annual report
Support for Coroners
Rule 43 reports-collating and publishing
Case Law
Consultation/involvement with Coroner appointments
Liaison with relevant organisations
Inspections (operation/standards of service not Judicial
functioning)
• Appeals (on fact and law)
• Directing other Coroners to conduct investigations
• Applications where no body exists
…and more
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Applications for search and entry
Retention/release of bodies
Investigation of (non judicial) complaints
Conducting an Investigation
Designation of medical practitioners
Emergency Planning
Issuing Practice Directions to Coroners
Identifying and disseminating best practice to Coroners
Determining how the standards of service in the Charter
for Bereaved People will be applied
• Liaison with other stakeholders HMICA: LGA: Audit
Commission
A Poisoned Chalice
Death Certification
• Improve the quality and accuracy
• Effective medical scrutiny of all deaths not
reportable to the Coroner
• Transparency for bereaved families
• Strengthen clinical governance/public health
surveillance
Medical Examiners
• Scrutinise and confirm cause of deaths (not
investigated by the Coroner)
• Talk with the next of kin and others to prepare for
scrutiny and after scrutiny to advise the
confirmed cause of death
• Where there is no attending doctor the ME will
scrutinise the death and prepare the MCCD
• ME Authorisation will replace the current
cremation forms and apply to burials also
• ME Authorisation will be transmitted to
Bereavement Office/GP/Funeral Director and
Disposal Authority
Impact
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Bereaved Families
Simpler process
Increased transparency
Confirmed cause of death explained
Easier to raise concerns
Improved quality of certification
Doctors
• Access to ME for discussion
• Improved quality of certification
• Reduced bureaucracy
Funeral Directors
• Less time/work involved with forms
• Notification of confirmed cause of death helps to
meet health and hygiene requirements
Coroners
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Fewer Investigations
Reduced post mortems
Medical Advice available from ME
The ability to transfer cases to other jurisdictions
The legalisation of the practice of transferring
bodies for PM’s to other jurisdictions
• To hear cases outside of the jurisdiction
• Leadership
Some problems
• CO’s may migrate to ME service (blight)
• Independence of the ME to the PCT who
appoints them?
• Pilots underway with staged roll out by 2011
• DoH awash with funds
• MoJ National leadership via Chief Coroner to be
funded centrally but LA continue to fund the
Coroner service although there will be a move to
full time Coroners and larger jurisdictions
(population areas 1m save for geographical
anomalies)
• No new money for LA’s to meet higher
expectations
Resources
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Demand led service
Statutory duty to investigate
S27 indemnity now and in the new Act
Full cost falls to LA (impact on other essential
services)
• No Budget (resource allocation/expenditure
forecast)
• Judicially independent of funding LA
• Failure to fund = breach of statutory
duty/Contempt/Obstructing Justice
If Coroners get it wrong…..
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A missed murder and possibly more deaths
Incorrect ID
Release of the wrong body
PM on the wrong body
Wrong information to the right relative
Failure to advise on tissue retention
Failure to deal with retained tissue correctly
Failing to spot something that may kill others
The CSEW welcomes the reforms (even though
they have been watered down )
• The devil will be in the detail of the regulations
and the resources applied
Registrars
• Reduced bureaucracy
• No requirement to interpret medical information
• Easier to monitor and manage workload
Rising costs (1)
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Whilst autopsies have come down in % terms,
the number of reported cases increases each
year
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The complexity and length of cases has
increased beyond reason in the last few years:
– increased public expectation
– effects of Article 2 ECHR
– greater risk of challenge in the High Court
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More second autopsies where the costs must
be met by the coroner
Rising costs (2)
• The NHS used to work with the coroner,
covering much of the costs that the case
incurred
• Then they needed to recover funds ….
• Sudden infant deaths
– used to cost only a minimal pathologists fee
– now we pay for everything
• Toxicology
– used to cost £5 for an alcohol test
– now we have to do a wide ranging screen
– Now far more cases where toxicology is
needed
Rising costs (3)
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The profile of the inquest has risen
significantly, and not only in Article 2 cases
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There is a greater expectation that the
coroner will use an independent expert
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As Article 2 ECHR spreads to medical
cases this will increase
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The new Corporate Manslaughter Act will
bring huge complications to a small number
of cases
Other thoughts
Non invasive PMs (10x the cost) and Coroner cannot
pass on the cost
Shortage of Paediatric Pathologists (shortage of experts
in Child Protection)
Drug Deaths - scaled down Police Investigation (appeal
in Evans)
2nd PM (no Defendant)
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At all?
Who?
Jointly?
Disclose to Police?
Maintain in sealed envelope?
Questions?