The Role of the Coroner. Tom Atherton Assistant Deputy Coroner for Cardiff and the Vale of Glamorgan

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1 The Role of the Coroner Tom Atherton Assistant Deputy Coroner for Cardiff and the Vale of Glamorgan

2 The Office of Coroner Dates back to at least Articles of Eyre Some evidence of pre conquest role Included revenue collection for Crown- as there were financial dues payable on death Coroner would attend the scene to investigate before authorising burial Very much a legal-medical role Corpse would be in court during the inquest!!

3 Death- consequences Estate of the deceased- probate/letters of administration Employment Family- children Mortgage/life insurance Requirements of the Birth Deaths and Marriages Act 1836 All deaths are investigated on behalf of the Crown

4 Coroner S 8 (1) Coroner s Act jurisdiction arises when A body is lying within the coroner s district and The death was violent or unnatural or Was a sudden death of unknown cause or The death occurred in prison ( includes death in police custody)

5 Investigation All deaths are investigated/certified All deaths must be registered with the registrar of Birth Deaths and Marriage- Death certificate issued which is required by law and is the first stage in the legal process of dealing with the deceased affairs. The investigation is conducted by a medical practitioner where death is from natural causes or the Coroner/police in all other cases. There is a considerable overlap between the Doctor and Coroner.

6 Death by Natural Causes Where a death occurs from natural causes a doctor( if able to do so) will issue a medical certificate of the cause of death (MCCD). The MCCD is lodged with the registrar and if it satisfactory the death certificate will be issued. What is a natural cause of death? What if the doctor does not know what caused the death even if it appears natural?

7 Reporting a death to the Coroner Where the circumstances suggest that any of the criteria are met the doctor must report the death to the coroner. Reg 41 registration of Births deaths and Marriages 1987 requires the registrar to report a death to the coroner if deceased not attended during last illness by a doctor Or in respect of which the registrar 1. Has not received a duly completed MCCD or 2. Has received a MCCD and it appears that deceased was not seen in last 14 days prior to death or after death Or cause of death is unknown or Registrar believes death is not by natural cause Which appears to have occurred during operation or before recovery from anaesthetic Where cause of death may be due to an industrial disease or industrial poisoning

8 Reporting a death to a coroner In practice most deaths will be reported by medical practitioners based on Reg 41, common law and case law. Examples are Cause of death unknown Cannot be readily certified as natural causes Deceased not seen by doctor in last 14 days Suspicions circumstance/violence Accident Self neglect/neglect by others Illness during or shortly after prison or police custody Deceased detained under mental health act Death contributed by actions of deceased- drug/alcohol overdose-self harm Death at work During operation or anaesthetic recovery Death due to medical procedure Lack of medical care Unusual or disturbing features Death within 24 hours of admission to hospital Medical mismanagement

9 Coroner s investigation Many reported deaths after investigation do not require further action. Where cause of sudden death unknown Coroner will order a post mortem under S19 or 20 of the Coroner s Act. Above enquires may reveal case is not within S8 and no inquest will be held and the coroner will issue a certificate allowing the death to be registered. Case is then closed. If enquires give coroner reasonable grounds to believe death falls within S8 ( unnatural/violent death: sudden death cause unknown and death in custody) then an inquest will be opened and usually adjourned for a full hearing.

10 Example Elderly person has a fall at home and is taken to hospital having fractured a femur. Operated upon but post operatively develops aspirational pneumonia and dies. PM confirms cause of death is pneumonia. What does a coroner decide?

11 Example continued Coroner will consider the chain of events. 1. The fall 2. Did the fall cause the fracture 3. Did the lack of mobility then lead to pneumonia? 4. Did the pneumonia cause the death. 5. Would the deceased have died at that time if he/she had not had a fall? The causal chain is fall- fracture- operation-pneumonia. On this basis the death could be considered to be the consequence of an accidental fall and is therefore not a natural death. Inquest therefore required under S8. What if deceased suffered from severe osteoporosis and the femur spontaneously broke causing the fall and same consequences. Is this a natural consequence of the illness leading to death?

12 The Inquest Having determined an inquest will be needed coroner will open and adjourn for a full hearing. Evidence prepared and witness determined and called. Rule 36 states that evidence will be directed solely to ascertain 1. Who was the deceased 2. When the death came about 3. Where the death took place 4. How the death came about. Coroner CANNOT frame a verdict in such a way as to appear to determine any question of civil or criminal liability (Rule 42). This is not the role of a coroner.

13 Inquest 2- R v Jamieson How- is to be understood as meaning by what means or how the deceased came by his death. It is not the function of coroner to determine civil or criminal liability but coroner may explore facts bearing on criminal and civil liability but the verdict must not appear to determine any question of criminal or civil liability. where a coroner has reason to believe neglect contributed to the death there is a duty to investigate such potential Neglect- R v Jamieson. neglect means a gross failure to provide basic care. There must be a clear and direct causal connection established between the conduct so described and the death. R v Middleton In a death in custody the coroner will broaden the enquiry to establish what caused the death and in what circumstances the death arose to fulfil the states obligation under article 2 of the European Convention on Human rights. R v Middleton

14 Inquest 3 - Natural or Unnatural? R v Inner London Coroner ex parte Touche Mrs T died from a cerebral haemorrhage the result of severe hypotension following delivery of twins- Deemed natural cause- no inquest Facts emerged that her blood pressure had not been monitored and if it had death would probably have been avoided. Family asked for inquestrefused and judicial review took place. Court of appeal said 1)that even if the death was strictly due to natural causes it may have been contributed to by neglect. The death could not be described as natural and therefore an inquest was required.2) unexpected deaths from natural causes which would not have occurred but for some culpable human failure makes the death unnatural

15 Inquest 4 Witnesses called and questioned by the coroner- inquisitorial system not adversarial. Properly interested persons (PIPS)have a right to ask questions of witnesses and be represented. Evidence depends on type of case but will usually rely on medical practitioners and pathologist.

16 Inquest 5 Example- death during surgery. GP for back ground information Medics involved in initial diagnosis and decision making Surgeon/ anaesthetist Pathologist Possible expert witness if neglect suspected.

17 Inquest 6-Coroners file Contents will depend on nature of the case. Example- food poisoning Is it a joint investigation ( prosecutors convention) Who has the lead Criminal proceedings? Evidence of enquiry to determine source of bacteria. From source to deceased-chain of events Food hygiene standards compliance or otherwise. Scientific evidence Medical evidence relating to the death. Many coroners will accept, in such cases, a statement of lead investigating office outlining full details of enquires made often resulting in reducing the need to call several witnesses.- it will depend on what evidence is likely to be challenged or needs to be clarified.

18 Inquest 7 Coroner will decide facts, summarise the case and the announce the verdict ( inquisition). Verdicts, with some exceptions, are based on balance of probabilities Possible verdicts include Natural causes Death from industrial disease Dependence on drugs/non dependant abuse of drugs Died from want of attention at birth Note- in the above and where appropriate following can be added and the cause of death was aggravated by lack of care/self neglect Suicide ( beyond reasonable doubt) Accidental death Unlawful killing ( beyond reasonable doubt) Lawful killing Open verdict- where evidence does not disclose the means by where death arose Complications of surgery Narrative verdict

19 After the Inquest The signed inquisition is sent to the registrar who will issue the death certificate. Coroner is then functus officio and can only re-open an inquest with the consent of the secretary of state.