Frustration of purpose: public health and the future of death investigation in England & Wales.

Abstract

Coroners have existed since the 12th century when they were created to support itinerant judges and, thus, facilitate the levying of fines on people living in England and (following the Edwardian Conquest) those in Wales. Over the centuries, the medieval coroner lost this function and his descendants have, in spite of a long-standing lack of central guidance, been forced to reinvent the coronial identity and to discover a modern purpose. The coroner operates in the space between law and medicine. Consequently, the coroner has been forced to adapt to the development of medical science, the normalisation and codification of human rights, and the development of the theory and practice of public health. Recent scandals - most notably the inquiry into the crimes of Harold Shipman - have highlighted the shortcomings of the office and have resulted in calls for reform. Though there is clearly a case for change, and many have made specific suggestions as to how the office should be modernised, few have considered that what underlies many of the problems of the coroner system/office, and its anachronistic and atavistic nature is a fundamental lack of a responsible and logical purpose. The study attempts to describe the problems encountered by the coroner in recent years, to provide a background to outline the coroner’s evolution from the 12th century, and to pose the question: what, ultimately, is the purpose of the coroner? This study is based on a) qualitative interviews with coroners in England and Wales, b) qualitative interviews with professionals who encounter coroners through their work, c) observation of coroners during inquests, and d) a written submission to coroners requesting inquest data. Coroners were asked to state and describe their purpose - there was no consensus. Coroners described their purpose in one of six ways: to ‘give families closure’, to protect public health and safety, to discover homicide, to enforce Article 2 of the European Convention on Human Rights, to provide public reassurance, and to investigate the military. One coroner believed the question of purpose not to be germane. This study considers each response and attempts to come to an evidence-based, normative conclusion as to the purpose of the coroner. Some have suggested that the coroner’s role is both complex and multifarious and should necessarily include several distinct purposes; however, in practice, these purposes often undermine and contradict each other. This study argues for a single, overriding purpose for the coroner. In addition, the work considers changes which might render the office capable of pursing the normative purpose in a contemporary context in which our understanding of public health is more developed.