The future of the coroner service: a medical examiner system in all but name

Abstract

I read Professor Derrick Pounder s paper on The Future of the Coroner Service with considerable interest and would certainly agree that the present system of death and cremation certification failed to detect that Dr. Shipman had killed any of his 215 victims, and that Shipman managed to avoid any coronial investigation in all but two of these deaths . To focus solely on the Coroner Service, as some have, in the aftermath of these appalling murders would clearly not have been appropriate and the Home Office Fundamental Review, ably chaired by Tom Luce, looked at the whole area of Death Certification and Investigation in England, Wales and Northern Ireland as its title indicates, and not just the role of the Coroner. The same can be said for Dame Janet Smith s Third Report from the Shipman Inquiry, which deals, not only with the investigation of deaths by coroners but also, quite properly, the whole area of death certification itself. The reasons for this are clear. At the present time in England and Wales two thirds of all deaths are dealt with by certification from the attending medical practitioner rather than by referral to the coronership, which is reactive rather than proactive and currently only has the legal powers to investigate once a death has been referred, and the coroner in whose jurisdiction Dr. Shipman practised referred matters to police at a senior level virtually immediately that concerns were expressed to him. The reviews, therefore, have focussed on the whole system of death investigation and certification, including cremation procedures, rather than just focussing on the duties and role of the coroner, and they highlight deficiencies in parts of the system, including the completion and countersigning of cremation forms, which clearly did not pick up what was happening in the Shipman case and need to be much more robust.