Coronial Jurisdictions Research Articles

Post-mortem CT service structures in non-suspicious death investigations

Abstract Post-mortem CT (PMCT) is increasingly used in adult post-mortem investigations as a non-invasive alternative to traditional autopsies. Using PMCT supports death investigations in the face of severe pathologist workforce shortages and the less invasive nature maintains respect for cultural sensitivities. This article reviews the diverse service structures of PMCT, highlighting the importance of customizing these structures to meet the specific needs of various coronial jurisdictions. These jurisdictions often face challenges such as limited access to imaging facilities and logistical issues with geographically dispersed mortuaries. We outline options for leading and operating PMCT services, including models led by pathologists, radiologist, or a hybrid of the two; use of static, relocatable, or mobile CT scanning units; as well as making the most of existing resources such as NHS or private scanning facility scanners already in place. We also explore different PMCT reporting structures through in-house NHS radiologists, combined in-house and teleradiology, or fully outsourced teleradiology services. Each of these offerings provides different levels of efficiency, cost-effectiveness, data security and challenges to set-up. Where applicable, we present and describe real-world examples as case studies for readers interested in replicating existing models.

Investigation of changing forensic pathology workloads over time, in coronial jurisdictions of Australia

ABSTRACT The workload of forensic pathologists involves performing autopsies for a coroner. In this study of Australia, it was hypothesized that autopsy numbers would increase over time owing to increasing numbers of deaths, but this potential trend could be influenced by changes in Coroners Acts. The five largest coronial jurisdictions of Australia were studied between 2006 to 2017. Regression analysis was used to compare autopsy numbers (from the National Coronial Information System) to the number of deaths (from the Australian Bureau of Statistics). The number of deaths increased over time in all jurisdictions. Two jurisdictions had changes to their Coroners Acts that appeared related to decreasing numbers of autopsies. Two jurisdictions had no changes to their Coroners Acts: one showed a greater increase in autopsy numbers than the increase in deaths, but the other's trend was significantly different to the increasing number of deaths. The fifth jurisdiction had a change in Coroners Act with a following, non-sustained decrease in autopsy numbers. The findings support the hypothesis that forensic pathology workload can be influenced by changes in Coroners Acts, but the finding also suggests that other factors may influence the number of autopsies that are performed by forensic pathologists.

An investigation of the coronial jurisdictions of Australia for the relationship between the cause of death provided on a post-mortem examination report and the corresponding coronial finding when the cause of death was determined, indeterminate and undetermined

ABSTRACT This study investigated the relationship between the cause of death stated on a post-mortem (medical) examination report and the subsequent cause of death given in a finding by a legal or judicial coroner (non-medical). A review of causes of death provided by forensic pathologists in their reports found the majority of cases (89%) were given in the traditional death certificate format, but were transformed to a sentence format in just over two thirds of coronial findings (68.5%). There was no evidence that converting the format of the cause of death statements caused a delay in finalizing the case. Of note, the post-mortem examination report provided an indefinite cause of death in 3.8% of cases and around a quarter (25.3%) of these were converted to a definite cause of death in the coronial finding (for example, by removing the word ‘probable’). Where the post-mortem examination did not determine a cause of death (5.2% of cases), most remained undetermined in the coronial finding. It is suggested that pathologists could work with coroners to ensure the cause of death provided on post-mortem examination reports are in the preferred style for their jurisdiction.

“Speaking for the Dead to Protect the Living”: On Audre Lorde’s Biomythography, Law, Love, and Epistemic Violence in the Coronial Jurisdiction in the Kimberley

From 2017–2019 I was counsel representing the families in a coronial inquest which looked at Aboriginal youth deaths in the Kimberley region of Australia with a particular regard to self-harm. A coronial inquest is a judicial proceeding that investigates unexplained deaths, unusual deaths, or deaths in state custody. In this paper I consider the epistemic violence my clients experienced, and I particularly examine the potential for affect and relationality to create connectors between epistemes in the hope of a more emancipatory conception of justice. I draw on Audre Lorde’s corpus as one that is worthy of serious regard in critical legal studies and useful in my work. In particular, I turn my gaze inwards and draw on Audre Lorde’s creation of biomythography as a method for legal writing and legal practice, to offer an account of my role in the Inquest. Biomythography is a form of writing which grounds subjective individual and collective experience, and its interrelationship with history and myth to centre experiences of justice and injustice. In using this methodology, I consider ways the civil law, through its interpretive function and authority in the coronial jurisdiction, oppresses First Nations Australians. Through writing my biomythography I show that the Coroner’s fact finding role arrives at truth in a way inherently embedded in Western knowledge systems and I regard the Coroner’s truth determining function as violent. Finally, I consider the potential of affect as a connector between epistemes to create emancipatory possibilities for justice.

Detection of novel benzodiazepines in post-mortem cases

The global prevalence of novel benzodiazepines (BZDs) has increased significantly in recent years with the predominant BZDs constantly changing to evade bans pertaining to specific chemical structures. As of 2020 the European Union Early Warning System (EWS) was monitoring 30 novel BZDs, 16 of which have been reported since 2016. Evidence of novel BZD-associated harms is growing and there is concern regarding their prevalence in drug-related deaths. We therefore analysed deaths in England, Wales, and Northern Ireland where novel BZDs, i.e., those that are not available on prescription via the National Health Service (NHS) in the United Kingdom, were detected at post-mortem in order to determine the circumstances surrounding novel BZD-associated fatalities. The National Programme on Substance Abuse Deaths (NPSAD) receives voluntary reports on drug-related deaths from coroners across England, Wales, and Northern Ireland that covers approximately 80% of all coronial jurisdictions. Deaths that occurred between 1999-2020 and were reported to NPSAD by the 1st of November 2021 where a novel BZD was detected at post-mortem were extracted for analysis. Qualifying cases contained toxicological evidence of novel BZDs and/or their metabolites in post-mortem tissue(s). Analysis and statistical tests were performed using the IBM® SPSS software (Version 26). 971 deaths were extracted from NPSAD where a novel BZD was detected at post-mortem, with the first post-mortem detection occurring in 1999 with flunitrazepam. A sharp increase in deaths has been reported since 2016 and a total of 16 different novel BZDs detected in submitted toxicology reports. Five of these novel BZDs were detected for the first time in 2019 and 2020 (flualprazolam, delorazepam, flubroalprazolam, cinolazepam, meclonazepam), but nevertheless represent 20% of total novel BZD detections ( n = 211/1,064 [note: in some cases multiple novel BZDs were detected]). The most commonly detected novel BZDs were alprazolam and phenazepam until 2018, after which etizolam, flubromazolam and flualprazolam detections prevail. The cause of death in 95% of cases ( n = 926/971) was due to drug toxicity in which novel BZDs were directly implicated in causing death in 34% ( n = 319/926). Polydrug use was evident in 99% of cases ( n = 964/971) and the majority involved the co-administration of at least one additional central nervous system (CNS) depressant (98%, n = 943/964), namely opioids (84%, n = 812/964). Most deaths were deemed to be accidental in nature (92%, n = 894/971), with small proportions due to suicide (4%, n = 42/971), natural causes (1%, n = 12/971), and those where intent could not be determined (2%, n = 23/971). Decedents were mainly male (83% of cases, n = 801/971), had a known history of illicit substance use (71%, n = 687/971) and lived in the most deprived areas of the country (deciles 1-3, 59% of cases; n = 541/971). The results of this study document a startling increase in novel BZD detections in post-mortem toxicology, with a shift in the predominant novel BZDs over time. As novel BZDs are sold on the Internet as ‘research chemicals’ or the illicit market at a low cost, there is greater access and less oversight which can lead to dosing errors and unintended adverse effects. The concomitant use with other CNS depressants furthers the likelihood of a fatal outcome through increased sedation and respiratory depression, as shown here with the majority of fatalities resulting from mixed drug toxicity. To our knowledge this is the largest dataset on novel BZD-related fatalities to date. Reporting of novel BZD deaths has increased considerably in England, Wales, and Northern Ireland with specific concerns relating to polydrug use. The wide availability of novel BZDs combined with the lack of complete understanding regarding their pharmacology is likely contributing to the exponential rise in novel BZD-associated fatalities.

Coronial postmortem reports and indirect COVID-19 pandemic-related mortality

AimsWidespread disruption of healthcare services and excess mortality not directly attributed to COVID-19 occurred between March and May 2020. We undertook the first UK multicentre study of coroners’ autopsies before...

High Prevalence of Pre-Existing Liver Abnormalities Identified Via Autopsies in COVID-19: Identification of a New Silent Risk Factor?

A high prevalence of hepatic pathology (in 17 of 19 cases) was reported in post-mortem (PM) examinations of COVID-19 patients, undertaken between March 2020 and February 2021 by a single autopsy pathologist in two English Coronial jurisdictions. The patients in our cohort demonstrated high levels of recognised COVID-19 risk factors, including hypertension (8/16, 50%), type 2 diabetes mellitus (8/16, 50%) and evidence of arteriopathy 6/16 (38%). Hepatic abnormalities included steatosis (12/19; 63%), moderate to severe venous congestion (5/19; 26%) and cirrhosis (4/19; 21%). A subsequent literature review indicated a significantly increased prevalence of steatosis (49%), venous congestion (34%) and cirrhosis (9.3%) in COVID-19 PM cases, compared with a pre-pandemic PM cohort (33%, 16%, and 2.6%, respectively), likely reflecting an increased mortality risk in SARS-CoV-2 infection for patients with pre-existing liver disease. To corroborate this observation, we retrospectively analysed the admission liver function test (LFT) results of 276 consecutive, anonymised COVID-19 hospital patients in our centre, for whom outcome data were available. Of these patients, 236 (85.5%) had significantly reduced albumin levels at the time of admission to hospital, which was likely indicative of pre-existing chronic liver or renal disease. There was a strong correlation between patient outcome (length of hospital admission or death) and abnormal albumin at the time of hospital admission (p = 0.000012). We discuss potential mechanisms by which our observations of hepatic dysfunction are linked to a risk of COVID-19 mortality, speculating on the importance of recently identified anti-interferon antibodies.

Improving Indigenous family engagement with the coronial system in New South Wales

This article explores the barriers experienced by Indigenous Australians that prevent adequate engagement with the coronial system in New South Wales. The findings presented here are the result of a qualitative study involving key legal professionals and advocates in the coronial jurisdiction. A number of significant shortcomings are identified, including inadequate funding, a lack of information and appropriate communication, and significant delays between time of death and conclusion of the inquest.

An investigation of changing forensic pathology workloads in the coronial jurisdictions of Australia

The workload of forensic pathologists involves performing autopsies for the coroner. Over the period 2006–2016 it was expected to see a change in autopsy workload of forensic pathologists in Australia due to the increasing number of deaths per year. This study investigated if trends in Australian coronial autopsy workload are related to changes in Coroners Acts. Analysis was performed using data from the National Coronial Information System (NCIS), which was compared with the death data from the Australian Bureau of Statistics (ABS) and Coroners Acts between 2006–2016. In every jurisdiction, the number of deaths per year increased during the study period, but not all jurisdictions observed an increase number of autopsies per year. In three of the eight coronial jurisdictions of Australia, changes in autopsy numbers coincided with changes in Coroners Acts. However, changes in autopsy numbers per year were also observed in without modifications to Coroners Acts. The findings suggest that forensic pathology autopsy workload can be influenced by changes in Coroners Acts and by changes relating to operating polices within individual jurisdictions.

Submission to New South Wales Parliament Select Committee Inquiry on the NSW coronial jurisdiction

Submission to New South Wales Parliament Select Committee Inquiry on the NSW coronial jurisdiction

Submission to New South Wales Parliament Select Committee Inquiry on the NSW Coronial Jurisdiction

Submission to New South Wales Parliament Select Committee Inquiry on the NSW Coronial Jurisdiction

Organ donation in the forensic setting

In 2018, over 1,782 Australian’s lives were transformed by organ and tissue donation. Although Australia generally performs well in this area the aim is to further improve organ and tissue donation rates, and these rates vary between states. However, there are numerous barriers to successful organ donation. Many of the cases in which organ and/or tissue donation is requested fall within the Coronial jurisdiction / forensic medicine setting. In this setting the final decision regarding consent, and/or restriction of organ and tissue donation lies with Coroner who is advised by the forensic pathologist. However, within New South Wales there are no objective guidelines for forensic pathologists and Coroners to follow, and consequently subjective decisions are made which are reliant on experience and personal preference in a time critical and challenging setting. Ultimately, maintaining the principles of autonomy, justice, beneficence, and non-maleficence while trying to optimise organ donation is not an easy task. This presentation provides a review of the Coronial cases within New South Wales Health Pathology Forensic Medicine (Sydney and Newcastle sites) in which organ donation was requested in 2018 and 2019, and highlights Coronial consent issues in certain cases. Furthermore, objective guidelines are proposed to facilitate consistency and streamline the decision-making process in future cases.

An Opportunity to Be Heard: Family Experiences of Coronial Investigations Into Missing People and Views on Best Practice.

Experiences of 15 family members and friends of missing people of a coronial investigation into the suspected death of a missing person in New South Wales (NSW), Australia were examined via in-depth interviews. This study explored participant perceptions of the impact of coronial proceedings on well-being, and views on best practice approaches to families in the Coroner’s Court. Transcripts were thematically analysed, yielding six key themes in participant experiences of inquests: (1) Opportunity to be heard, (2) A chance for education, (3) If you are human with me (sensitive treatment and language), (4) Timely investigations, (5) A public and formal court environment, and (6) Coronial outcomes. Overall, families benefitted from opportunities to have input and feel heard, compassionate treatment, and appropriate education about the process and available support services. A detriment on well-being was described when these factors were precluded. Some participants perceived positive outcomes arising from public awareness of cases of missing people, formalities that conveyed respect, and timeframes that enabled further investigation or preparation for the inquest. Others reported distress and trauma in response to significant delays that led to a loss of evidence, intrusive media and unknown persons in court, and unwelcoming, formal court environments. Some participants were profoundly distressed by a finding of death and by the procedures that followed the inquest, emphasising the need for post-inquest debriefing and ongoing support. These findings deepen our understanding of coronial practices, and of measures to prevent harm, that will be instructive to other coronial jurisdictions. Further research should examine family experiences in contexts where there are variable coronial proceedings or procedures that result in legal findings of death.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

Background and objectivesDeaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery. MethodsWe examined the Coroners’ inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model. ResultsOne hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25–50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or “within minutes” in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively. ConclusionsA high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

Abstract Background and objectives Deaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery. Methods We examined the Coroners’ inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model. Results One hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25–50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or “within minutes” in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively. Conclusions A high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

Anaesthetist's guide to the Coroner's Court in England and Wales

### Key points Coroners have been part of the English Legal System since 1194 and have evolved from being a form of mediaeval tax gatherer to an independent judicial officer charged with the investigation of sudden, violent, or unnatural death. In the last 800 yr, the role of the coroner has changed substantially culminating in The Coroners and Justice Act 2009 (enacted July 2013). This is the result of many reports leading to fundamental reform of the Coronial service (Table 1). The reforms were instigated following the Luce report 20031 and the Shipman inquiry (The Shipman Inquiry) led by Dame Janet Smith. Coronial reform has been on the political agenda for many years but the UK's financial situation delayed the implementation. This article will update anaesthetists with the information needed to understand the reforms and to be able to understand what will be required if called as a witness at an inquest. View this table: Table 1 Key points from the Coroners and Justice Act 2009 The new legal framework will ensure all 96 coronial jurisdictions in England and Wales will work to the same standards, ending the past inconsistencies of practice that led to criticisms of a postcode lottery with bereaved people in some areas facing long delays for inquests. Coronial services are now being overseen by the first Chief Coroner of England and Wales, …

Post-mortem toxicology: A pilot study to evaluate the use of a Bayesian network to assess the likelihood of fatality

The challenge of interpreting post-mortem drug concentrations is well documented and relies on appropriate sample collection, knowledge of case circumstances as well as reference to published tables of data, whilst taking into account the known issues of post-mortem drug redistribution and tolerance. Existing published data has evolved from simple data tables to those now including sample origin and single to poly drug use, but additional information tends to be specific to those reported in individual case studies. We have developed a Bayesian network framework to assign a likelihood of fatality based on the contribution of drug concentrations whilst taking into account the pathological findings. This expert system has been tested against casework within the coronial jurisdiction of Sunderland, UK. We demonstrate in this pilot study that the Bayesian network can be used to proffer a degree of confidence in how deaths may be reported in cases when drugs are implicated. It has also highlighted the potential for deaths to be reported according to the pathological states at post-mortem when drugs have a significant contribution that may have an impact on mortality statistics. The Bayesian network could be used as complementary approach to assist in the interpretation of post-mortem drug concentrations.

Evaluation of the statewide paediatric observation and response charts in Victoria

Introduction:Despite improvements in diagnosis andmanagement of hydrocephalus in the paediatric population ventricularperitoneal (VP) shunts remain themainstay of treatment. VP shunts are prone to failure, with blockage the commonest reported complication. If not detected early shunt blockage can lead to death and in some cases death occurs in the paediatric intensive care unit (PICU). Objectives: To determine, from the perspective of coronial findings, predictive indicators and common features associated with deaths in Australia related to VP shunt failure in children. Methods: A review of coronial inquest cases sourced from available coronial jurisdictions (1995-2010) and theNational Coronial Information System (July 2000–December 2012). Transcripts involving children between 0 and 17 yearswho died as an outcome of a blocked VP shunt were analysed using content and comparative methods to determine the presence of predictive indicators (symptoms, signs and radiographic findings); common associated factors and recommendations of reporting coroners. Results: A total of 11 cases were subject to coronial inquest. Predictive indicators of drowsiness, headache and vomiting were present in the majority of cases when the child first presented to a doctor. Common features that led to delayed diagnosis/treatment were: initial assessment conducted by inexperienced doctor; poor/inadequate documentation in case notes; delays in organising neurological referrals and/or CT scans; misinterpretation of CT scans or unavailability of previous CT scans; delayed patient transfer to hospital with a PICU/neurosurgical facilities. Key recommendations includedwarnings todoctors tomaintain ahigh indexof suspicionwhena sick childpresentswithaVPshunt; need for timely, expert opinion on interpretation of CT imagery; need for standardised clinical guidelines/protocols to assess and treat symptomatic children with VP shunt malfunction. Conclusion: Standardised clinical guidelines/protocols for assessing and treating children with VP shunts who present with predictive clinical indicators are essential to prevent further avoidable deaths.

An evaluation of overnight fixation to facilitate neuropathological examination in Coroner's autopsies: our experience of over 200 cases

AimsFollowing recent changes in Coroner's Rules, there has been a desire to examine brains at the time of autopsy, rather than after a prolonged period of immersion fixation. Examination of...

Withdrawal of ventilatory support outside the intensive care unit

Aims Withdrawal of invasive organ support, if aggressive treatment is no longer in a child9s best interests, traditionally occurs within intensive care units (ICU). Sporadic reports of transfer outside ICU for withdrawal exist with evidence suggesting many families would prefer their dying child to go home, and in this context choice in place of care, and subsequently of death, should be offered. Our hospital is a tertiary paediatric hospital with children from throughout the UK, meaning such discharges present specific challenges with practical, logistical and legal considerations that must be addressed. Methods Retrospective eight-years (2003-2011) case-note (ICU and palliative care notes) review of transferring children out of ICU for withdrawal of ventilatory support. Common themes and specific incidents were identified in order to develop local guidelines for transfer and subsequent management. Results 13 children were considered, but 3 died prior to transfer organisation. Of those transferred 4 went home, 4 to hospices, 1 to another hospital ward and 1 to a residential school. Ages ranged from 1-month to 16 years. There were a variety of primary pathologies (malignant, neurological, renal and respiratory diseases). Formal multidisciplinary team meetings prior to discharge were recorded in only 5 cases prior to transfer, and community team involvement was not documented at this stage in any case. 6 children had Symptom Management Plans and 1 an emergency care plan in event of longer than anticipated survival. No documented fluid management plan for longer-term survival was found in any case, though these existed, and 1 transfer occurred without discharge medications. Concerns raised included: transfer timings, health professionals availability to manage transfer and withdrawal, access to properties, availability of support in the community, symptom management post ventilation withdrawal and drug administration. Legal concerns included death certification, cremation form completion and the transfer of coronial jurisdiction and National legal administration. Conclusion Although National guidance has recently been published, we have developed local guidelines based on our own experience as specific considerations occur dealing with teams from different regions. This is especially challenging when transfer must be arranged rapidly. Specific documentation is now mandatory.