Coronial System Research Articles

Investigating deaths of people with autistic spectrum disorder in health and social care in England and Wales

PurposeThis paper aims to examine the trends identified in inquests conducted in the Coronial system in England and Wales for individuals formally diagnosed with autism spectrum disorder (ASD), where the death occurred within a health or social care setting.Design/methodology/approachIt uses data from 42 reports to prevent future deaths (PFDs) issued by Coroners to establish where and in what contexts each death occurred. PFDs are sent to organisations that Coroners believe could act to PFDs.FindingsThe research identified four key findings. Firstly, 33% of the deaths identified were not recorded as suicides, marking a clear departure from the extant literature on this issue. Secondly, data highlighted a lack of training and education of staff to understand the complexity of autism. Thirdly, this lack of understanding was often compounded by a lack of specialist provision for people with ASD. Fourthly, Coroners attributed a number of deaths to an individual’s autism, which served to some extent to mask the failures of the agencies involved in the care of the decedent.Originality/valueThere is limited research available about the preventable deaths of individuals with ASD in health and social care settings. This paper makes an initial step in highlighting significant structural failures that can lead to preventable deaths.

Improving state medicolegal death investigation: Does system level reform improve public health data concerning drug-related mortality?

In the United States, the governance of unnatural death certification varies greatly by state. Although cross-sectional research has linked mortality data quality with variation in medicolegal death investigation systems across states-especially with regards to drug-related deaths-this relationship has not be sufficiently tested using longitudinal data. This research assesses the impact of system governance reform on the quality of drug mortality data by assessing the impact of transitioning from a coroner system to a medical examiner system on data quality. The research finds no evidence that system-level reform is associated with improved drug-related mortality data quality. These findings suggest that alternative methods should be examined for improving public health data concerning drug-related mortality. These likely include focusing on individual-level characteristics and practices of officials and offices, rather than system-level variables.

The Goudge Inquiry and Forensic Pathology in Canada.

This article analyses the effects of The Inquiry into Pediatric Forensic Pathology in Ontario, commonly known as the Goudge Inquiry, and its effects upon forensic pathology in Canada. The Goudge Inquiry was a Government of Ontario public inquiry that examined the delivery of pediatric forensic pathology services to the Ontario Coroner's Office and the Canadian criminal justice system. The inquiry was conducted by Mr. Justice Goudge, a court of Appeal Judge and made substantial recommendations of improving forensic pathology in a Coroner system and its role in delivering evidence to the criminal justice system. This article reviews the inquiry and discusses the effect of the inquiry on the development of forensic pathology in Canada and academic literature about the inquiry. The Inquiry has had important effects on the role of all expert witnesses in the courts and is the most substantial examination of forensic pathology by any judicial inquiry. The Goudge Inquiry has been considered a significant success, being described as transformative.

Characteristics of Coronial Autopsy Cases in the London Area of the United Kingdom, Pre and Post COVID-19 Lockdown.

In order to reduce transmission of COVID-19, in March 2020 the UK national and devolved governments imposed restrictions including spatial distancing, stay-at-home orders, and travel restrictions. The aim of this study is to compare the characteristics of cases referred to the Coronial system for autopsy in the months before and during the lockdown period. In all, 580 autopsy cases, performed in the London area between January and June 2020 were included in the study. In the postlockdown period, there was an increase in the proportion of black individuals referred for autopsy, which just attained statistical significance (p = 0.047). The proportion of decomposed bodies submitted for examination was significantly increased (p = 0.011). The study did not show a significant increase in the proportion of out-of-hospital (community) deaths, traumatic deaths, or deaths due to alcohol or drug abuse or overdose. The study shows no evidence that COVID-19 preventative measures led to a change in the causes of death referred to the Coroner, except, of course, for COVID-related deaths. The proportion of black people among subjects for autopsy increased, probably because of a relatively higher incidence of COVID deaths among this group. Decomposed subjects were more common, probably due to social isolation.

The Coronial System: A Short History

The system of death investigation in England and Wales is complex and its origins based in history and is commonly referred to as the ‘coronial’ system. The coronial system was established in England during the reign of Richard 1st

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.

Suicide in England in the COVID-19 pandemic: Early observational data from real time surveillance.

BackgroundThere have been concerns that the COVID-19 pandemic may lead to an increase in suicide. The coronial system in England is not suitable for timely monitoring of suicide because of the delay of several months before inquests are held.MethodsWe used data from established systems of "real time surveillance" (RTS) of suspected suicides, in areas covering a total population of around 13 million, to test the hypothesis that the suicide rate rose after the first national lockdown began in England.FindingsThe number of suicides in April-October 2020, after the first lockdown began, was 121•3 per month, compared to 125•7 per month in January-March 2020 (-4%; 95% CI-19% to 13%, p = 0•59). Incidence rate ratios did not show a significant rise in individual months after lockdown began and were not raised during the 2-month lockdown period April-May 2020 (IRR: 1•01 [0•81–1•25]) or the 5-month period after the easing of lockdown, June-October 2020 (0•94 [0•81–1•09]). Comparison of the suicide rates after lockdown began in 2020 for the same months in selected areas in 2019 showed no difference.InterpretationWe did not find a rise in suicide rates in England in the months after the first national lockdown began in 2020, despite evidence of greater distress. However, a number of caveats apply. These are early figures and may change. Any effect of the pandemic may vary by population group or geographical area. The use of RTS in this way is new and further development is needed before it can provide full national data.FundingThis study was funded by the Healthcare Quality Improvement Partnership (HQIP).The HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review programs and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage, and develop the National Clinical Audit and Patient Outcomes Program (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The program is funded by NHS England, the Welsh Government and, with some individual projects, other devolved administrations, and crown dependencies.

Killing with No Punishment: Police Violence and Judicial (In)justice

This article offers a critical reading of the Limbu Case that took place in 2009 in Hong Kong. The Limbu Case was about an ethnic Nepalese named Dil Bahadur Limbu who was shot dead by a police constable on a hillside, which resulted in controversies around issues such as excessive police use of force and discretionary policing in Hong Kong. In the coroner’s inquest (court case no.: CCDI298/2009) regarding Limbu’s death, a verdict of lawful killing was reached by a jury of five. In other words, the killing was defined as a permissible killing. Drawing attention to the process of questioning “reasonableness” of the killing, I attempt to shed light on the ambiguities of the coronial system in Hong Kong which results in a missed opportunity to prevent future deaths. In other words, this article uncovers how the state is unable to live up to its promise to protect people's right to life.

“Architects’ mistakes should be covered with ivy and doctors’ with sod”: Medical Malpractice, Morton Shulman, and the “Conspiracy of Silence”

Every year thousands of Canadians are killed or injured because of medical mistakes. Plaintiffs, however, face several challenges to suing doctors successfully for malpractice. One challenge is the reluctance of some doctors to criticize other medical professionals, sometimes referred to as the “conspiracy of silence.” This article focuses on the attention given to the conspiracy of silence in Ontario in the 1960s when Dr. Morton Shulman, the pugnacious and flamboyant Chief Coroner of Toronto, alleged that doctors routinely covered up medical errors. Shulman drew media attention to irresponsible doctors, poor practice, and negligent treatment. He demanded more accountability and better care, and deplored efforts to silence him to protect the reputation of doctors. A decline in public trust of experts and of the professions created conditions that lent credence to Shulman’s claims. However, many medical professionals chafed at the questioning of their professionalism, expertise, and ethics. The provincial government’s responses, which included coroner system reforms, expanding the powers of the Ontario College of Physicians and Surgeons, and attempting to silence Shulman, primarily aimed to meet the concerns of the state and medical professionals, rather than those of patients and the public.

Suicide in England in the COVID-19 Pandemic: Early Figures from Real Time Surveillance

Background: There are concerns that the COVID-19 pandemic may lead to an increase in suicide. The coronial system in England is not suitable for close monitoring of suicide because of the frequent gap of several months before inquests are held. Methods: We used data from established systems of "real time surveillance" (RTS) of suspected suicides, in areas covering a total population of around 13 million, to examine for any increase after the first national lockdown in England. Outcomes: The average monthly number of suicides in the months before lockdown, January-March 2020, was 125·7, compared to 121·3 in April-October 2020 (-4%; 95% CI -19% to 13%, p=0·59). Incidence rate ratios did not rise significantly in individual months after lockdown began and were not raised during the 2-month lockdown period April-May 2020 or the 5-month period after the easing of lockdown, June-October 2020 (IRR: 1·00 [0·8-1·25] and 0·94 [0·81-1·08]). Comparison of the suicide rates after lockdown in 2020 for the same months in selected areas in 2019 showed no difference. Interpretation: We did not find a rise in suicide in England in the months after the first national lockdown began in 2020, despite evidence of greater distress. However, a number of caveats should be noted. These are early figures and may change. Any effect of the pandemic may vary by population group or geographical area. The use of RTS in this way is new and further development is needed before it can provide full national data. Funding: The study was carried out as part of the role of the National Confidential Inquiry into Suicide and Safety in Mental Health in supporting suicide prevention in England, funded by NHS England/NHS Improvement.Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: LA chairs the National Suicide Prevention Strategy Advisory Group (NSPSAG) at the Department of Health and Social Care in England; NK is a member of the Group, chaired the guideline development group for the 2012 National Institute for Health and Clinical Excellence (NICE) guidelines on the longer-term management of self-harm, currently chairs the guideline development group for the NICE depression in adults’ guidelines, is currently the topic advisor on the new NICE guideline on self-harm, and reports grants from the Department of Health and Social Care, National Institute of Health Research and NICE. All authors work with NHS England on the National Quality Improvement initiatives for suicide and self-harm. LA, NK, and PT report grants from the Health Quality Improvement Partnership.

From Colonial Coroner to American Medical Examiner: A Way Forward in Sri Lankan Death Investigation System

The Death Investigation system (DIS) in a given country is an administrative office, that is essential in many directions. Different DIS are existing worldwide differing on its investigating authority but are mainly consisted of Coroner and Medical Examiner systems. These systems are indefinitely being modified to be fitted with the advancement of forensic investigations and social needs, and the trend runs towards the medically trained Death Investigator System. Current DIS in Sri Lanka is adopted from the British Coronial system and is still being practised without significant adjustments since 1892, which has given rise to numerous discrepancies. The objective is to emphasizes the need for establishing the Medical Examiners (ME) System in Sri Lanka and to address the issues in converting to the proposed system. The Main drawbacks concerning this conversion in other countries are related to administrative, legislative, financial, and political issues. Nevertheless, every country does not acquire similar challenges, and our country may easily accept and overcome the difficulties mentioned above. As an example, the current DIS can be swiftly converted into ME centered approach with minor modifications to the criminal procedure code such as by appointing a Forensic Medical specialist as a death investigator with all the powers of existing Inquirer into Sudden Death who can conduct inquest to decide whether autopsy examination is necessary or not. This process does not require any infrastructural modifications as well. Stepwise conversion of Coroners to ME in the States in America can be taken into consideration as a role model. This paper highlights the necessity of introducing the Medical Examiner System in Sri Lanka and provides guidance to overcome the drawbacks.

Human identification: a review of methods employed within an Australian coronial death investigation system.

Whilst many identification methods have been widely described and discussed in the literature, and considered in disaster and humanitarian contexts, there has been limited reporting and evaluation of the identification methods used in domestic medico-legal death investigation contexts. The aim of this study was to evaluate the identification methods utilised at the Victorian Institute of Forensic Medicine (VIFM), which forms part of a coronial medico-legal death investigation system. The method of identification and time taken to complete the identification were reviewed for all cases admitted to the VIFM over a five-year period from 1 July 2015 to 30 June 2020. The majority, 91%, of individuals admitted to the VIFM were visually identified. The remaining 9% of cases required identification by primary methods (i.e. fingerprints, DNA or dental) or, when those methods were not possible, by secondary methods (i.e. circumstantial). Visual identifications were the timeliest, taking an average of 1.5days, whilst primary identification methods required an average of 5days to complete. The triaging of identification methods, dependent on the case context, body preservation, availability of ante-mortem data, legal requirements and admissibility of the method, are determined by identification coordinators within the Human Identification Service (HIS) to ensure the most appropriate and timely method is employed. This review of human identification methods provides the foundation for future analyses to compare workflow processes and improve identification methods utilised in domestic medico-legal contexts.

Study on death certificates and postmortem examination certificates written by Korean emergency physicians

IntroductionStatistics on death are the basis of a country's health, safety, and welfare policies. Emergency physicians issue a postmortem examination certificate (PEC) for death outside the hospital as well as a death certificate (DC) for death in the hospital. This study investigated the actual conditions and criteria for writing a DC and PEC, writing environment, and doctor's experience. Material and methodsThe physicians' DC and PEC writing experience and demographic data were analyzed. The questions focused on CPR, patient's medical certificate, time and place of death, difficulty in writing the PEC and DC, and education in certificate writing. Results229 emergency physicians were included. Physicians’ opinions differed for CPR patients in terms of time of death, location, and whether or not to issue DC/PEC. The causes of death were also different. Further, 76.9% of the doctors did not have enough time to write a medical certificate and about 45% of them wrote it within 30 min; 76% had DC-related complaints, and 7.0% faced legal problems due to the DC; 93.3% of the emergency physicians stated that a coroner system is needed in South Korea. ConclusionEmergency physicians are responsible for writing DCs and PECs. The standards vary from physician to physician at the time of writing. Writing DCs and PECs is also burdensome. In South Korea, it is necessary to separate the DC and PEC, to develop national data management networks, and to introduce a postmortem examination system.

Postmortem Computed Tomography: An Overview for Forensic Nurses Involved in Death Investigation.

The traditional invasive autopsy has been considered the "gold standard" for death investigation worldwide. However, this has now been challenged by a new minimally invasive approach that utilizes cross-sectional radiological imaging to investigate the death. Globally, postmortem computed tomography is the most commonly used modality and is becoming increasingly available throughout the world. Forensic nurses working in association with coroners and medical examiners' offices, as well as mass fatality incidents, now need to update their knowledge base to understand these innovative techniques, the advantages and disadvantages to their use, and how they impact on medicolegal death investigation and the care of the deceased and bereaved. Using the example of the coroner system of England and Wales, this article provides a comparison between the traditional invasive autopsy and postmortem radiological alternatives and presents the impact postmortem radiology is now having on death investigation.

Unintentional Drug-related Deaths in Cambridgeshire: A Retrospective Observational Study.

Background: Drug-related deaths are a growing public health problem in the United Kingdom, overtaking road fatalities and homicides in terms of annual deaths. In this study, we investigated the causes and circumstances of unintentional drug-related deaths occurring in the county of Cambridgeshire, with the objective of identifying the prevalence of physical, mental, and social health problems within this cohort.Methods: We collected data on the demographics and mental and physical health of, and drugs contributing to, 30 consecutive unintentional drug-related deaths recorded by the Cambridgeshire and Peterborough County Council Coroners in 2017. A retrospective observational study was used, and data were collected by manual extraction from coroners’ files.Results: Social isolation was identified as a recurring theme amongst the decedents, although homelessness was found in very few cases. Pharmacologically, multiple drug toxicity and opioid toxicity were highly prevalent, whilst prescription opioids were implicated in more cases than heroin. Chronic pain was also highly prevalent amongst the decedents, and a history of mental illness was found to occur in the majority of cases.Discussion: Our findings show that reports from the coronial system provide a rich narrative to understand the causes of drug-related deaths. We have identified that individuals who die from drug-related deaths frequently have multiple adverse physical, mental, and social problems. This implies that any attempt to reduce drug-related deaths requires a multi-faceted and multi-disciplinary approach.

Investigating suspected suicides: New Zealand coroners’ experiences

To understand how suspected suicides are investigated in New Zealand we conducted a thematic analysis of in-depth interviews with coroners. Coroners identified the inquisitorial nature of the coronial system and coroners’ wide powers of jurisdiction as key strengths of the system. Important influences in key areas of coronial decision making in cases of suspected suicides included; the need for more evidence – especially to determine intent, and family factors, including therapeutic jurisprudence. Coroners identified lack of follow up and monitoring of recommendations, poorly resourced coronial training and the personal impact of suicides as challenges of working in the coronial system.

Epilepsy and seizure-related deaths: Mortality statistics do not tell the complete story

IntroductionThe objective of the study was to identify where epilepsy or seizures may be the underlying cause of death but not identified by the death certification process in the Australian coronial system and to better characterize such deaths. MethodsAustralian National Coronial Information System (NCIS) closed cases for the Australian Capital Territory (ACT) (population average 348,000) over 13 years were searched using cause of death, and a text search of police and autopsy reports, to identify all deaths where epilepsy or seizures were mentioned. Deaths where the underlying cause of death was not seizures or epilepsy were excluded (including suicide). The remaining cases (75) were categorized by the circumstances of death. Suspected sudden unexpected death in epilepsy (SUDEP) cases were further classified using the unified definition of SUDEP of Nashef and colleagues (2012). ResultsOf the final 75 cases, only 44 were found by the cause of death search. Key word document searches found another 31. Cases were classified as Definite SUDEP (37), Definite SUDEP Plus (10), Probable SUDEP (1), Possible SUDEP (3), Near SUDEP (4), Near SUDEP Plus (1), Asphyxia (3), Treatment-related (1), Head injury (2), Drowning (2), motor vehicle accident (MVA) (1), deaths related to a single convulsive seizure (6), and status epilepticus (SE) (4). Cases were 80% male. ConclusionsEpilepsy and seizure-related deaths are underreported in the Australian Coronial system. Enhanced documentation of the causal chain of events leading to deaths would increase recognition. Using the unified SUDEP definition would expand SUDEP identification.

Using narrative to construct accountability in cases of death after police contact

This paper examines the use of narrative verdicts in the coronial system in England and Wales to record findings in cases of death after police contact. It uses a dataset of 68 verdicts into such cases in the period 2004–2015. The paper considers how regulation is constructed in a way that makes complex cases comprehensible through narrative. The construction of these narratives is affected by legal structures, institutional structures, but also the structures imposed by narrative convention. The paper argues that the relationships between these structures affect what type of narrative is constructed in the aftermath of a death after police contact. It further suggests that devices within narratives enable the construction of a comprehensible narrative verdict in such cases.

Coronial Practice, Indigeneity and Suicide.

All available data suggest that, like many other Indigenous peoples, Australian Aborigines are significantly more likely to kill themselves than are non-Aboriginal Australians. This statistical disparity is normally positioned an objective, ontological and undeniable social fact, a fact best explained as a function of endemic community disadvantage and disenfranchisement. This research explores the possibility that higher-than-normal Aboriginal suicide rates may also be a function of coronial decision-making practices. Based upon in-depth interviews with 32 coroners from across Australia, the following conclusions emerged from the data. First, coroners have differing perceptions of Indigenous capacity, and are less likely to have concerns about intent when the suicide is committed by an Indigenous person. Second, coroners have identified divergent scripts of Indigenous suicide, particularly its spontaneity and public location, and this supports rather than challenges, a finding of suicide. Third, the coronial perception of Indigenous life is a factor which influences a suicide determination for Indigenous deaths. Finally, the low level of Indigenous engagement with the coronial system, and the unlikelihood of a challenge to the finding of suicide by Indigenous families, means that a coronial determination of suicide is more likely.

Coronial Consideration of Patient Deaths in Paramedicine

During the course of a paramedic's duties, it is inevitable that they will deal with patient death in some way. Australia's coronial system is a safeguard to ensure deaths are investigated where their cause is not immediately known, or the circumstances surrounding the death is unusual. This article considers three recent coronial inquests involving paramedic care in Australia; identifies the significant observations that can be made from analysing the paramedics’ actions during patient treatment; and comments on how the coronial system can be used to improve patient outcomes.