How friends and families are treated and what answers they receive to their questions at the inquest will depend entirely on the way an individual coroner runs his court. Each coroner covers a particular area and he or she is responsible for investigating all deaths occurring in that area that are referred to him. There is no consistency between different coroners’ approach to their investigations and how the inquest itself is conducted.
If a family is unhappy with the outcome of a Coroner’s investigation, after an informal approach to the coroner himself the only recourse is to Judicial Review. This process is highly complicated, expensive and permission has to be granted for a review which may be refused.
While some coroners are also doctors many coroners have no medical knowledge or experience beyond what they have learned on the job. Yet they are not compelled to obtain medical advice or evidence even in the most complex medical deaths (although many do).
Because there is no central organization governing the role of coroners and their courts there is no opportunity to spot problems in a particular area. Time and again we have seen scandals involving particular doctors or hospitals (Shipman, Gosport War Memorial Hospital and Stafford Hospital come immediately to mind) but with no central system of overview it is difficult to spot trends
Last year AvMA and many other organizations involved in helping bereaved families welcomed a new law that was intended to put these problems right. The Coroners and Justice Act 2009 included three important reforms:-
- The appointment of a Chief Coroner
- The introduction of medical advisors for every coroner
- An appeals process that was straightforward and accessible to ordinary people
The Chief coroner was to have supervised a system of reporting, enabling trends to be spotted, ensuring uniformity of training and dissemination of information. He would also oversee a new appeals process and each coroner would have the benefit of sitting with a medical advisor.
After years of consultation and a brief period of celebration that the major concerns about the coronial system may be about to be addressed we heard recently that the government intends to abolish the role of chief coroner, delay indefinitely the appointment of medical advisors and that there will not be an appeals process. The news was broken to us and fellow representatives from other NGOs including INQUEST and The Royal British Legion at a meeting called by the Justice Minister Jonathan Djanogly..
And now legislation is before parliament to do just that in the form of the Public Bodies Bill that reaches the committee stage in the House of Lords on Tuesday 23 November.
AvMA together with INQUEST and The Royal British Legion are calling for the government to urgently to reconsider its decision to abolish this key role that would ensure fairness and justice for bereaved families. Baroness Finlay of Llandaff has put down an amendment to the Bill removing reference to the abolition of the roles of Chief Coroner and Medical advisor which we strongly support