Reform of the coroner system and death certification
Authors: Tom Luce
Journal: BMJ (2007)

Last year, the UK government published a draft bill to reform the coroner system in England and Wales.1 The intention is to bring coroner reform legislation to parliament next month. 

The draft bill proposed fewer and larger coroner districts, led by full time legally qualified coroners. A new office of chief coroner would improve consistency of practice between local coroners and deal with appeals. There would be a new emphasis on prompt and sensitive service to bereaved families, and both nationally and locally the new service would have its own medical advice.

In 2006, Baker and Cordner wrote an editorial in the BMJ on the government's approach.2 They criticised the decision to leave responsibility for the appointment and support of coroners with local authorities and the failure to tackle reform of death certification, as recommended by both the Home Office review and the Shipman Inquiry.3 4 These criticisms and others were made in a well researched and strongly argued report from the Parliamentary Select Committee on Constitutional Affairs.5

There are no indications of a government rethink on the continuing role of local authorities in the coroner service, but a recent consultation document from the Department of Health outlines important changes in death certification now proposed for England and Wales.6 A uniform certification process would be introduced for all deaths, which would abolish the extra forms and processes currently needed for cremation. A new post of medical examiner would also be introduced. These examiners would be attached to the clinical governance teams of primary healthcare trusts and would scrutinise all deaths after the completion of a medical certificate of the cause of death by the treating doctor. 

The medical examiner would have the power to authorise disposal of the body without waiting for registration of the death. Certification by single doctors in burial cases would cease, as would payment of private fees to doctors for the cremation certificates; instead, a fee would be payable in all cases to the medical examiner service. Medical referees at crematoriums would be abolished.

Medical examiners would be doctors with at least five years' full registration. No specialist background would be required—they would not need to be pathologists and perform autopsies as medical examiners in North America do. Before counter-certifying a death and authorising disposal of the body they would talk to the first certifier and see relevant parts of the care record. 

They would train local doctors in death certification, audit local standards of death certification, and use information from the medical certificates of the cause of death to analyse local mortality trends. They might be part time, and might be co-located with coroners to ensure proper liaison with them. 

According to local preference they might also provide general medical advice to local coroners, and there might be a “professional line of accountability” between local medical examiners and the new national medical adviser to the chief coroner. They themselves would receive special training, the details of which are still to be worked out.

No substantial change seems envisaged in the medical certificate of the cause of death. Referrals to the coroner would usually be made by the treating doctor, but they could be made by the medical examiner. A separate consultation document from the Ministry of Justice proposing a new statutory duty on doctors and others to report deaths to the coroner proposes dropping the existing requirement that the certifying doctor should have seen the patient no more than 14 days before the death, or should view the body.7

Still absent from the government's proposals to date is anything on verifying the fact and recording the circumstances of death. No follow-up has been announced to recommendations by the Shipman Inquiry and the Home Office review that death should be verified in all cases by properly accredited and suitably skilled personnel, not necessarily doctors, who would also see the body. 

Doctors and the public are unlikely to be happy with a process that—as described so far—would allow people to be buried or cremated without being seen in the final stage of life or after death by a doctor or other qualified health worker, and with no professional verification that the person is actually dead. And it is strange that responsibility for this aspect of the new system seems to lie with the Ministry of Justice rather than the health departments.

Another matter likely to prompt debate is the medical examiner's closeness to the National Health Service (NHS). A crucial defect in the present system is the lack of any independent means of ensuring that deaths that should be reported to the coroner are reported. The new medical examiners could fulfil this role. However, their close links to the NHS—in which most people receive their final care—may undermine perceptions of the post's independence.

The Department of Health's emphasis on the need for links between the new death certification process and public health analysis and NHS quality control makes sense, but the government should explore ways of providing reassurance about the medical examiner's independence. These could include medical examiners being appointed jointly by the coroner (or supporting local authority) and the NHS, and explicitly requiring in the legislation that all the medical examiner's casework responsibilities should be performed independently of any public authority.

In many respects the government's reform package has sensible aims, which doctors and all informed opinion would support—modernising the ancient and long neglected coroner system, abolishing single doctor certification in burial cases and the elaborate extra process for cremations, introducing monitoring and support for the death certification process, and improving links between death regulation and public health analysis. It is now seven years since Harold Shipman's conviction for the multiple murder of patients and four years since the two reform reports commissioned in its wake. With much important detail still to settle, legislation to enact, and implementation to deliver, no one can accuse the government of excessive haste.