Written evidence from Dr. S. Leadbeatter

EXPLANATORY NOTE – the numbers of the paragraphs in this evidence are not to be regarded as reflecting the numbering of the items set out in the call for evidence. 


  1. I am Senior Lecturer in Forensic Pathology at Cardiff University but this document expresses my personal views; I have worked as a pathologist in the Coroner Service since 1984 and have made submissions to previous inquiries into its functions. 


  1. In summary –the provision of this service is fragmented between too many agencies and individuals    with no uniform vision or standards; despite the desire to place the needs of the bereaved at the centre of the service, it is my view that   those needs are subordinate to the needs or interests of those who provide the service, and that the interests of the agencies and individuals working within this fragmented service are the barrier to change; the recommendations of the Hutton Review should be implemented


  1. In my view, an important improvement in the service for the bereaved would be a decrease in the number of invasive post-mortem examinations:  it appears to me that the coroner system considers invasive post-mortem examination to be the easiest default position to allow the decision as to whether a death is natural or unnatural and, therefore, subject only to investigation, if natural, or subject to inquest, if unnatural – this “quick fix” appears acceptable to pathologists who may argue that they lack time to consider all the medical history which may be available, and that they are unable to provide a plausible cause of death in the absence of invasive post-mortem examination.  Such a post-mortem examination might be acceptable – in deaths where initial scrutiny indicates no evidence to suggest that the death is other than natural – with the informed consent of the bereaved to such an examination but, at this time, the wishes of the bereaved have no legal weight in this decision – that, to me, is wrong in any system which professes to place the needs of the bereaved at its centre.


  1. Coroners investigate deaths where the deceased is, or is not, subject to care provided by other individuals or specific agencies:  where the deceased is not subject to such care, the issue for the investigation is to determine what is the cause of death and whether that cause is natural or unnatural, a distinction which is derived from police and medical sources; where the deceased had been subject to care during life, the issue for investigation frequently is not so much what is the cause of death but whether the care provided to that individual had been suboptimal, that is, there had been failure in provision of care.  Unless the failure to provide that care has been so abject as to warrant criminal charges, a Coroner is dependent not upon the police to provide an investigation but, at least in health care settings, upon what may be the results of investigations made by a health care agency in a root cause analysis or otherwise to facilitate clinical governance.  Inquiries into such deaths – for example, the Cumberlege and Francis Inquiries – do not allow confidence that the interests of the bereaved are of primary importance to the health care agencies concerned, but those agencies are better placed to make investigations than is a Coroner Service without easy access to appropriate expert evidence which is independent of the health care agency.  Were Coroners and the bereaved to be confident that such expert, independent investigation had been undertaken – might not the Healthcare Safety Investigations Branch be involved here, should they be established as an independent public body when parliamentary time allows? then inquests into such deaths should be necessary only to ratify the findings and recommendations of such scrutiny, and need investigate in an active manner only those deaths where such an inquiry has been inadequate or fails to satisfy bereaved who have been engaged fully with the inquiry ab initio.  In those deaths which occur in hospitals, it should be unnecessary for there to be invasive post-mortem examination of the deceased unless ante-mortem clinical investigations have been so inadequate as to allow no attempt at properly informed diagnosis.


  1. Where a deceased had not been subject to the care of others when alive, what is necessary is expert investigation to eliminate the actions of another individual as instrumental in causing death; the majority of such deaths, where there is a trained detective input into the circumstances of the death, and where there is, when necessary, early input from forensic pathology into the investigation, require invasive post-mortem examination only where there is any doubt as to whether another individual may be involved in the death, or where the investigation, and the antecedent medical history of the deceased, yield no plausible explanation for death.  I would consider that little confidence can be placed in the forensic skills of histopathologists who have had no formal forensic training – and yet the majority of Coroner’s post-mortem examinations are made by such histopathologists and the Royal College of Pathologists published no standards for the making of such post-mortem examinations until February 2014.


  1. I cannot be optimistic that any further inquiry into the Coroner Service will yield positive action:  what appeared to me to be eminently sensible suggestions for the future – the October 2012 Report from the NHS Implementation Sub-Group of the Department of Health Post Mortem Forensic and Disaster Imaging Group (PMFDI) [https://www2.le.ac.uk/departments/emfpu/national-documents-1/Can%20CrossSectional%20Imaging%20as%20am%20Adjunct%20andor%20Alternative%20to%20the%20Invasive%20Autopsy%20be%20Implemented%20within%20the%20NHS%20%20FINAL.pdf], and the March 2015 Review of forensic pathology in England and Wales (the Hutton Review), [www.gov.uk/government/publications/review-of-forensic-pathology-inengland-and-wales] – appear to have been shelved, with little or no evidence of interest – if not frank resistance –  from the Department of Health, the Royal College of Pathologists, and  the British Association in Forensic Medicine. 


  1. Professor Peter Hutton wrote – “To ensure that both services [Forensic Pathology, and the Coronial Pathology Service] are fit for public interest going into the future requires a rationalisation of these variables [multiplicity of masters in both responsibility and resource], and regionalisation of services … the most cost effective solution to the present problems is to change the way in which we investigate and certify death and to reduce the strict division between forensic and coronial work …”.  My colleagues and I endeavoured to implement such a scheme in a local mortuary, publishing the results as How can we ensure that the Coroners autopsy is not an invasion of human rights? [https://dx.doi.org/10.1136/jclinpath-2017-204323-] but were unable to take this beyond a “pilot” stage because of organisational and financial issues.



  1. I would emphasise again Professor Hutton’s recommendation “that a new nationally based ‘Death Investigation Service’ should be introduced for England and Wales” (4.3.2 of the Hutton Review) and that “an exercise is undertaken to identify and bring all this financial resource [drawn upon by forensic and coronial practitioners] under a common organisation which has no affiliations that would allow its independence to be successfully challenged” (4.5 of the Hutton Review).


  1. The provision of mortuary services to Coroners appears not to be uniform throughout England and Wales:  some Coroners have access to mortuaries provided by Local Authorities whereas others, in particular those in Wales, are dependent upon mortuaries provided by the National Health Service where there may be access to radiological facilities which may be used for computerised tomographic scanning of the dead but neither that access, nor a wilingnessl among pathologists to utilise such, is uniform.    Where the capacity of such NHS mortuaries for body storage is limited, there may well be obstacles to dealing locally with any mass fatality incident – attention has been directed to this issue during the early months of the Covid-19 pandemic but whether options explored during that pandemic will be factored in to everyday practice remains moot.


  1. Where there is no standardisation in determination of what issues about a death require investigation, no formal training or assessment of those who determine and/or investigate those issues, and no appropriate and uniform provision of the necessary resources and skills, then it appears to me that the Coroner’s system in England and Wales cannot provide fairness to the bereaved.


27th August 2020