Written evidence from Ryk James, Senior Lecturer in Forensic Pathology and Home Office Registered Pathologist, Wales Institute of Forensic Medicine, Cardiff University
My response to the call for evidence addresses aspects of:
- The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service
- Improvements in services for the bereaved
- Fairness in the Coroners system
I am a Home Office Pathologist in my late fifties employed by Cardiff University. I have undertaken “suspicious death” cases for 4 police forces under a contract with Cardiff University for the last 28 years. I have also become a “pathologist of last resort”. Coroner’s officers or coroners call when they can find no paediatric pathologist, where no “general pathologist” is prepared to undertake an examination or does not possess the skills so to do, or when the number of bodies awaiting post mortem examination has become so great in their locality that they must get assistance. I end up taking on cases where the initial investigation has been inadequate (to the extent of missing overt signs of homicide), where there is no clear rationale for post mortem examination other than “process”, where delay and consequent deterioration of the body renders post mortem examination sub-optimal or pointless, and where the needs of the bereaved go unmet. I assist not for money – because I am a salaried employee of Cardiff University – but because the system is unfair upon the bereaved. It remains unfit for purpose.
This should not be interpreted as a tirade against coroners; it is not. It is exasperation at the failure of government. There have been numerous diligent inquiries over the last century, none of which has overcome the inertia of government and vested interests to deliver a consistent national service to audited standards, which robustly investigates deaths where the public interest arises, whilst being cognisant of the human rights of the bereaved. There is little to be said that has not already been said by Brodrick, Smith or Hutton, but my main points are that:
- There are too many invasive post mortems; many, if not most, are unnecessary in order to exclude criminality, the neglect of a duty of care, or matters of public interest. Most post mortems are superficial and made by those who do not have familiarity with the kinds of death which they are attempting to exclude.
- There is excessive delay in making post mortem examinations – this, and the high rate of invasive examination does not pay proper respect to HRA Articles 8 and 9, given the diversity of our society.
- Coroners are currently expected to uncover covert homicide where police investigation has not occurred; reveal substandard practices in hospitals and workplaces; prevent the repetition of circumstances prejudicial to public safety, and provide causes of death for registration, disposal and statistical purposes – yet without expertise in criminal investigation or medicine and without the resourcing such a wide remit would require. The value of coroners lies in independent judicial scrutiny and the holding of public hearings, but, where we already have agencies able to carry out investigative processes to a high standard – the police, HSE, IOPC, NHS and other NHS regulatory bodies – would it not be more efficient to place the obligation to investigate deaths on such agencies and to allow the coroner to concentrate more on scrutiny of those investigations and on holding more selective but detailed public hearings where the findings of those investigations are in dispute or where public interest demands it?
- In the absence of circumstances that clearly point towards malpractice, the NHS should not be referring deaths directly to coroners but should undertake a standardised and universal process of mortality governance, with early engagement of relatives, who would need to consent to any further examinations whether by CT/MRI or biopsy or dissection. This would assist in identifying missed opportunities and aid quality improvement; it would address families’ concerns early and ensure that such concerns were addressed in the right arena (coroners inquiries do not usually assist in resolving matters unrelated to the death). It would still be incumbent upon the NHS to make reports to the coroner but it would place the emphasis on robust internal inquiry, subject where necessary to scrutiny by a regulator and to judicial scrutiny by coroners, in cases where dispute remained or which required public hearings.
- Exclusion of criminality and of matters potentially prejudicial to the public interest is a police obligation – sometimes alongside HSE, IOPC and others – and they should have the necessary forensic pathology expertise to assist them in carrying out investigations expeditiously and efficiently. The current system whereby a “case fee” of some £2750 is paid whenever a forensic pathologist is called, is unnecessary and inefficient; it results in police attempting to exclude criminality by other means in order to save expenditure – and pathologists accruing income through case numbers rather than by the extent of their investigations. It would be far better to have forensic pathologists employed as part of health – they are doctors revalidated by the GMC after all – who can be available to police to discuss cases, view images and attend scenes of death where necessary. This would enable informed triage of cases such that each case is investigated to the degree required to exclude criminality/duty of care/public interest issues, whether that be through circumstances, images, scene attendance, CT scan, medical history or external/invasive post mortem examination. Once criminality/duty of care/public interest issues are excluded, all that remains is the need for a “cause of death” for registration and statistical purposes. At this point, Articles 8 and 9 must be engaged, and invasive examination of the body should not proceed without next of kin consent; other means of providing a plausible cause of death should be used, such as review of medical history and circumstances, and CT scanning. Our pilot study in Bridgend demonstrates the feasibility of this approach, reducing the need for invasive PM by 40% (Leadbeatter and James, 2016). Placing the forensic pathologist with clinical colleagues makes sense; there will increasingly be replacement of the autopsy by scanning technologies and we will need forensic pathologists to share their skills with other doctors – particularly radiologists and medical examiners – in order to develop a high quality – but different – service for the future.
- I have heard it said that “the NHS does not do death” and that investigation of hospital deaths must be done externally. The NHS has the facilities – the mortuaries, the CT/MRI scanners, the expertise in safe management of the dead and the doctors whose interpretative skills are needed in any inquiry. It does transplantation, bereavement and hereditary diseases. The NHS is intimately involved with death and it should abide by the mantra “from the cradle to the grave”. It is only by embracing an obligation to explore deaths openly and honestly, for itself and for families, that we can achieve both the learning from death that is vital for improvement and the fairness and justice that is due to families.
How can we ensure that the coroner’s autopsy is not an invasion of human rights?
Stephen Leadbeatter, Ryk James