Written evidence from Professor Raymond Agius, MD, FRCP
Thank you for this opportunity for the public to give evidence regarding the Coroner Service to your Parliamentary Select Committee.
By way of a personal introduction: I am an Emeritus Professor of Occupational and Environmental Medicine at the University of Manchester, having retired in September 2017 from my substantive chair at that University as well as my position as honorary NHS consultant to Manchester University NHS Foundation Trust. This evidence is offered in my personal capacity and not on behalf of any organisation.
I am a registered medical practitioner (GMC No: 2401593) and my licence to practise (relinquished voluntarily by me since my retirement) was restored as part of the response to the covid pandemic, under the ‘emergency powers’ provisions of section 18A of the Medical Act 1983.
In order to fulfil my obligation of transparency, I should add that I hold 'public office' as a member of the Industrial Injuries Advisory Council (IIAC). Although I am not making this submission in my capacity as member of IIAC neither do I believe that this presents a conflict of interest.
My reasons for submitting evidence can be summarised as follows: My research interests have included contending with novel diseases contracted from work. For example, I had led a four year international collaboration entitled “Monitoring trends in Occupational Diseases and tracing new and Emerging Risks in a Network” (MODERNET). I have a responsibility to support society by giving evidence to parliamentarians and have given oral and written evidence to Parliamentary Select Committees at Westminster, and in the EU. Since I started practising medicine in 1977 I have respected and valued the important role of the coroner service. Since early in the covid-19 pandemic, I have been highlighting the relevance and importance of the coroner service in respect of preventing future deaths arising from occupational exposure. This is attested by my recent publications in the British Medical Journal and elsewhere, which include:
One of my papers still ‘in press', the following in “Occupational Medicine” is fortuitously very pertinent to this enquiry, and I shall be referring to its findings in the specific responses below:
“Covid-19: Statutory means of scrutinising workers’ deaths and disease”
NB: This paper is not yet available online at the time of making this submission, however I have just received the ‘proofs’ and the editorial assistant has advised me that it will be published this month with the following URL: < https://doi.org/10.1093/occmed/kqaa165 >
1. The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service
I have no comments to make with regards to possible unevenness of Coroners services, and have no knowledge of any local failures.
In my opinion, in respect of covid-19, a National Coroners Service with systematic collection and timely uploading of data into a central (national) relational database would have permitted valuable information to be generated early (see below especially section 4 for more detail).
2. The Coroners Service’s capacity to deal properly with multiple deaths in public disasters
Four aspects might need improvement:
[2.1] The first relates to the numbers of coroners and the ability of the service to deal quantitatively with increased demand. I am not qualified to discuss this aspect. I recognise that steps have been taken to recruit additional assistant coroners and this is clearly welcome.
[2.2] The qualitative aspect i.e. the knowledge of the coroners and the expertise that they can call on in respect of the challenges posed by the specific disaster. This is very important in the context of covid (see below).
[2.3] The third, and very important aspect relates to the central / national co-ordination of the process, and of the processing of the information generated both in so far as fulfilling the long standing statutory functions of the service but also in making recommendations for action to prevent future deaths. The current service does not, in my opinion, collate relevant information centrally in a timely and practical manner. I shall elaborate on this below in relation to the pandemic in section 4.
[2.4] Moreover in cases of ‘multiple deaths in public disasters’ it is important that the activities of the coroners, essential and independent though they are, should act coherently with other organisations helping the public.
In the covid pandemic, the Office for National Statistics (ONS) has admirably performed essential services by informing the public, policy makers and scientists. However, in the ONS’ publication of age standardised mortality rates (for England and Wales) in relation to employment the early data has been biased by the non-registration of cases notified to the coroners: I shall elaborate on this in relation to the covid pandemic in a later section (4), and will suggest a remedy.
3. Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths
The statutory duty currently placed on coroners to issue a PFD report to prompt action to prevent avoidable future deaths is a welcome example of past strengthening of this provision.
However more needs to be done:
[3.1] Historically coroners’ principal source of professional advice has been from the pathologist conducting the post-mortem examination. It is recognised that Memoranda of Understanding exist, for example with the Health and Safety Executive (HSE), and the HSE may help in an inquest where special issues such as ‘health and safety’ arise. However it might be alleged at the inquest that a “culpable human failure” or “failure of systems or procedures at any level” within an agency such as the HSE’s recommendations on personal protective equipment contributed to the death. Therefore the HSE could potentially be ‘conflicted’.
Recommendation: as exemplified by the context of covid, coroners should be given the authority, guidance and resources to seek further independent expert advice.
[3.2] Moreover, at a national level, the Chief Coroner needs to have a system, access to the experts and other resource as well as a statutory duty to produce an over-riding / national PFD report on common ‘areas of concern’ as might be expected to arise following multiple deaths in public disasters. This is especially the case when they are scattered all over the country.
4. How the Coroners Service has dealt with COVID 19
Consistent with the rest of my responses, my focus in this section relates to the need for timely information and recommendations to mitigate the risk of occupationally contracted disease, and death.
[4.1] In common with other scientists and doctors I perused the Office for National Statistics (ONS) bulletins on mortality involving covid (with special reference to occupation). However as is evident from the first such ONS bulletin (see link below) the data excluded those deaths which had been notified to coroners and which had not been registered:
These missing data were, and still are, frustrating attempts to secure the best estimates of the risk of death associated with occupations.
However there is a potential remedy: Regulation 9 of the Coroners (Investigation) Regulations 2013 states that "Where a coroner has begun but not yet completed or discontinued an investigation, he or she may, if requested to do so by the next of kin or personal representative of the deceased, provide that person with a certificate of the fact of death." In practice these certificates tend to be issued almost routinely if a Medical Certificate of Cause of Death (MCCD) has not been issued since they are needed to permit disposal of the cadaver, and for other practical purposes e.g. notifying banks, starting probate proceedings etc.
Recommendation: The process in England and Wales should therefore emulate that in Scotland, by allowing the provisional registration of deaths based on the information in the “Coroner's Certificate of the Fact of Death “. These entries would be provisional and flagged as such but would permit ONS to include them in the analyses for their bulletins. Once the inquest is over, the data can be updated. (In Scotland there is a Register of Corrected Entries (now the Register of Corrections Etc (RCE), following an investigation).
[4.2] Through a ‘Freedom of Information request on my part I sought information from the Chief Coroner’s office on:
 number of notifications to HM coroners of Covid (coronavirus) deaths suspected to be attributable to employment.
 what number out of the above have been deemed as warranting a coronial inquest.
 the number of certificates of Fact of Death which have been issued and which mention covid (coronavirus)
The response from the Judiciary advised me that: “The Ministry of Justice does not hold this information. Coroners do not collect data on the employment of the deceased. Coroners do not collect data on the number of certificates of Fact of Death.”
I found the above response from the judiciary surprising since the Coroner's Certificate of the Fact of Death has essentially the same fields as a MCCD including: name, surname, age. gender, date and place both of birth and of death, occupation and usual address and 'cause of death': Ia b c, II.
Therefore what appears to be lacking is not the information at a local coroner’s level but at the level of the Chief Coroner’s Office.
Recommendation: This shortcoming should be remediable through a system for the timely coding and entering of these ‘fact of death’ data, and their uploading to a central (national) relational database. This is also relevant to points 1 (national coroners’ service) and 2 (dealing with multiple deaths in national disasters).
[4.3] Inter alia I should add that central collation of the above information could be of value to the Chief Coroner for other reasons such as to determine and understand variations between coroners in the ratio of inquests conducted to notifications received.
5. Progress with training and guidance for Coroners
Although the Chief Coroner provides guidance for coroners, for example in relation to the covid pandemic, the exercise of the coroners’ individual judgement in specific novel circumstances could benefit from additional training.
[5.1] For instance, as regards occupational (industrial) disease (as distinct from trauma) the whole Coroners Service for England and Wales has on average been generating only one PFD report per year. Over the last four years (2016-2019) respiratory protective equipment (RPE) does not appear to have been mentioned once in any PFD. In a sample of 81 PFDs relating to deaths in hospital concerns about infection were raised in 10. <https://doi.org/10.1093/occmed/kqaa165> However infection contracted by a sick hospitalised patient bears limited analogy with occupational infection contracted by a previously fit worker, so coroners are likely to need additional training and guidance.
Recommendation: To fulfil their functions adequately, coroners would benefit from additional training and guidance on matters such as the routes and the risk of contracting covid from work, and the science and practice of mitigating such risk for example through respiratory protection.
[5.2] Furthermore it might be necessary to guide the coroners as to how to secure additional knowledge or access to expertise to ensure that appropriate and adequate PFD reports are produced in such cases.
6. Improvements in services for the bereaved
[ I have no comments to make in respect of topic No 6 ]
7. Fairness in the Coroners system
[ I have no comments to make in respect of topic No 7 ]
Thank you for having given me the opportunity to respond through your solicitation of views from the public. I hope that my observations might be of some value. I shall send a pdf of my paper entitled “Covid-19: Statutory means of scrutinising workers’ deaths and disease “ to your secretariat as soon as it is published. Please do not hesitate to contact me should you require further information or clarification.
1st September 2020