Written evidence from The Medical Protection Society (MPS)


Opening remarks


The Medical Protection Society (MPS) welcomes the opportunity to provide evidence to the Committee’s inquiry of the Coroner Service.


MPS is the world’s leading protection organisation for doctors, dentists and healthcare professionals with more than 300,000 members around the world.


In 2019 alone, we assisted 1,300 members involved in coronial investigations, and too often we see prolonged investigations in some parts of the country, where a comparable incident elsewhere would see the same case swiftly closed.


Our ambition is to create more consistency in the Coroner Service which would be fairer for families of the bereaved as well as healthcare professionals and which would ensure better use of public resources. We believe this could be best achieved by the creation of a National Coroner Service.



Question 1: The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service


MPS believes there needs to be one National Coroner Service in England and Wales. This would lead to a more consistent application of the rules, a more robust coronial system and it would ensure better use of public resources. The creation of a National Coroners Service should be accompanied with greater accountability and significant governance for it to be successful.


MPS assisted over 1,300 doctors involved in coronial investigations in 2019. Through our work assisting doctors through a coronial investigation, we see considerable inconsistencies across England and Wales.


In some parts of the country a coroner’s investigation into a patient’s death would take place, when a comparable incident elsewhere may be resolved at hospital level. Similarly, for some areas, investigations will be unnecessarily prolonged and expensive when a comparable investigation elsewhere would be resolved promptly. There are inconsistencies across England and Wales resulting in a postcode lottery service not benefiting anyone involved.


There is also a significant contrast between the way the system operates in Scotland in comparison to England and Wales – where the Crown Office and Procurator Fiscal Service decide when an inquiry is in the public interest. In our experience, this approach yields greater consistency across Scotland, which serves everyone well.



Question 2: The Coroners Service’s capacity to deal properly with multiple deaths in public disasters


MPS believes that the main issue for the Coroner’s Service capacity is underfunding. The Coroners Service is stretched and this lack of capacity becomes all the more apparent if a major disaster breaks out.


Some public disasters such as terrorist attacks tend to happen in bigger cities where there is likely to be more resources to deal with them. However, there are some concerns that in the case of a disaster occurring in a rural area whether the local coroner’s office would have the capacity to cope.  Where there are complex multiple deaths, such as we have seen in residential homes during the COVID-19 pandemic, multiple inquests that examine common themes could be inefficient and lead to lack of consistency.



Question 3: Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths


MPS believes that the guidance by the Chief Coroner issued during the Covid-19 pandemic has been good. We have also observed plenty of best practice performances by individual coroners. We believe that a National Coroners Service structure would help to ensure more consistency across the country.


A suggestion to prevent future avoidable deaths could be for the Coroners’ to collect views and examples of good practice and do a national collection and responses document which could be distributed annually so all coroners can all learn from each others’ cases.



Question 4: How the Coroners Service has dealt with COVID 19


MPS believes that the Chief Coroner and the coronial services in general have responded well to the pandemic. We would however like to stress that – much like the NHS - the successes in dealing with Covid-19 could be a result of having stopped mostly all other work unrelated to Covid-19. The broader implications of this will become more apparent in the upcoming months.


We welcomed the decision of conducting remote hearings amidst the pandemic. We have seen its success in some cases involving our members and we believe this could continue to be applicable in the future as a way of reducing pressure on the service.


We also welcomed the Essex Coroners’ Service reversal of the announcement by the Essex Chief Coroner that GPs had to verify all deaths in person during the pandemic. We disagreed with this position and welcomed the reversal of this policy in May 2020.



Question 5: Progress with training and guidance for Coroners


MPS believes the Coroners service could benefit from having greater consistency of training and guidance as well as supervision of how it is applied to individual coroners increasing accountability. We support the creation of specific guidance and an approval process for all inquests which will create further accountability for coroners and ensure consistency and fairness throughout the country.


MPS understand that coroners have been receptive about joining the Royal College of Pathologists to participate in a joint training together with the medical examiners. We welcome this initiative as we believe it will be beneficial to both coroners and medical examiners. The Chief Coroner has also introduced annual days with conferences to bring coroners together, which we strongly support.


Lastly, we believe that some coroners could benefit from greater training in legal medicine using the education resources available to them.


Question 6: Improvements in services for the bereaved


As a general point, which will not only improve the services for the bereaved but for all interested parties, MPS believes that the unevenness which currently exists in the Coroner Services leads to several delays and doesn’t serve any of the involved parties well.


Unnecessary or very long investigations can be very stressful for the deceased patient’s family as they wait to get the answers they deserve. We believe that families would benefit from the creation of a National Coroners Service which will serve them more consistently regardless of what part of the country they are based in. This also affects healthcare professionals who may be subjected to the stress of a needlessly long or unnecessary coroner’s investigation. Finally, it is the taxpayer who too often must fund delays and unnecessary processes in these investigations.


MPS believes that an improvement in services for the bereaved could be to introduce a pre-inquest review and an agenda to which the family of the deceased would have to attend. This will be beneficial to the family as it will give them an understanding of what will happen at the inquest as well as an opportunity to ask informed questions.


A good example of an improvement in Coroners services for the bereaved is the emergency Coronavirus Act. This is the best example in terms of identification and registration. However, this is an emergency Act and can be repelled at any point.


Question 7: Fairness in the Coroners system


We believe that a National Coroner Service would be the fairest option creating greater consistency on application of the rules.


The Coroners system could also be fairer if a culture of greater accountability is introduced to the service in order to ensure that guidance is applied more consistently when appropriate.


About MPS


MPS is the world’s leading protection organisation for doctors, dentists and healthcare professionals with more than 300,000 members around the world, more than 8,000 of which are in Northern Ireland.


Our in-house experts assist with the wide range of legal and ethical problems that arise from professional practice. This can include clinical negligence claims, complaints, medical and

dental council inquiries, legal and ethical dilemmas, disciplinary procedures, inquests and

fatal accident inquiries.


MPS is not an insurance company. We are a mutual non-for-profit organisation and the benefits of membership of MPS are discretionary as set out in the Memorandum of Articles of Association.


August 2020