Written evidence from The British Medical Association

 

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

 

Overview

The BMA welcomes the Justice Select Committee’s inquiry into the progress of the Coroners and Justice Act. The BMA has historically been supportive of reforms to the coroner service and the death certification and cremation systems in England and Wales as far back as the Broderick report, the Shipman inquiry and Dame Janet Smith’s subsequent reports. Our members interact with coroners regularly for varying reasons, but collectively do so as part of their legal and regulatory duties towards deceased patients as well as being supportive of their grieving families.

This response represents the views of members working within secondary and primary care whose patients deaths are being investigated by a coroner and pathologists who undertake post-mortems and reports for their local coroner service.

Summary

 

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

1.1   The BMA appreciates and acknowledge the role of the Chief Coroner and all that has been achieved to improve the messages and guidance for coroners collectively, but it is clear that the role’s legal powers and authority over individual coroners is limited and does not extend far enough to ensure there is consistency, sufficient authority and joint working practice. We would, therefore, fully support the case for a National Coroners Service if it were to provide the governance and legal authority needed.

1.2   In making this point we fully accept the Chief Coroners reported arguments that each coroner must be free to make their own professional legal judgements in each case. We would argue that idiosyncratic approaches to the requirements to report deaths to HM Coroner, and the acceptance, processing and administration of cases is inappropriate in the 21st Century. Current arrangements, particularly where doctors have to deal with multiple different coronial jurisdictions, lead to confusion, inefficiency and delays.

1.3   Our GP members continually highlight the extent of unevenness within the coroner’s service to us. Local Medical Committees (LMCs) - the statutory regional and professional representative structures for GPs across the UK - vary in their relationship, approach and involvement with the local coroner. Some LMC’s have excellent working relationships and can come together to discuss any issues of concern, however others cannot. This we feel is very much based on how much value each individual coroner places on engagement with GPs and LMCs and how they choose to communicate with them. We would like to see consistent and collaborative working relationships across all coronial areas to ensure coroners and doctors are supporting each other and are respectful of the challenges general practice face so that local procedures can be agreed to the benefit of all.

1.4   The variation in interpretation of national guidance and the procedures implemented by coroners has been highlighted most recently during the management of the Covid-19 pandemic. Inconsistent, and at times, concerning coronial responses gave rise to us having to consider taking steps to ensure the safety of our members. Such coronial responses were not confined to a single locality. For example, one member reported that their local coroner was insisting doctors attend the deceased in person presumed to have died of COVID-19 to verify their death, despite national guidance stating otherwise[1]. In this instance we were able to resolve the issue without resorting to further legal measures, but it is concerning that the BMA had to consider such measures to ensure adherence to national emergency guidance designed to protect the safety of all parties.

1.5   Although this issue was rectified we are extremely concerned with how coroners will individually navigate the gradual implementation of the medical examiner system in England and Wales and if and when this moves into the community, how medical examiners, coroners and the relevant doctors will interact. The focus of the medical examiner system was to unify and strengthen the way in which deaths are recorded, scrutinised and investigated. If coroners continue to interpret rules and guidance differently to others, the new ME system risks becoming unworkable.

1.6   We are also aware that many coroner's have sustained significant and ongoing funding cuts which has impacted their office staffing levels and at times caused difficulties in speaking to a coroner's officer which in turn causes delays in handling cases. Consequentially doctors must spend more time interacting with the coroner’s office, reducing the time they then have to see patients.  This has led to local systems being put in place requiring online contact with a coroner in the first instance rather than being able to make initial referrals through a telephone call. This can add to a GPs workload as a result because a single issue must be acted upon multiple times rather than acted upon and finalised once. This must be addressed with coroners being provided with sufficient resource to undertake their work in an effective and timely way.

 

  1. The Coroners Service’s capacity to deal properly with multiple deaths in public disasters

2.1   The BMA has long held concerns with operational capacity of pathologists who undertake post-mortems for coroners and whether the service would cope with a large-scale emergency. For many years now, there have been ongoing workforce issues for pathologists who are trained to undertake post-mortems. Currently, there is a national shortage of autopsy pathologists, and fewer pathology trainees are showing an interest in pursuing autopsy work by taking the CHAT exam.  As an example of this a member reported that from their own large Teaching Hospital of 34 Consultant Pathologists there is only one prepared to do adult autopsies.

2.2   In addition to this for some time now, the funding for pathologists to complete post-mortems for Coroners and the related reports have not been sufficient to incentivise existing practicing doctor or trainees to enter this specialty. The MOJ’s reluctance to increase fees for pathologists has undoubtedly had an impact upon suitably qualified doctor’s willingness to perform extra non-NHS duties.

2.3   With so few pathologists undertaking post-mortems for coroners we are concerned that the number of autopsy pathologists will diminish further without sufficient investment in training and funding. It is crucial that this matter be addressed by the MOJ to ensure there is a sufficient number of pathologists performing post-mortems to meet the demands of coroners now and in the future.

 

  1. Ways to strengthen the Coroners role in the prevention of avoidable future deaths.

3.1   The BMA recommends the creation of a coroner’s registry capable of collating all cases where prevention of avoidable future deaths is apparent. Such a central registry would provide the Chief Coroner with the evidence to make recommendations to government to amend the law where appropriate.

 

  1. How the Coroners Service has dealt with COVID 19

4.1   Part of our response concerning the coronial response to Covid-19 has been illustrated in our response to question one. Doctors have an on-going concern that those colleagues deaths whilst caring for Covid-19 patients, especially where there are questions of inadequate personal protective equipment (PPE), should be appropriately investigated to ensure their families and the profession as a whole receive the reassurances they require and that society learns from this and reduces the possibility of  any further unnecessary deaths.

 

 

September 2020

 

 


[1] DHSC Guidance, Coronavirus (COVID-19): verifying death in times of emergency, 05 May 2020, https://www.gov.uk/government/publications/coronavirus-covid-19-verification-of-death-in-times-of-emergency/coronavirus-covid-19-verifying-death-in-times-of-emergency