Written evidence from Dr P D Lumb, B.Med.Sci (Hons), MB ChB, DipRCPath (Forensic), DMJ (Path), FRCPath, MFFLM, Forensic Pathologist on the Home Office Register


I am currently the President of the British Association of Forensic Medicine (BAFM), the membership which comprises most of the forensic pathologists in the United Kingdom, trainee forensic pathologists, retired forensic pathologists and members from abroad.  Although many of the issues we cannot comment upon directly I make the following observations:


There do appear to be some inconsistencies from the perspective of a forensic pathologist in the coronial services.  Most of these inconsistencies are relatively trivial, for example, non-standardised forms (e.g. differing cause of death forms).  However, there are some more striking differences/inconsistencies.  Some jurisdictions treat road traffic collisions and deaths in custody very differently.  For example, a prisoner committing suicide by hanging in one jurisdiction might be conducted by a histopathologist as a “routine” post mortem examination, whereas in another jurisdiction an identical case would be treated as a “Home Office Autopsy”, with the police, scenes of crimes officers, exhibits officers and forensic imaging specialists attending with the forensic pathologist.  Road Traffic Collisions where a criminal charge may be forthcoming are also sometimes dealt with in this inconsistent manner.  My view is that any case in which there might be a criminal conviction or a death in custody should be conducted as a Home Office Autopsy – there should be a consistent approach throughout the country.


In broad terms, speaking with colleagues, from our perspective during a number of mass fatality incidents, the Coroners Service has coped well with handling these incidents.  Certainly, from my own perspective, in the Manchester Arena Bombing the local Coroners were very much directly involved, being present at the scene and in the mortuary – immersed in the processThe local Coroners all co-operated well and very competently carried out their tasks.  The Coroner’s Officers were very effective in their roles during this incident from our perspective.  However, our viewpoint is limited to the autopsy process in such incidents and the later inquest / inquiry process.


With regard to COVID, I have only attended one inquest since March – presumably a number of inquests are yet to proceed due to difficulties with facilities.  Although Coroner’s are inviting us to conduct inquests by remote connection, speaking with several colleagues this is not ideal.  Attending court in person appears to be favoured – I think it is important that the Coroner’s service ensures that attending court in person to give evidence always remains an option.


We regard to training, it is difficult for us to comment upon this matter, although I am not aware of regular training provided to the Coroners from the forensic pathology community.  Perhaps, once the pandemic has passed, the BAFM and the Coroner’s Society could organise training for Coroners.  We sometimes encounter cases whereby a decision has been made not to conduct an autopsy, or a delay has occurred over the decision whether to conduct a standard autopsy or a “Home Office” autopsy.  In these instances, the pathologist may not have been contacted – we can help the Coroner to make these decisions, and I often think we are sometimes underused in this capacity.


I note the question with regard to fairness – it was unclear precisely what this meant.  However, comment has been passed that despite being recognised in the Criminal Courts as Expert Witnesses, some Coroners will not afford the forensic pathologist this recognition when appearing in Coronial Courts, despite giving evidence upon very difficult and challenging cases.  Concerns have also been raised with regard to the second post mortem examination upon behalf of a defendant in Criminal Cases.  Currently, the situation appears to be that the defendant’s representatives have to justify to the Coroner why they require a second autopsy – if the Coroner is not satisfied with the arguments put forward by the representatives, then permission may not be given for the second autopsy (please see Guidance 32).  Overall, it would appear that there has been a fall in the number of second autopsies conducted on behalf of a defendant.  Whilst I fully understand that a second autopsy may cause further distress to a family and possibly delay the autopsy, my concern is that there is an increased risk for a miscarriage of justice.  I think this area needs much more consideration (indeed, hopefully I shall publish some data on this later in the year)


The view of many of my colleagues is that the Coroner’s System is underfunded – particularly with regard to the fees for non-suspicious post mortem examinations, perhaps contributing to a short fall in pathologists wishing to undertake this work.


I also believe that it is very important that when making decisions that impact upon the Coronial system that all the stakeholders, particularly the histopathologists and forensic pathologists are permitted to have an input.

September 2020