Written evidence submitted by Imogen Jones (TCS0004)
The Justice Committee, The Coroner Service: follow-up
Dr Imogen Jones, School of Law, University of Leeds
1. I am an academic based in the School of Law at the University of Leeds. My research relates primarily to the autopsy stage of medico-legal death investigations. I have conducted empirical research involving forensic and, most recently, coronial pathologists, as well as with the Anatomical Pathology Technologists (APTs) who play a crucial role in assisting the process. The latter research was funded by the British Academy/Leverhulme. Besides forthcoming publications, it has led to the establishment of a network of interested practitioners, including pathologists, APTs, coroners and others.
2. My expertise and experience allow me to combine professional views and experiences with rigorous academic analysis. Qualitative interviews provide deep insight into the experiences, views, and practices of individuals. While often not generalisable to all, they can identify trends and common concerns. These methods enable researchers and policy makers to explore the impact on both individuals and society.
3. I specifically address the elements of your call for evidence related to the structure of the coronial system in England and Wales, with an emphasis on its resourcing and the implications of these for both the bereaved and the deceased person. My research is the only example of its kind, in bringing together these diverse and important voices, all of which are relevant to policy formation in this area. As the latter research is still being written up and disseminated, I have not included references to publications, but I am more than happy to send these to the Committee in due course.
Summary
Pathology service and resource
4. It is regrettable that the government rejected the previous recommendation to reconsider the fee paid to pathologists who carry out coronial autopsies. In my research, the lack of adequate remuneration was cited as the primary reason for the increasing crisis in the number of pathologists willing to carry out coronial work. The work is unpleasant and hard, it is additional to already busy roles, and often carried out at the cost of family life.
5. There has been some local negotiation resulting in geographical variation in fees paid. Pathologists are aware of this and resent differing treatment where they are not beneficiaries. The different rates and approaches to this (whether a flat fee, additional payments for extra services and so on) reflect the wider lottery and inconsistency of the Coroner Service.
6. This variation in practice is also reflected in the approach to whether, and in which cases, invasive post-mortems are required. Pathologists introduce an additional layer of difference, by each having their own approach and beliefs about what is appropriate in each case.
7. The result of this is a variable experience for the deceased and the bereaved.
8. Within the pathology community, I found no sense of there being any meaningful move towards the integration of coronial pathology services into NHS contracts, although this would be welcome by many pathologists. It would not only give professional recognition to this work but would ensure comparable payment across the jurisdiction.
Placing bereaved families at the heart of the Coroner Service
9. In his lecture of 19th November 2023, ‘Death and taxes: the past, present and future of the coronial service’, the Chief Coroner explained that he understood the commitment to ‘place bereaved families at the heart of the Coroner Service’ to be a derivative of the primary goal of promoting the interests of the now deceased person.
10. In my research, I have found that the respectful treatment of the deceased is often understood to primarily benefit the bereaved. This extends to information, presentation, and empathy with the bereaved. Whilst the inquest may often be a site of trauma, or therapy, for the bereaved, there is little coherence regarding who the system is ‘for’ and how their needs are reflected in practice and support mechanisms.
11. Where a case is taken to inquest, there are clear opportunities, in theory at least, for the bereaved to ask questions and raise concerns. However, the majority of cases do not result in an inquest. The ways in which the bereaved and, indeed, the deceased are served by the entire coronial process needs to be considered. I would also suggest that the interests of wider society, for example, in accurate death data are also important. These do not need to be mutually exclusive but may impact on emphasis and reasonable expectations of the parties involved.
Improving consistency
12. As was highlighted in evidence to your previous hearings, there is scant consistency across England and Wales. The Chief Coroner’s Guidelines are just that, meaning that there is limited meaningful oversight of regional variation. This postcode lottery means differing treatment, experiences, and outcomes at all stages.
13. In my research, pathologists were clear that coroners exercise different judgements regarding when to require investigation, post-mortem (and what type), and what to pay. This can lead to considerable resentment, and impacts the experiences of all involved.
14. This lottery also extends to pathologists who, depending on the attitude of the coroner, may apply their own views regarding the necessary extent of post-mortem. This variation exists despite, and sometimes contrary to, RCP guidelines.
15. It is also clear that local culture and practice pervades the mortuary sector. The care received by the deceased and the bereaved is impacted by the resources and practices of the mortuaries and APTs who staff them. In addition to approach to evisceration, reconstruction, and viewing, the extent to which bereavement services are integrated with mortuaries affects the experience of the bereaved.
16. It is hoped that the introduction of the medical examiner system will improve the experience of the bereaved and reduce the number of unnecessary invasive procedures. However, there is potentially a gap between the care extended in that service and that of the Coroner Service. Much reliance is placed on often under-resourced Coroner’s Officers to plug that gap.
17. In my research, I found wide acceptance of the need to adapt processes to accommodate the preferences of faith communities. This included changing the order of post-mortems to facilitate the prompt release of deceased bodies and amending methods (or at least attempting to avoid invasive procedures if possible). Considerable progress towards this in nationwide coronial practice was widely reported. The pathologists and APTs appropriately defer authority and responsibility for this decision to the coroner.
18. There was, however, some discomfort amongst APTs, who care for the deceased, that the inherent unpleasantness of invasive autopsies ought to be recognised, whatever the faith or culture of the deceased/bereaved. It was often argued that invasive post-mortem ought to used only when necessary.
Wider system and purposive driven approach
19. My evidence has been underpinned by two interlinked concerns. First, the first report did not consider the earlier but important stages of the coronial process in sufficient detail. Second, my view that (in)consistency is a primary concern.
20. Underlying both of these; is the lack of proper resourcing, absence of power to implement meaningful oversight, and a resulting geographical lottery. There is wide consensus that this critical medico-process simply cannot continue to serve the needs of individuals or society without considerable investment.
21. My view is that incremental change without system-level evaluation of the purpose of the coronial system will inevitably fail. This central goal needs to drive resources, process, and reform. Such an exercise has been carried out in Australia and, whilst not perfect, has led to considerable improvement in both coronial practice and the resourcing of death investigation. The hub system proposed by Hutton, and advanced in your last report was based on that system. However, our jurisdictions are different, and the exercise would need to be adapted to local context. This, in my view, should be the priority.
Acknowledgements:
I would like to recognise the work, time and care of the pathologists and APTs who have contributed to my research thus far. The research was funded by the British Academy/Leverhulme, to whom I also extend my thanks.
December 2023