Written evidence from Doctor Nicholas Shaw, GP locum [retired from full time general practice] and Assistant Coroner for Cumbria at 1953

I would like to comment on one aspect -The Coroners Role in prevention of future deaths.

1] As A GP I greatly valued seeing PM reports which always used to be shared routinely. This stopped some years ago, I believe due to data protection issues. When a patient died unexpectedly it was of great educational value to see these reports and to be able then to tie them in to whatever clinical information I had as the doctor who had been responsible for the deceased’s care. It is of course still possible to do this with next of kin consent but I my coronial experience it very rarely happens, the doctor may well be unaware that a PM has taken place. Could not this be rectified and reports added to medical records routinely.


2] The Chief coroner does publish R28 reports to prevent future deaths but the system does not allow for it to be searched for similar cases. For instance deaths associated with toxicity of a particular drug. This issue was raised in a couple of letters to The Times a few years ago by scientists trying to research adverse drug reactions. I did raise it with the Chief but no changes have yet taken place -in my view the system should be updated to allow for this.


3] I would like to suggest consideration be given to wider publication of reports that may have national rather than purely local relevance. For instance a hospital or public service omission or procedural gap that has contributed to a death. I have in mind something similar to the Medical Defence Union’s circular’s giving examples of cases that have learning points for doctors. Could not something similar be circulated to relevant authorities perhaps twice a year? The choice of cases to highlight would be a matter for the office of the Chief Coroner.


Finally a comment on the fees paid to pathologists, you will be aware of the difficulty many coroner areas are experiencing because declining numbers of pathologists are willing to undertake coronial PMs. The basic fee for examination and report is merely £92 and has been unchanged for nearly 20 years. This is only £10 more than a doctor receives for signing a cremation certificate and it needs to rise substantially to recognise the work entailed.


August 2020