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is aware that evidence of good practice in the coroners system remains sporadic and
geographically inconsistent.
Case study: An example of bad practice in the coroners system:
Mark Cannon was a 30 year old man, who had a severe learning disability and
epilepsy. He had very little speech, but was able to communicate with his family and
sister, Jane, to whom he was very close.
Mark lived at home with his mother and stepfather and attended a day centre, five
days a week. He occasionally stayed at a care home run by his local authority.
In June 2003, for reasons unknown, Mark broke his femur while staying at the care
home. He was subsequently in and out of hospital. His condition continued to
deteriorate and in the middle of August 2003, he had a heart attack while on the High
Dependency Unit in Hospital. At the end of August 2003, his life support machine
was switched off.
The family believed Mark’s death was avoidable and an inquest decided that he died
as a consequence of an “accidental death.” Mark’s family contested this view and
made complaints against the local authority concerned, his GP practice and the
Healthcare Commission. None of these complaints were upheld.
However, when the Parliamentary and Health Service Ombudsman (PHOS)
investigated the family’s complaints they were upheld. The report said: “Mr Cannon’s
parents said they were appalled by what happened to their son. At one point in the
complaints process they said:
“All of Mark’s 30 years had been a struggle for equal rights to health care, support
and the services within the society he lived. We battled continuously with virtually no
progress”.
If Mark’s family had relied entirely upon the coroners service to establish the correct
details as to the cause of their son’s death, they would still not be aware of the truth.
The Death by indifference report raised some key failings of the coroners system as
bereaved people are being let down, made to wait lengthy periods for decisions and
denied the answers they require to achieve the causes of a loved one’s death.
Mencap believes that the Office of the Chief Coroner is vital in seeking to overcome
these failings by ensuring that inquests are of an approved national standard and
that accountability for the findings of the inquest is achieved. This will help to bring
about a coroners system which meets the needs of the bereaved and learns from the
past in order to prevent similar incidents in the future.
A more effective coroners system would be better placed to spread the lessons of
failing practice, achieve higher standards and help prevent unnecessary deaths in
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