Review of the Coroner Service - The Department of Justice and ...

ISSUES AND RESPONCEScycle of coroner activities. A wide range of issuesarise in relation to inquests and will now beconsidered. These include:• courtroom facilities• jurisdiction of the coroner• verdicts• recommendations• discretionary and obligatory inquests• inquests without a post-mortem• disclosure of documentation in relation to aninquest• adjournments• disqualification from holding• ensuring attendance• immunity• juries.Courtroom facilitiesIn terms of the Group’s commitment to a renewedfocus on service to relatives, it was felt thatphysical facilities in the form of waiting rooms,toilet facilities and other basic infrastructureshould be available at inquests. This is bestachieved by an active and focused engagementwith the Courts Service on how best to integratedevelopments in court facilities with the specialrequirement of those who must take part in aninquest process, which can often be a source ofgreat trauma and upset.Jurisdiction of the coronerOne of the most important issues addressed bythe Group related to the question of coronerjurisdiction. In simple terms, this is oftenexpressed in the form of a question as to how farthe coroner can or should go in investigating thecause of death. Section 30 of the Coroners Actstates:“Questions of civil or criminal liability shall notbe considered or investigated at an inquestand accordingly every inquest shall beconfined to ascertaining the identity of theperson in relation to whose death the inquestis being held and how, when and where thedeath occurred.”A number of important legal cases have arisenover this issue and these are outlined in Cases A, Band C in Appendix G. Essentially, the argumentfocuses on the interpretation of “how” the deathoccurred. Should the interpretation be confinedto the proximate medical cause of death, e.g.“asphyxia” or should the coroner look behind themedical cause and explain the death in terms of“asphyxia due to accidental hanging” or“asphyxia due to self-inflicted hanging.” Shouldthe interpretation of “how” be confined to“heart failure” or “heart failure due to anaccidental overdose of a drug”?The Group debated this issue at length andagreed that its resolution lay at the heart of thevery reason for the coroner’s existence. It must beremembered that the role of the coroner isactivated by circumstances where a death hasoccurred in a violent or unfair manner or throughnegligence, malpractice misconduct, orunnaturally. There is an assumption of thepossibility, given the particular circumstances, thatan investigation is warranted in the publicinterest. The system reflects the value placed byour society on the preciousness of life and is partof the checks and balances used to account forsudden and unexpected death in whatever form.These public interest functions which point toallaying suspicion and making recommendationsin the public interest are clearly set out in Case C,Appendix G.Against this background, if the interpretation of“how” someone died is confined to the proximatecause of death (as some would argue) then therole of the coroner is confined to merelyadmitting the pathologist’s post-mortem report atthe inquest.61