Headlines: August 1st, 2006



The Government is being warned today that it is in danger of “wasting a golden opportunity” to reform the system for issuing death certificates which includes Coroners investigating certain deaths. The present system dates partly from Victorian times and partly from even earlier. The warning comes from the Commons Constitutional Affairs Committee.

In its report, “Reform of the Coroners’ System and Death Certification”, published today, it says that although the draft Bill on Coroners Reform will improve the coronial system, it will do nothing to remedy critical defects in death certification.

Dame Janet Smith, chair of the Shipman Inquiry, gave evidence to the Committee and told members that proposals in the Bill “would go no way at all towards remedying the defects that failed to detect or deter Shipman. If these reforms go through – and they are good in themselves and I have no criticism of them – there could still be a Shipman out there killing patients”.

In today’s report, the Committee says that neither the Department for Constitutional Affairs nor the Department of Health is taking responsibility for death certification. “If anything specific is being done at all, it amounts to tinkering at the edges of a system which has already been deemed unsafe and unsatisfactory by two Government-commissioned reviews,” the report concludes.

The Committee says coroners carry out their functions in a fragmented and localised system that has been largely unchanged since Victorian times and the system is ill equipped to deal with the modern expectations of society. It urges the Government to look again at its plans that exclude reform of death certification and return instead to the proposals put forward by the Home Office in 2004. At the same time, the Committee says, it must ensure there are sufficient resources in place to support this. At least, the report adds, Government should introduce a clear system of a duty for doctors to refer certain categories of death to the coroner and they should ensure all doctors understand the requirement.

The Committee also recommends there should be a strategy for reducing the number of post-mortem examinations performed and it argues that the coronial system lacks national direction. The report says: “The police and local authorities provide varying degrees of financial and administrative support for the coronial system, there are also hidden subsidies, the magnitude of which is almost impossible to calculate. The system is beleaguered, with insufficient training for coroners and their staff, inadequate funding, a lack of facilities and uneven distribution of resources, leading to inconsistent levels of service across England and Wales.” It recommends the creation of a national service with central and adequate funding so all coroners can work to the same high standards.