Letters

The coroner service

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7216.1072 (Published 16 October 1999) Cite this as: BMJ 1999;319:1072

Coroner service could indeed be improved

  1. James Pilpel, general practitioner
  1. The Surgery, Tean, Stoke on Trent ST10 4EG
  2. The Surgery, Hampton-in-Arden, Solihull B92 0AH
  3. Academic Department of Paediatrics, North Staffordshire Hospital, Stoke on Trent ST4 6QG
  4. Imperial College School of Medicine, London W2 1PG
  5. Manor Hospital, Walsall WS2 9PS
  6. GP Direct, West Harrow, Middlesex HA5 4EA
  7. North Thames Perinatal Public Health, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ

    EDITOR—I recognise the need for society and the judiciary to be able to check up on medical practitioners, but I strongly concur with Pounder's views that the coroner service could be improved.1 A 49 year old patient of the practice where I work died peacefully at home recently of cerebral metastases from lung cancer. He had been ably cared for by his wife and daughters with help from the district and hospice nurses in liaison with one of my partners and our local oncologist. I attended to confirm death, but as he had not needed to see a doctor in the last month or so the coroner would not permit me to issue the death certificate. After some negotiation and despite being sympathetic, he did consent to my partner issuing the death certificate on her return from holiday four days later, although he would not have done so had she not been due back so soon.

    There seemed no doubt about our patient's identity or place or cause of death, and there certainly was no hint of foul play.

    This case is by no means an isolated one, and I am sure that many of my general practitioner colleagues are tempted to overlook the rules in straightforward natural deaths to protect relatives from interference. I believe that the public would welcome the opportunity to express their views and am equally sure that they would support modernisation of this archaic but important service.

    References

    1. 1.

    Inquests often facilitate grief

    1. Rodger Charlton, general practitioner principal (charlton{at}monfode.demon.co.uk)
    1. The Surgery, Tean, Stoke on Trent ST10 4EG
    2. The Surgery, Hampton-in-Arden, Solihull B92 0AH
    3. Academic Department of Paediatrics, North Staffordshire Hospital, Stoke on Trent ST4 6QG
    4. Imperial College School of Medicine, London W2 1PG
    5. Manor Hospital, Walsall WS2 9PS
    6. GP Direct, West Harrow, Middlesex HA5 4EA
    7. North Thames Perinatal Public Health, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ

      EDITOR—Pounder's editorial on the coroner service fails to raise important issues in relation to bereavement and the existing coroner service.1 There is a conflict of interest between the “enforceable intrusion” of a coroner's inquest to ascertain the cause of a sudden death and the needs of relatives.

      A previous editorial in the BMJ stated that an inquest is conducted at a “time of greatest grief, distress, and uncertainty,”2 and yet general practitioners do not routinely receive necropsy reports from the coroner and so are not in an informed position to tell relatives how the person died. Furthermore, doctors may be inhibited by the standard admonition regarding a coroner's report that the content should not be disclosed to a third party without consent.3

      Pounder correctly questions why so many inquests are conducted. But inquests provide relatives with an opportunity to understand the cause of death, which may aid in the grieving process after this traumatic and intimate examination. Indeed, this information may assist in confirming the inevitability of death and help to dispel feelings of doubt, guilt, and anger.4

      References

      1. 1.
      2. 2.
      3. 3.
      4. 4.

      All sudden infant deaths must be investigated thoroughly

      1. Martin Samuels, senior lecturer in paediatrics (doctorsamuels{at}hotmail.com)
      1. The Surgery, Tean, Stoke on Trent ST10 4EG
      2. The Surgery, Hampton-in-Arden, Solihull B92 0AH
      3. Academic Department of Paediatrics, North Staffordshire Hospital, Stoke on Trent ST4 6QG
      4. Imperial College School of Medicine, London W2 1PG
      5. Manor Hospital, Walsall WS2 9PS
      6. GP Direct, West Harrow, Middlesex HA5 4EA
      7. North Thames Perinatal Public Health, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ

        EDITOR—Pounder states that the coroner service should focus “more narrowly on deaths of legitimate medicolegal interest” and implies that a reduction in referrals and necropsies could “reflect a greater sensitivity to the rights of the next of kin.”1 I am concerned that such a move might reduce the coroner's role in sudden and unexpected infant deaths, resulting in poorer detection of cases of child abuse or neglect. This is highlighted by a development in Australia, where the coroner's right to necropsy has been overturned in its High Court by parents on religious or ethical grounds.2

        Cases of sudden and unexpected infant death in the United Kingdom are referred to the coroner for investigation, and the police are responsible for determining whether deaths are natural or arise from child abuse or neglect. Deaths arising from child abuse or neglect are difficult to detect, even when minor, but non-lethal, injuries are found at necropsy.3

        There are now reports of cases of infant death that have been presumed to be natural (sudden infant death syndrome) but on subsequent presentation of a sibling with child abuse were found to have been due to infanticide only after further investigations by several agencies.4 It is accepted that a postmortem examination alone may not be able to identify intentional suffocation as a mechanism unless there are other injuries. Thus a postmortem examination cannot differentiate between intentional suffocation and sudden infant death syndrome (a diagnosis of exclusion).

        I suggest that multiagency investigations by child death review teams should become mandatory to help distinguish deaths resulting from abuse or neglect from those due to natural mechanisms.5 The coroner should initiate such reviews to ensure that deaths due to abuse are not missed and that living siblings may be adequately protected from the abuse that can be meted out by parents who kill their children in this way. Recent data show that a proportion of sudden infant deaths result primarily from abuse or neglect (figures of 10% quoted5) It is therefore in the interests of living and dead children, as well as innocent parents who have suffered a natural tragedy, for the recommendations of the Confidential Enquiries into Stillbirths and Deaths in Infancy to be implemented by statute.

        References

        1. 1.
        2. 2.
        3. 3.
        4. 4.
        5. 5.

        Culturally sensitive care for the dying is basic human right

        1. Aziz Sheikh, clinical research fellow (aziz.sheikh{at}ic.ac.uk),
        2. A R Gatrad, consultant paediatrician,
        3. Sangeeta Dhami, ocum general practitioner
        1. The Surgery, Tean, Stoke on Trent ST10 4EG
        2. The Surgery, Hampton-in-Arden, Solihull B92 0AH
        3. Academic Department of Paediatrics, North Staffordshire Hospital, Stoke on Trent ST4 6QG
        4. Imperial College School of Medicine, London W2 1PG
        5. Manor Hospital, Walsall WS2 9PS
        6. GP Direct, West Harrow, Middlesex HA5 4EA
        7. North Thames Perinatal Public Health, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ

          EDITOR—In many traditions the concept of “a good end” has reality and significance. This is particularly true for Muslims. Much time and energy will be invested by family and friends to help ensure that the dying end the earthly phase of their existence in a state of peace in both their internal and their external worlds. Internally, this involves inculcating in the dying a sense of hope and optimism in Allah's forgiveness, mercy, and reward. Externally, this involves setting matters right with one's relatives and friends while the opportunity still exists. Those who are fortunate enough to die in such a state are, within the Muslim paradigm, successful. On death there is a communal responsibility to lay the dead person to rest swiftly and with dignity.

          The hope for a good end is the silent lifelong prayer of many people, yet in the course of our daily work we are reminded that achieving this basic human right is often difficult for British Muslims. We welcome Pounder's editorial,1 recognising how deeply disturbing a coroner's investigation and the necropsy that often follows can be for those from certain religious traditions.2

          We would agree that the coroner's service is “a relic in need of reform,” but it is just one of many issues that need to be tackled if we are to deliver culturally competent care to the dying and their families Hospital visiting restrictions should be more flexible, the rule of two visitors per bed being inappropriate for dying patients from cultures in which visiting such people is regarded as a religious obligation. In addition, appropriate hospital prayer facilities should be available for patients and their relatives and visitors.

          The importance of a prompt burial for Jews and Muslims must be recognised, and systems put in place to facilitate this practice, such as the ability to register and bury one's dead at weekends and on public holidays. Perhaps the single most important change that will result in culturally sensitive care is a greater emphasis on transcultural medicine in the medical curriculum; tomorrow's clinicians and health policymakers would then have the opportunity to understand the range of needs of dying patients found in modern day pluralist Britain.

          References

          1. 1.
          2. 2.

          A national service would be more consistent

          1. Judith Levitan, information manager, CESDI North Thames West (nwthames{at}cesdi.org.uk)a,
          2. Brenda K Dines, database manager, CESDI North Thames East (safe{at}capt.demon.co.uk)
          1. The Surgery, Tean, Stoke on Trent ST10 4EG
          2. The Surgery, Hampton-in-Arden, Solihull B92 0AH
          3. Academic Department of Paediatrics, North Staffordshire Hospital, Stoke on Trent ST4 6QG
          4. Imperial College School of Medicine, London W2 1PG
          5. Manor Hospital, Walsall WS2 9PS
          6. GP Direct, West Harrow, Middlesex HA5 4EA
          7. North Thames Perinatal Public Health, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ

            EDITOR—In his editorial Pounder suggests that the coroner's service could be vastly improved by having a national system in place rather than the local services that currently exist.1 Our work on the Confidential Enquiry into Stillbirths and Deaths in Infancy incorporates two health regions, and we rely on the coroners to provide us with information about fetal and infant deaths. We have found many local variations.

            One difference is that in some districts a specialist perinatal pathologist performs the necropsies on babies while in others this is not the case. Such specialist reports provide valuable and sometimes previously unknown information on the cause of death and can help in the management of the future pregnancies of the parents of children who have died.24 The Royal College of Pathologists strongly recommends that necropsies on infants should be carried out by a specialist pathologist,5 and we at the Confidential Enquiry into Stillbirths and Deaths in Infancy agree with this. This is true of all cases, including (and perhaps especially) those reported to the coroner.

            We have always found the coroners and their staff to be extremely helpful and supportive of our work. We agree with Pounder, though, that a national system would be far more beneficial and consistent, both for the families of the infants who have died and for data collection purposes.

            References

            1. 1.
            2. 2.
            3. 3.
            4. 4.
            5. 5.
            View Abstract

            Sign in

            Log in through your institution

            Free trial

            Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
            Sign up for a free trial

            Subscribe