The UK government has recently published a draft bill for reform of the investigation of deaths in England and Wales by the coroner system.1 A coroner is an independent judicial officer and must be a barrister, solicitor, or, currently, a medical practitioner of not less than five years' standing (the last qualification is abolished in the draft bill). This proposed legislation heralds many changes, several with implications for doctors (box). These are all sensible evolutionary changes that will lead to a more consistent, effective, and better managed service. There are several problems, however, that the draft bill does not tackle.

The draft bill fails to cover important recommendations made by a government review of death certification and investigation,2 by the Shipman Inquiry (which followed the murder of more than 200 patients by general practitioner Harold Shipman),3 and by the UK Home Office.4 Moreover, it does not give detailed instructions on the categories of deaths that should be investigated. Section 1 of the bill simply requires a senior coroner to investigate if she or he suspects that …