Views & Reviews Personal View

What are coroners and pathologists for?

BMJ 2009; 338 doi: (Published 01 April 2009) Cite this as: BMJ 2009;338:b1355
  1. Colin Reisner, retired consultant physician, Staffordshire
  1. c.reisner475{at}

    Around 10 years ago my mother began to show signs of dementia, and over the ensuing years she gradually deteriorated. Happily, the hard work and dedication of a band of professional carers meant she was able to stay in her own home. By autumn 2007 she was chair-bound or bed-bound, was speechless, and needed to be fed, although she still seemed to take some pleasure in life. In December of that year she seemed to be actively refusing food, and liquids would often just run out of her mouth. Apart from her poor brain, all other internal organs seemed to be working satisfactorily. Notably there was no dyspnoea, orthopnoea or oedema, nor did I ever spot a raised jugular pressure.

    A few days after Christmas we were not surprised to get a call from her devoted and longstanding carer, telling us that she was even less well. The carer had already called the emergency doctor, who telephoned me after assessing my mother. He thought she was dying. He doubted that hospital treatment would be in her best interests and anyway noted the advanced care plans that had been drawn up with such a situation in mind. We all agreed she should stay in her own home. My wife and I packed and set off to be with her.

    We arrived about three hours later to find the carer much distressed. Death had come even sooner than anticipated, but this was not the cause of her agitation. Realising that my mother had died she had, quite correctly, phoned the medical service again. The emergency doctor had returned and had verified the death. But the rules meant he had to call the police—who dutifully attended and followed their rules in insisting that the body be removed then and there, in the dead of night, to the public mortuary. This is what had upset the carer so much. After years of working to keep my mother in her own home, the satisfaction of seeing this care right through to the end was denied her. And where my mother should have been lying at peace, the bed, was empty.

    Subsequently all players followed their rules. My mother’s GP, having had no cause to see her recently, was unable to issue a death certificate. The emergency doctor did not believe that his attendance in the last minutes of her life was sufficient contact to permit him to know the cause of death with enough accuracy to be safe, legally, to issue a certificate. So the coroner felt forced to require a postmortem examination. The pathologist took as the history the minimal statements gleaned from the police on the night. Thus he remained unaware of the strong clinical evidence of lack of nutrition and hydration as a result of brain failure and of the complete absence of signs of cardiac failure. In his examination he found evidence of heart disease—how many 98 year olds would not have evidence of heart disease?—and so gave her cause of death as “myocardial fibrosis due to coronary atherosclerosis,” without mentioning her dementia.

    All the officials followed their rules but ended up causing unnecessary anguish to someone very close to the deceased, wasted public money on transfer to a public mortuary and on the postmortem examination, and then ultimately failed to identify the correct cause of death. In their defence, it may be argued that the purpose of involving the police and coroner is simply to rule out foul play. But, if there had been any, would the actions of those involved have detected it? How carefully did the pathologist consider, for example, the possibility that death might not have been due to natural causes?

    These days there is, I am pleased to say, increasing interest in care at the end of life, including support for those left behind. Would such a situation as my mother’s be better managed in future? It would probably have helped if successive governments had taken more action on the reports they have received over many years showing that the coroners’ system is no longer fit for purpose. In my mother’s case, had there been a medical coroner to support the legal coroner, he might well have been satisfied, having spoken with my mother’s GP, her carer, and myself, to have a certificate issued without a postmortem examination. And even within the present system I wonder whether things could not have been done differently. Were the police compelled to have the body removed? A phone call to me would have entirely supported what the carer had told them. Would that not have been evidence enough that the death was expected? (Indeed, had there been any foul play, leaving the body where it was would have better preserved any evidence.) As for the coroner: was there really no way he could have avoided the postmortem examination? Could he not have supported my mother’s GP in issuing a certificate by the coroner’s “form A.” Finally, why can’t pathologists seek out information from the living while hunting the cause of death in the dead?


    Cite this as: BMJ 2009;338:b1355

    View Abstract

    Sign in

    Log in through your institution

    Free trial

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