Coroner
Reform
Reforming the Coroner and Death
Certification Service - A Position Paper – published
12 March 2004
The Government’s proposals on the way forward
on reforming the coroner and death certification service
were announced today (12 March 2004) by Home Office
Minister Paul Goggins, publishing a paper outlining
proposals for reform.
The Government’s Position Paper draws on the
work of, and the recommendations from, the Government-commissioned
independent Fundamental Review of Coroner and Death
Certification systems, chaired by Tom Luce CB, former
Head of Social Care Policy at the Department of Health,
and the Third Report of the Shipman Inquiry chaired
by Dame Janet Smith, an Appeal Court judge.
The paper proposes a coherent system with oversight
of all deaths based around full time independent coroners
with legal qualifications who will be closely supported
by appropriate medical expertise. It also tightens up
the death certification process by increasing medical
scrutiny in the system.
In future, all deaths will be referred to the coroner
service and will be studied by a medical team trained
to identify cases needing further investigation, with
ready access to the coroner in cases of doubt.
Home Office Minister, Paul Goggins said:
“The legal framework for coroners dates back to
the 19th century and has come under increasing strain
in adapting to the needs and expectations of today's
society. Coroners in the main perform their duties satisfactorily
but the time has come for reform. Shortfalls have become
painfully evident through tragedies such as the Marchioness
disaster and the murders perpetrated by Harold Shipman.
“Most deaths do not require detailed scrutiny
or judicial investigation but we must ensure that families
can find out how their relatives died and that avoidable
deaths are prevented. The proposals outlined today will
introduce a new system that will combine an independent
check on all deaths and a professional oversight of
death patterns, with, for the majority of cases, the
minimum of bureaucracy.
“An effective death certification and investigation
system is a vital component of a civil society. It is
essential for a modern system of public health monitoring
as well as for the detection of suspicious circumstances
or medical errors. These proposals are an important
step to restoring public confidence and building a better
system of death investigation.”
The paper is available to purchase from The Stationery
Office (TSO, PO Box 29, Norwich, NR3 1GN) or to download
from its website (http://www.official-documents.co.uk/document/cm61/6159/6159.htm).
Coroner and Burial Team
The Coroner and Burial Team has been established in
the Home Office. It is looking at improvements to the
coronial and certification systems that can be made
in advance of any change to legislation. It is also
planning ahead for possible legislation that Ministers
agree is required to ensure that the systems are effective,
supportive and transparent. It holds regular discussions
with stakeholders; including other Government Departments
and Local Government; coroners and their officers, to
consider these interim improvements and set up longer-term
reform.
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