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Annex A > Chapter 18 - Medical and Clinical Audit > Audit: the national perspective > `Unnatural death' and `death by natural causes'

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`Unnatural death' and `death by natural causes'

136 The extent to which the coroners' system may provide a useful forum for audit in part depends on the interpretation that individual coroners (and others) place on the terms `unnatural death' and `death by natural causes' as verdicts open to the coroner.

137 The Inquiry heard from Mr Donald Hawkins [160] that:

`During the period 1974 to 1991 I took the view that deaths following operations to correct medical conditions were deaths arising from natural causes and as such only referable to the coroner if the cause of death was unknown, or unknown without a hospital post mortem examination. However, I did require to be notified of deaths that actually occurred on the operating table. When such a death was so referred and the cause of death was known and was natural I dealt with the matter by way of Form A without a post mortem examination.' [161]

138 Mr Paul Forrest, Coroner for Avon who succeeded Mr Hawkins, stated: [162]

`You will be aware ... that the switch [163] deaths reported to me from 1992 onwards were, following post mortem examination, recorded and registered as deaths from natural causes.'

139 The terms `unnatural death' and `death by natural causes', are not defined by statute even though provisions such as Regulation 41(1)(d) of the Registration of Births and Deaths Regulations 1987, and Section 8(1) of the Coroners Act 1988 use the term `unnatural' in relation to the requirement to investigate a death further.

140 R v Price interpreted `unnatural' as `a reasonable suspicion that there may have been something peculiar about the death; that it may have been due to other causes than common illness' [164]. A commentator described it as a death which was `wholly or in part caused, or accelerated, by any act, intervention or omission other than a properly executed measure intended to prolong life.' [165]

141 In R v Poplar Coroner ex parte Thomas [166] the deceased suffered an asthma attack which, had an ambulance arrived sooner, she had a real possibility of surviving. In the event she arrived some 40 minutes later at hospital and could not be revived. The Court of Appeal decided that asthma was a natural cause of death, and that the death was not made `unnatural' by the late arrival of the ambulance.

142 `Jervis on Coroners' [167] suggests that the proper view in that case would have been that the deceased died of `untreated' asthma, and that if the treatment given seriously departed from the norms for the time, it would be sensible to conclude that this was an `unnatural' cause of death.

143 In R v Birmingham Coroner ex parte Benton [168] it was decided that where a patient was suffering from a potentially fatal condition and the medical intervention (even if wrong) merely failed to prevent the death, then the proper verdict was `death from natural causes', as it was the underlying condition which had caused the death. If the patient was not suffering from a life-threatening condition but the treatment given for whatever reason caused the death, the proper verdict was accident or misadventure, unless there was a question of unlawful killing. [169]

144 The memorandum `Coroners and the Investigation of Deaths' describes the verdict of death by natural causes at Appendix C:

`A death is considered to have arisen from Natural Causes if the evidence shows that it is probable (that is, more likely than not) that the cause of death was the result of a naturally occurring disease process running its [full] course.

`The word "natural" should be given its "usual meaning".' [170]

145 The memorandum then refers to Leckey and Greer, `Coroners' Law and Practice in Northern Ireland': `It is the underlying cause of death rather than the terminal event which is the test as to whether the death is from unnatural causes and therefore properly referable to the Coroner'. [171]

146 In evidence Mr Burgess, in commenting on the decision-making process in respect of a death of someone with a life-threatening condition, who has died during or following surgery, told the Inquiry:

`What he [the coroner] is trying to do is maybe simplify what is probably quite a complex and difficult situation: was the death hastened by or brought about by the surgery, or was it that the death arose regardless of the surgery? I think it is often a debate that can quite properly result in well-held beliefs which are totally opposite.' [172]

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[160] HM Coroner for Avon from April 1978 to April 1992

[161] WIT 0348 0002 Mr Hawkins

[162] WIT 0039 0017; letter to the Inquiry dated 31 March 1999

[163] See Chapter 3 for an explanation of this term

[164] R v Price (1884) 12 QBD 247

[165] `Natural and unnatural deaths': Herbert H Pilling, `Medicine, Science & the Law', April 1967

[166] [1993] QB 610

[167] Sweet and Maxwell, 11th edition at paras 8-20, p. 137

[168] [1997] 8 Med LR 362

[169] With specific reference to death during or after surgery, the determining factor according to the case law, therefore, appears to be whether the deceased would have died from the medical condition in any event, regardless of whether the surgery accelerated the death, rather than the standard of care received, or whether the medical condition could have been survived with appropriate treatment

[170] WIT 0039 0031 Mr Burgess

[171] WIT 0030 0031 Mr Burgess (emphasis in original)

[172] T43 p.19 Mr Burgess