Annex A > Chapter 18 - Medical and Clinical Audit > Audit: the national perspective > The role of the coroner

The role of the coroner

121 Thus far, evidence relating to the NHS has been set out. Other individuals and institutions are also concerned with deaths or critical incidents in hospital: for instance, the coroner, the registrar of deaths and the Home Office. The Health and Safety Executive also has a role, but principally as regards the health of healthcare workers and potential accidents to them or others within hospital. In this section we set out the principal evidence received relating to the coroner, the registrar of deaths and the Home Office, as possible monitors of health outcomes from outside the NHS.

The coroner

122 Coroners are required by Rule 54 of the Coroners Rules 1984 [146] to maintain an indexed register of all deaths reported to them, with prescribed details. [147]

123 A number of witnesses commented to the Inquiry on whether the coroner's court is an appropriate means of enabling audit or for identifying local or national trends in mortality.

124 Professor Roderick MacSween, the then President of the Royal College of Pathologists, stated that the coroner's court could act as a `... useful unofficial forum for audit ...' [148] and that if certain patterns of death emerged in a particular hospital or at the hands of a particular clinician the coroner could comment upon these and draw them to the attention of the appropriate authorities.

125 Mr Robert Clifford, Head of the Coroners Section of the Animals, Bye-laws and Coroners' Unit of the Home Office, told the Inquiry that the system of inquests was designed to look at individual deaths and that there was no requirement on a coroner to look across a range of deaths in a way that would enable trends to be discerned. He identified a number of matters which made such spotting of trends difficult, including: the limited records of previous cases which the coroner is required to maintain; some cases would be dealt with not by the coroner but by a deputy or assistant deputy; there was no one with responsibility to maintain and analyse a database of all the information that came out of individual inquests; such information would in any event exclude deaths that had not been reported to the coroner; and each coroner's jurisdiction is limited to bodies lying within his district. [149]

126 Professor Jeremy Berry, Professor of Paediatric Pathology, stated:

`The statutory role of the Coroner is limited to determining the cause of death, and does not extend to monitoring the adequacy of surgical or other services. The pathologist may mention minor deficiencies in treatment in his or her report, but it is generally only major errors that might lead to an inquest (e.g. mis-matched blood transfusion, major equipment failure, or some surgical disaster). The Coroner's system is therefore best suited to recognising individual or repeated gross deviations from normal medical practice ... It is not intended to carry out long term monitoring of individual specialised clinical services, which is the function of clinical audit.' [150]

127 The Inquiry heard from Professor Michael Green, Consultant Pathologist to the Home Office and Emeritus Professor of Forensic Pathology, University of Sheffield, that he was aware of only two episodes in the last ten years when the coroners' post-mortem examination system had identified a particular surgeon in a particular specialty within surgery as having a high mortality rate. [151]

128 The Coroners' Society memorandum, `Coroners and the Investigation of Deaths', prepared by Mr Michael Burgess, Honorary Secretary of the Coroners' Society of England and Wales and HM Coroner for Surrey, states that: `The limited nature of the inquest may make it difficult to examine anything other than the circumstances of the single death before the coroner at that time'. [152]

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Footnotes

[146] 1984 SI No 552 (as amended by the Coroners (Amendment) Rules; 1985 SI No 1414)

[147] The form of the register appears at `Schedule 3, 1984 Rules' and requires the following to be recorded: date on which the death is reported to the coroner, full name and address, age and sex of the deceased, cause of death, whether the case was disposed of, Pink Form A or Pink Form B or whether an inquest was held, and the verdict at inquest if any

[148] WIT 0054 0033 Professor MacSween

[149] T42 p.129-30 Mr Clifford

[150] WIT 0204 0005 - 0006 Professor Berry

[151] T42 p.101 Professor Green

[152] WIT 0039 0027 Mr Burgess