Chief coroner warns over watered down medical examiner role

Judge Mark Lucraft QC said medical examiners working in the NHS needed to be seen to be independent and he cautioned the system might “not flourish” unless his concerns over increased workload and a lack of resources for coroners were addressed.

In his annual report to the Lord Chancellor, Judge Lucraft repeated warnings about the failure to address what he called a “lacuna in the law” which meant doctors were under no legal obligation about when to report deaths to coroners.

He warned of the impact of a shortage of pathologists to carry out post-mortems which was leading to unacceptable delays in releasing bodies to families.

The government has announced plans to launch a national medical examiner service from April 2019, but this will be a service based within the NHS and looking only at acute hospital services.

This will be a watered down system compared to an independent medical examiner service as proposed by the Dame Janet Smith Inquiry into Dr Shipman, the Mid Staffordshire inquiry and the Morecambe Bay inquiry. This would have seen MEs employed by local authorities examining all deaths not reported to a coroner including those in the community and mental health services.

Legislation was passed to bring in the service in 2009 but has not been fully implemented.

In his report, Judge Lucraft said he was “disappointed that the scheme that was consulted on in 2016 which covered all deaths will not currently be implemented. [The chief coroner] remains of the view that the interlocking system of oversight for community, hospital and all other deaths by the ME, with the coroner performing a more specialist role in relation to their legal jurisdiction, as envisaged in the 2009 Act, should be the ultimate objective”.

“Until then, the issues the ME was designed to address, as highlighted in Dame Janet Smith’s Shipman report and elsewhere, will not be fully dealt with,” he said.

His report added that he wanted to be “assured” over the independence and quality of medical examiners, adding: “Will they be and be seen to be, sufficiently independent of those they are scrutinising? If they are (or were) hospital doctors, will they be sufficiently independent of their present and former colleagues and of hospital trusts in England and health boards in Wales? It is fundamental to the essence of the ME scheme that they must be independent in their appointment and in the execution of their functions.”

He also warned coroners could face an increased workload caused by fewer but more complex cases needing to be considered at an inquest without sufficient resources being available.

Other concerns mentioned by the chief coroner were:

• The need for a national service to provide structure and funding to deliver standardisation, consistency and reforms;
• “Inconsistency of practice among senior coroners [which sees some coroners] request doctors to report all still births and all child deaths… There is no legal basis for this approach and a neighbouring coroner area may have no such policy”;
• The “dwindling availability of pathologists to carry out post-mortem”, and “worrying inconsistencies of practice across the country… symptomatic of system without properly funded and organised national foundations”; and
• “No government department wishes to take responsibility for this service.”