Who to report to the Coroner? A survey of intensive care unit directors and Her Majesty's Coroners in England and Wales

Abstract

Summary We performed a postal survey to assess the ability of intensive care unit directors and Her Majesty's Coroners to recognise deaths that should be reported to the local coroner. The survey questionnaire consisted of 12 hypothetical case scenarios. Coroners were significantly better at identifying reportable deaths than intensive care unit directors (median correct recognition scores of 11 (interquartile range 9.25–11) vs. 8 (interquartile range 7–10), respectively, p < 0.01). Deaths associated with an accident, medical treatments, industrial disease, neglect and substance abuse were significantly under‐reported by intensive care unit directors (p < 0.01). Results show that significant numbers of deaths on intensive care units in England and Wales may not be being referred for further investigation, and that wide variation in local coroners' practices exists. Improvements in postgraduate medicolegal education about deaths reportable to a coroner are required. National regulations need to be more detailed and standardised so that regional variation is eliminated.

Are Statutory Requirements Followed in the Certification of Traumatic, Unexpected, and Unattended Deaths in Missouri?

“…Differences in county‐level strategies for complying with ME/C state statute may help explain some of differences in reliability between MOD and COD. Strategies that have been used to improve ME/C contact and certification have included physician education and monitoring noncompliant practices with timely feedback .…”

Contradictory coroners? Decision-making in death investigations

“…Relevant evidence is thin on the ground. Sainsbury and Jenkins5 referred to coroner idiosyncrasy in passing when comparing suicide rates from one area to another; Roberts et al 4 used differing unpublished free text comments when discussing varied choices of verdicts by coroner respondents to a postal questionnaire; Booth et al 6 commented that varying coroner opinions compounded difficulties for clinicians in identifying reportable deaths, supporting their position with postal survey findings that coroners had failed to identify deaths that should be reported; Thornton,7 in a presentation to the Coroners Society just days into his appointment as Chief Coroner, referred to his role as being to bring national consistency and quality of standards and approach, and repeated the point in his first annual report to the Lord Chancellor by referring to ‘the less good practice of some coroners and the inconsistency in practice across England and Wales which a local system can sometimes produce’8, p. 10 and the Ministry of Justice statistics bulletin for 2012, when comparing the differing results of an analysis of narrative verdicts by two assessing retired coroners, referred to the exercise as ‘based on their own individual opinions; it is therefore important to note the subjectivity of this analysis’ 9,. p. 28 Recent research among coroners (and pathologists) in Ireland10 showed divided opinions between coroners regarding the utility of their forensic toxicology services, leading to incorrect outcomes of inquests through inadequate testing or interpretation.…”