1. New legislation: May 2010

2. The Coroners & Justice Act 2009 Christopher P Dorries OBE HM Coroner South Yorkshire (West)

3. A short guide to survival in a changing world

5. Some facts: 2008  502,600 deaths in England & Wales  234,800 referred to coroners (47%) of which:  108,400 subject to post-mortem ( 46% )  31,000 inquests ( 13% )  Amongst those inquests there were:  3,300 suicide verdicts (80% male)  2,946 traffic fatalities  750 homicides (75% male)  270 railway deaths  3,300 narrative verdicts

6. Autopsy as % of reported deaths

7. Will it happen?

8. Will it be funded?

9. The impact of Article 2 – Dale’s case  Dale was 21 when he absconded from a mental health unit and died on a nearby railway line whilst in MHA detention  An inquest was held which took just over two hours  The family sought judicial review on the basis of a recent case which found that the death of a detained patient could engage Article 2 ECHR  A consent order was agreed and the fresh inquest was heard before a jury in view of the C&JA 2009 changes  The resultant Article 2 jury inquest considered 16 formal questions in the verdict  With only two extra witnesses the case took.....

10. The impact of Article 2 – Dale’s case  Dale was 21 when he absconded from a mental health unit and died on a nearby railway line whilst in MHA detention  An inquest was held which took just over two hours  The family sought judicial review on the basis of a recent case which found that the death of a detained patient could engage Article 2 ECHR  A consent order was agreed and the fresh inquest was heard before a jury in view of the C&JA 2009 changes  The resultant Article 2 jury inquest considered 16 formal questions in the verdict  With only two extra witnesses the case took five days

11. Starting point  Target date is April 2012  Coroners Rules and Regulations yet to be written – see consultation paper  Thus talking about detail is not yet possible  Charter for the Bereaved is yet to be written  Will there be other Charters for court users?  Shadow Chief Coroner to be announced shortly

12. Some problems  Lots of good ideas – but where are the resources coming from?  Much reliance seems to be placed on a hope that the Medical Examiner proposals will cut the coronial caseload......  No real measures to tackle lack of decent court accommodation  So much for ‘root and branch reform’!

13. Potential savings

15. Changes from current practice  A Chief Coroner to provide leadership  guidance should aid consistency over time  but he/she holds no budget + it’s not a ‘national service’  Doctors no longer eligible for appointment  Terminology: coroners become ‘senior coroners’ and all deputies become ‘assistant coroners’.  New concept of an ‘investigation’ which may, or may not, lead to an inquest – e.g. await toxicology result or perhaps an expert opinion

16. Reporting of deaths  Rules will provide that doctors must report certain categories of death to the coroner  But there will be no specific penalty, even for a wilful and deliberate failure!  Criteria must be based on statutory jurisdiction so no great change in reportable deaths  May lead to greater consistency in time  Work on this is relatively advanced

17. Jurisdiction  The criteria for the coroner’s jurisdiction remain much as before (violent, unnatural or unknown)  But a death in prison now includes ‘in state detention’ which specifically means MHA order.  Thus MHA patient now has an inquest even if the death is natural  But a ‘state detention’ inquest need not be before a jury unless violent, unnatural or unknown. This may cause difficulties?  Jurisdiction is still geographical but rather less rigid so inquests may be moved

18. New powers of investigation  Power on warrant from the Chief Coroner to enter, search and seize.  Consultation document discusses how this might work  Power to require a written statement or report within a set time, punishable by a fine (Schedule 5)  Coroner may summon a witness as before but now can require that an item or document be produced for examination, punishable by a fine (Schedule 5)  Specific criminal offences of distorting or altering a document, and for concealment or destruction of evidence, punishable by imprisonment

19. The inquest  Little change to inquest practice save for:  Increased provision for disclosure  Specific recognition of ‘in what circumstances’  There may be guidance on the use of narrative verdicts which are disliked by ONS  Some minor changes on juvenile witnesses

20. Juries  Basic principles remain the same, still between 7-11  Police deaths requirement moves from “in police custody or resulted from an injury caused by an officer” etc to “death resulted from an act or omission of a police officer in purported execution of duty”  Notifiable accident, poisoning or disease requirement remains despite efforts to remove this  Whilst majority verdict remains, jury must announce how many agreed

21. Appeals  Any PIP may appeal to the Chief Coroner against a coroner’s decision:  whether or not to conduct an investigation  not to conduct an autopsy  to discontinue an investigation  to resume or not a suspended investigation  to request/allow a second autopsy  to issue a Schedule 5 notice  whether there should be a jury  to exclude persons from an inquest  as to findings at an inquest  Most appeals will be dealt with on the papers but it still carries serious resource issues

22. Other provisions  Chief Coroner must be notified of cases taking more than a year  Rules 36 + 42 go into the primary legislation, as does rule 43  Specific duty on local authority to secure the provision of staff and accommodation  Chief Coroner may make regulations about training  Greater power to request suspension of coroners investigation if someone ‘may be charged’

23. The Medical Examiner Scheme  Sheffield Pilot running for two years with 2000+ cases  Comparison is difficult, thus far only one big hospital without a public mortuary but.....  Overall we have seen:  a slight reduction in reported deaths,  around the same number of autopsies  a slight rise in inquests  Conclusion: the pilot project shows this scheme to be of great benefit to bereaved, hospital and coroner alike

25. The Medical Examiner Scheme  All deaths, other than those investigated by the coroner must be reported to the Medical Examiner  Proportionate scrutiny to establish whether:  death should have been reported to the coroner  proposed cause of death is appropriate  Scrutiny is likely to include review of medical notes  Funded through the PCT but with statutory independence  The Sheffield pilot project shows this to be of great benefit to bereaved and coroner alike