CORONERS' COURTS A GUIDE TO LAW AND PRACTICE Second edition CHRISTOPHER DORRIES OXFORD UNIVERSITY PRESS
CONTENTS Dedication Foreword Acknowledgements Preface Table of Cases Tables of Legislation Table of Abbreviations v vii ix xi xxix xxxvi xlv 1. THE CORONER 1 1.01 Introduction 2 The Office of Coroner 2 1.02 Creation of the Office 2 1.03 The Medieval Coroner 3 1.04 Early Duties 4 1.05 Development of the System 5 1.06 Modern Developments 6 1.07 The Last 30 Years 7 1.08 Review of the Coroner System 8 1.09 The Shipman Inquiry 9 The Independence of the Coroner 12 1.10 Importance of Independence 12 1.11 The Local Authority 12 1.12 Central Government 13 1.13 Coroners' Service Model Charter 13 Qualification and Appointment 14 1.14 Qualification 14 1.15 Appointment 15 1.16 Removal from Office 16 1.17 Resignations 17 1.18 Salary Arrangements 17 1.19 Part-time Coroners 17 1.20 Deputies 18 1.21 Coroner of the Queen's Household 19 1.22 The Courts and Legal Services Act 1990 19 1.23 Immunities 20 xv
Financing and Staffing 1.24 Payments by Councils 1.25 Types of Payment 1.26 Staffing Coroners' Districts 1.27 Statistics 1.28 Division of a County 1.29 Alteration of Coroners' Districts The Coroner's Officer 1.30 Introduction 1.31 Civilianization 1.32 Manner of Work Summary 20 20 21 22 22 22 23 24 24 24 24 25 27 2. JURISDICTION 2.01 Introduction 2.02 The Legislation 2.03 Exceptions to Jurisdiction The Body of a Person 2.04 Introduction 2.05 Human Remains 2.06 Remnants of a Body 2.07 Foetus 2.08 Death 2.09 Persistent Vegetative State 2.10 Switching off Ventilators 2.11 If No Body Exists Territorial Considerations 2.12. Deaths at Sea or in the Air 2.13 Territorial Transfers 2.14 Deaths Abroad 2.15 Deaths in Scotland Statutory Jurisdiction 2.16 Sufficient Grounds for Inquiry 2.17 Violent Death 2.18 Unnatural Death 2.19 The Thomas Case 2.20 The Touche Case 2.21 Conclusion 2.22 Unnaturally Contracted and Rare Diseases 2.23 Sudden Death of Cause Unknown 29 30 30 30 31 31 31 31 32 33 33 34 35 36 36 37 38 38 39 39 40 40 41 43 44 45 46 XVI
2.24 Prison and Police Deaths 46 2.25 Functus Officio 47 2.26 Removal out of England and Wales 48 Summary 48 3. REPORTING DEATHS 49 3.01 Introduction 49 3.02 The Problem 50 The Duty to Report a Death 51 3.03 The Necessity to Report 51 3.04 Sources of Referrals 52 3.05 Common Law Duty upon all Citizens 53 3.06 Common Law and Statutory Offences 53 3.07 NHS Responsibilities 54 3.08 Statutory Requirements upon a Doctor 56 3.09 Recognized Practice 57 3.10 Regulation 41 the Registrar's Obligation 58 3.11 The Anomaly of Regulation 41 59 3.12 Written Advice 60 Ability to Recognize 60 3.13 Hospital Deaths 61 3.14 General Practice 61 3.15 Conclusion 61 Reportable Deaths 62 3.16 Practical Guidance 62 3.17 Old Age 67 3.18 Osteoporosis 67 3.19 Reporting Medical Deaths 68 3.20 Comparison with the Scottish Requirement 68 3.21 A Simplified Guide to Reportable Deaths 69 Conclusion 70 3.22 Common Errors 70 3.23 Sources of Advice 71 Summary 71 4. DECISIONS AND INQUIRIES 73 4.01 Introduction 74 Death Certification 74 4.02 Certifying Deaths A Confusion of Terminology 74 4.03 Issue of Papers for Registration and Disposal by a Doctor 76 4.04 The Chain of Causation 76 xvn
The Decision to Inquire 4.05 Introduction 4.06 Lack of Information 4.07 Referrals not Requiring a Post-mortem Examination 4.08 Recording Cases that do not Require Further Investigation 4.09 Referrals where the Cause of Death is Unknown 4.10 Deaths which are Clearly Violent or Unnatural The Decision to Hold an Inquest 4.11 Introduction 4.12 Extent of Inquiries before the Decision is Made 4.13 Basis of the Decision 4.14 The Question of Discretion Ancillary Decisions 4.15 Organ Donation and Transplants 4.16 Power of Exhumation 4.17 Removal out of England Procedural Matters 4.18 Introduction 4.19 Form 100A Procedure 4.20 Form 100B Procedure 4.21 Additional Information 4.22 Statistics Release of the Body 4.23 The Coroner's Right to Possession 4.24 Disputes 4.25 Criminal Cases 4.26 Deceased without Relatives or Funds Disposal of the Body 4.27 Registration 4.28 Burial 4.29 Cremation 4.30 Bodies Returned from Abroad 4.31 Removal out of England and Wales Suspicious Deaths 4.32 Introduction 4.33 Notification of the Death 4.34 Examination of a Scene, or of the Living 4.35 The Right to Choose the Pathologist 4.36 Who Can Attend the Post-mortem? 4.37 The Second Post-mortem 4.38 Transplant Cases 77 78 78 79 79 80 81 81 81 82 83 84 84 84 86 86 87 87 87 89 89 91 92 92 92 93 93 94 94 95 95 96 96 97 97 98 98 99 99 100 101 xvin
4.39 Opening and Adjourning the Inquest Section 16 102 4.40 Resuming the Inquest 104 Human Rights 105 4.41 The Human Rights Act 1998 105 4.42 Interpretation of Convention Rights 106 4.43 Article 2: The Right to Life 107 4.44 Article 6: The Right to a Fair Trial 108 4.45 Article 8: The Right to Private and Family Life 108 4.46 Article 9: Freedom of Thought, Conscience, and Religion 109 Summary 110 5. THE CORONER'S POST-MORTEM 111 5.01 Introduction 112 The Power to Order an Examination 112 5.02 Possession and removal of the body 112 5.03 Necessity for Examination 113 5.04 The Modern Trend Questioning the Need? 114 5.05 Section 19 Post-mortem Without Inquest 116 5.06 Section 20 Post-mortem with Inquest 118 5.07 Section 20 Special Examinations 119 5.08 Section 21 The Power to Summon Medical Witnesses 119 5.09 Power of a Jury under Section 21 120 5.10 Retention of Tissue Rules 9 and 12 120 5.11 Second Examinations Request by the Family 121 5.12 Second Examinations Homicides 122 5.13 Testing for Other Purposes 123 Families and the Post-mortem Examination 124 5.14 Introduction 124 5.15 Information about the Autopsy to Families 125 5.16 Objections to Post-mortem Examination 126 5.17 Information about Tissue Retention 127 5.18 Tissues Retained Indefinitely 128 5.19 Return of Tissues 129 5.20 Criminal Cases 130 Before the Post-mortem Examination 130 5.21 Necessity for a Full History 130 5.22 Choosing the Pathologist 132 5.23 Suitable Premises 135 5.24 Notification of Post-mortem 135 5.25 Considering Alternatives The Limited Autopsy 136 5.26 Considering Alternatives The Non-invasive Autopsy 136 xix
The Post-mortem Examination 5.27 Nature of the Examination 5.28 Identification 5.29 Who should Eviscerate the Body? 5.30 Process of the Examination 5.31 Taking Histology and Toxicology Specimens 5.32 Interpreting the Post-mortem 5.33 Difficulties of Interpretation 5.34 Release of Bodies Special Examinations 5.35 Toxicology 5.36 Histology 5.37 Neurological Cases 5.38 Industrial Lung Diseases 5.39 Payment The Post-mortem Report 5.40 Need for Accuracy 5.41 Clinical History 5.42 The Summary and Conclusion 5.43 Delay in Submitting the Report 5.44 Release of the Report The Pathologist s Evidence at Court 5.45 Documentary Evidence 5.46 Preparation for Court 5.47 Giving Evidence 5.48 Change of Opinion 5.49 When Should the Pathologist Give Evidence? Summary 6. PREPARING FOR THE INQUEST 6.01 Introduction The Coroners Preparation 6.02 The Coroner's Responsibility 6.03 The Investigation 6.04 Choosing the Witnesses 6.05 Plans and Photographs 6.06 Viewing the Scene 6.07 Pre-inquest Review Notification of Hearing 6.08 The Family and Other Interested Persons 6.09 Persons whose Conduct may be Called into Question 138 138 138 139 140 140 141 142 142 143 143 145 145 146 146 147 148 148 148 149 150 152 152 152 153 153 153 154 155 156 156 156 157 157 158 158 158 159 159 160 XX
6.10 The Press 161 6.11 Warning the Witnesses 161 6.12 Witness Summonses 162 6.13 Compelling Production of Documents 163 Releasing Documentation before the Inquest 164 6.14 The Post-mortem Report 164 6.15 Statements of Witnesses who will give Oral Evidence 165 6.16 Disclosure of Witness List 166 6.17 Release of Documentary Evidence 167 6.18 Deaths in Custody Disclosure by the Authorities 167 6.19 Reports from NHS Staff 168 6.20 Health Records 169 6.21 Privileged Documents 169 Preparing a Report or Statement 170 6.22 The Legal Position 170 6.23 Who May See the Report 171 6.24 Contents of the Report 171 6.25 Seeking Legal Advice 173 The Advocate 174 6.26 Taking Instructions 174 6.27 Contact with the Court 174 6.28 Applications for Funding 175 6.29 Briefing the Client 177 6.30 Final Arrangements 178 The Witness 178 6.31 The Dangers 178 6.32 Two Weeks before Court 179 6.33 The Day before Court 180 6.34 On the Day of the Inquest 181 Summary 183 7. INQUESTS 7.01 Introduction The Purpose of the Inquest 7.02 The Coroner's Remit 7.03 The Meaning of'how' 7.04 The Conflict with Rule 42 7.05 The Nature of the Inquiry 7.06 Increased Scope where Article 2 is Engaged 7.07 Rule 43 Prevention of Similar Fatalities 7.08 Overall Purpose of the Inquest 185 186 187 187 187 188 188 189 190 191 XXI
A Public Hearing 7.09 Who May Take Part 7.10 Nature of the Right to Ask Questions 7.11 Representation 7.12 Inquest to be Held in Public 7.13 Screening of Witnesses 7.14 The Press 7.15 Photographs and Tape Recorders Preliminaries 7.16 Opening the Inquest 7.17 Adjournments under Section 16 7.18 The Order of Witnesses 7.19 Presence of Witnesses in Court 7.20 Inquests Heard by Deputy Coroner 7.21 Coroner Sitting with an Assessor 7.22 Others on the Bench 7.23 Counsel to the Inquest 7.24 Joinder of Inquests 7.25 Bias 7.26 Legal Aid Taking the Evidence 7.27 Formalities 7.28 Initial Matters 7.29 Evidence to be Given on Oath 7.30 Notes to be Taken of the Evidence 7.31 Questioning of Witnesses by the Coroner 7.32 Questioning of Witnesses by Advocates 7.33 Questioning of Witnesses by Unrepresented Persons 7.34 Evidence Differing from Statement 7.35 Child Witnesses 7.36 Evidence that is Likely to be Distressing 7.37 Submissions on Law to Coroner 7.38 Criminal Offences Apparent during Evidence Requirement to Answer Questions 7.39 Competence and Compellability 7.40 The General Rule Witnesses Must Answer Questions 7.41 Giving Evidence Documentary Evidence 7.42 Documentary evidence Rule 37 7.43 Requirements for Using Documentary Evidence 7.44 Suicide Notes 192 192 194 194 195 196 197 199 199 199 200 203 203 204 204 204 205 205 206 207 207 207 207 208 208 209 210 211 211 212 212 213 213 214 214 215 218 220 220 221 222 xxn
Keeping Order in Court 7.45 Failure of Witness to Attend 7.46 Failure of Witness to Answer Questions 7.47 Disorder in the Courtroom Evidential Matters 7.48 Introduction 7.49 The Coroner's Discretion 7.50 Relevance of Evidence 7.51 Admissible Evidence 7.52 Opinion Evidence 7.53 Evidence of Character 7.54 Documents Concluding the Inquest 7.55 Delivering the Verdict Summary 223 223 224 225 226 226 226 227 227 227 227 228 229 229 230 8. JURIES 231 8.01 The Problems 232 8.02 Historical Perspective 232 The Requirement to Call a Jury 233 8.03 Deaths in Prison 233 8.04 Police Deaths 234 8.05 Deaths Reportable to a Government Department 235 8.06 Deaths Concerning Public Safety 238 8.07 Persons Detained under the Mental Health Act 239 8.08 Reason for Summoning Jury becoming Apparent 239 8.09 Coroner's Discretionary Power 240 8.10 Opening an Inquest without a Jury 240 8.11 Deaths Abroad 240 Administrative Matters 241 8.12 Warrant to Summon a Jury 241 8.13 Summoning a Jury 241 8.14 Composition of the Jury 242 8.15 Insufficient Number of Jurors Present 242 8.16 Failure of Juror to Answer Summons 242 The Jury in Court 243 8.17 The Role of the Jury 243 8.18 Preliminary Matters 243 8.19 Objection to a Particular Juror 243 8.20 Introducing the Case before a Jury 244 8.21 Power to Discharge a Juror 244 xxni
8.22 Length of Sitting 245 8.23 Allowing the Jury to Ask Questions 245 8.24 Viewing the Scene 245 8.25 No Person to Address the Jury 246 8.26 Seclusion of the Jury 246 8.27 Unanimous and Majority Verdicts 247 8.28 Recording the Verdict 248 Summing Up 248 8.29 Introduction 248 8.30 The Purpose of the Proceedings 249 8.31 Rules 36 and 42 249 8.32 Questions to be Answered on the Inquisition Sheet 250 8.33 Verdicts to Consider 250 8.34 Issues for the Jury 251 8.35 Standard of Proof 252 8.36 Summary of the Important Points of Evidence 253 8.37 Assessing the Evidence 254 8.38 Issues of Causation 254 8.39 Advice as to the Jury's Task 255 8.40 The Right to Ask for Further Advice 255 8.41 Documentation in the Jury Room 255 Summary 256 9. THE VERDICT 257 9.01 Introduction The Problem with Verdicts 258 9.02 Differences of Approach 259 9.03 No Definitive List of Verdicts 259 9.04 The Future 260 The Standard of Proof 260 9.05 The Standard of Proof Conclusion as to the Death 260 9.06 The Standard of Proof Other Matters 261 Requirements of the Inquisition 262 9.07 Name of the Deceased 262 9.08 Cause of Death 262 9.09 Statement of Circumstances 264 9.10 Conclusion as to the Death 265 9.11 Particulars under the Registration Act 265 Limitations of the Verdict Rule 42 265 9.12 Criminal Liability 266 9.13 Civil Liability 266 9.14 The Duty to Inquire A Conflict with Rule 42? 266 xxiv
Common Verdicts 267 9.15 Natural Causes 267 9.16 Accidental Death 269 9.17 9.18 9.19 9.20 9.21 9.22 9.23 Neglect 9.24 9.25 9.26 9.27 9.28 9.29 Misadventure Suicide Open Verdict Drugs Deaths Industrial Disease Less Common Verdicts Narrative Verdicts Introduction The Jamieson Case The Meaning of'gross Failure' Causation Recent Developments Summary 270 271 272 273 274 275 276 278 278 279 280 282 283 283 System Neglect 284 9.30 Background 284 9.31 The Amin and Middleton Judgment 284 9.32 Post-Middleton 287 9.33 Summary 288 Unlawful Killing 289 9.34 Scope of the Verdict 289 9.35 Road Traffic Offences 289 9.36 Involuntary Manslaughter 290 9.37 Effect of an Unlawful Killing Verdict 293 9.38 Involuntary Manslaughter The Future 293 Summary 294 10. AFTER THE INQUEST 295 10.01 Introduction 296 Administrative Matters 296 10.02 Form 99 Certificate after Inquest and Registration 296 10.03 Notification to Inspectors and Government Departments 296 10.04 Payment of Fees and Expenses 297 10.05 Upkeep of Register and Annual Return 297 Judicial Review 298 10.06 Introduction 298 10.07 The Statutory Remedy under the Coroners Act 299 10.08 The General Provisions under the Supreme Court Act 300 xxv
Rule 57 Supply of Documents 10.09 Introduction 10.10 Register of Deaths 10.11 Retention of Exhibits 10.12 Retention of Records 10.13 Rule 57 The Supply of Documents 10.14 Reports of Post-mortem and Special Examinations 10.15 Transcripts and Notes of Evidence 10.16 Documents put in Evidence at an Inquest 10.17 Other Documents 10.18 The Press 10.19 Researchers 10.20 Data Protection and Tracing Inquiries The Aftermath of the Inquest 10.21 10.22 10.23 10.24 10.25 Summary Introduction Debriefing the Client Dealing with Press or Media Rule 43 Reports Admissibility of Evidence given at the Inquest 301 301 301 302 302 304 305 305 305 306 307 307 307 308 308 308 308 309 310 310 11. DISASTERS 313 11.01 Other Reading 314 What Makes a Disaster 315 11.02 Special Demands 315 11.03 The Coroner's Overall Responsibilities 316 Preparing for Disaster 317 11.04 Establishing Key Relationships 317 11.05 The Police 317 11.06 The Other Services 318 11.07 'The Advocates' 318 11.08 The Concerns of the Relatives 319 11.09 Summary 322 Temporary Mortuaries 322 11.10 Need for a Special Facility 323 11.11 The Supervising Pathologist 324 11.12 The Major Disaster Advisory Team 324 11.13 Purpose ofa Temporary Mortuary 325 11.14 Procedures 325 XXVI
11.15 Requirements of the Temporary Mortuary 325 11.16 Temporary Mortuary Plan 327 11.17 Planning for Radiography at the Temporary Mortuary 328 Dealing with the Disaster 328 11.18 The Role of the Coroner in the Early Stages 328 11.19 Site Visit 330 11.20 Mortuary Arrangements 330 11.21 The Decision to Open a Mortuary 330 11.22 Recovering Bodies 331 11.23 The Body Holding Area 333 11.24 Post-mortem Procedures 334 11.25 Extent of the Examination 335 11.26 Viewing by Relatives 336 Identification 337 11.27 The Difficulties 337 11.28 Senior Identification Manager 338 11.29 Use of Family Liaison Officers 339 11.30 The Identification Commission 339 11.31 The Release of Bodies. 342 11.32 Identification Features 344 Conclusion 346 11.33 The Inquest and the Public Inquiry 346 11.34 Expectations 347 Summary 348 12. TREASURE 349 12.01 Historical Perspective 349 12.02 The Treasure Act 1996 350 12.03 Requirement to Declare Finds 350 12.04 Definition of Treasure 351 12.05 Definition of'the Same Find' 352 12.06 Items that have been Lost or Ritual Deposits 352 12.07 No Requirement for a Jury 352 12.08 Procedure on a Find being Made 353 12.09 Procedure if Objects Disclaimed 353 12.10 Procedure at a Treasure Inquest 354 12.11 Procedure if the Find is Declared Treasure 355 12.12 Speed of Handling Cases 356 Summary 356 XXVll
Appendices 357 1 1997 OPCS Guidance on Referral 357 2 The Jamieson Case 361 3 Review of Vost-Jamieson cases 365 4 Definition of death ofa member of the public during or following Police contact for the purposes of reporting by the Police to the Home Office 375 5 Coroners Act 1988 377 6 The Coroners Rules 1984 405 7 The Coroners' Records (Fees for Copies) Rules 2002 429 8 Treasure Act 1996 431 Index 437 XXVlll