In the first of a new series, Andrew Cox explains the work of a deputy coroner and says that, even in Cornwall, there are dozens of deaths that need investigating every week


You have to feel for the Rt Hon the Baroness Butler-Sloss GBE. A judicial career that culminated with her appointment as President of the Family Division of the High Court, she must have eased into retirement believing she had fully earned the right to a good rest. What happened? She allowed herself to be talked into becoming Deputy Coroner of the Queen’s Household and Assistant Deputy Coroner for Surrey so she could deal with the inquests into the deaths of Diana, Princess of Wales and Dodi Al Fayed.



It is difficult to imagine there will ever be a more high-profile inquest. And it is the first one she will ever undertake. By any measure, it is a huge task, even for someone as capable as the former judge.



Her unenviable task has also thrust into the spotlight the role played by coroners, and their deputies, across the land. Most lawyers probably have a vague idea that a coroner’s role is to inquire into the circumstances of a death, provided certain pre-conditions are met. Specifically, he has a statutory obligation to hold an inquest where someone has died a violent or unnatural death, or a sudden death from an unknown cause. But what does this involve in practice?



I was appointed deputy coroner for Cornwall last year, and the past six months have been something of a revelation. I thought I lived in a supposedly sleepy part of the world. It came as something of a shock then to have more than 50 deaths reported to me during the course of the first week that I was left, metaphorically at least, holding the mortuary.



When a death is reported to a coroner, typically by a general practitioner or hospital doctor, the first decision to be made is whether any investigations are actually required. I have provided advice as to whether a death needed to be reported at all and also suggested the correct wording for the doctor to put on his medical certificate of cause of death.



Where a cause of death is unknown, or the death is obviously violent or unnatural, the coroner is likely to order a post-mortem investigation as a prelude to an inquest. On occasions, ordering a post-mortem report can be a troubling decision to make. No one wants to inflict a final indignity on someone who may well have suffered greatly in their last days and yet, once the body is released, the chance to obtain what may subsequently be shown to be essential evidence is, in all probability, lost forever.



As a novice, I doubtless ordered more post-mortem examinations than an experienced coroner would have. My general unease with the situation was further compounded when I read the 2006 report of the national confidential enquiry into patient outcome and death. This stated that nearly 120,000 autopsies were performed during 2005 in England and Wales. If that total figure was not itself startling, the conclusions that one in four autopsy reports was judged as poor or unacceptable, and in nearly one in five cases, the cause of death as stated appeared questionable, provided real pause for thought.



It took quite some time before I began to have a degree of confidence in what I was doing. Needless to say, it was at this point that things started to go wrong.



Late one afternoon, a police inspector rang me. He had two bodies of citizens believed to be from the UK, one of whom was thought to be a resident of Cornwall, the other from ‘up country’. They were understood to have been slain by pirates somewhere off Indonesia, although as the bodies had been under a tropical sun for several weeks before being discovered, this was a matter of some conjecture. Not unreasonably, the officer asked what I wanted to do. I told him I would have to call him back and then ‘phoned a friend – to be precise, a much more experienced deputy who mercifully volunteered to sort out the problem. Ultimately, the coroner with jurisdiction for the second body agreed to deal with the two inquests together.



On another occasion, I had a phone call from a woman claiming to have been the former common-law wife of a man who had died suddenly over the preceding weekend. She wanted a sample of blood from the deceased for DNA testing so that she could prove that he had been the father of her child, even though she admitted that he had not known this to be the case. The ‘child’ was now in his 20s.



I turned to Christopher Dorries’ excellent book, Coroners’ Courts, and was able to forgive his previous shortcoming (in not having a chapter on how to deal with pirate-related deaths) when my attention was directed to part III of the Family Law Reform Act 1969 and Home Office advice, which state that coroners should not agree to requests for DNA testing in the absence of a court order.



As time has passed, so my decision-making has become more assured. I have found myself agonising less and less over whether or not to order a post-mortem. What I have also begun to appreciate is the variable quality of the reports I receive. On occasions, a consultant rings, genuinely perturbed by a patient’s death and sufficiently humble to admit that he does not know the reason for it. Some have asked to attend the subsequent post-mortem.



More often than not, however, the reporting of a death is left to a junior member of the team who does not have a complete understanding of the relevant circumstances. There are times when I have gained the impression that the reporting is seen as an aggravation to be endured and the last thing to be done, with all possible haste, on the way home. I have acquired the confidence to say, when appropriate, that I need more information and that if the particular doctor is unable to provide it, that I expect to have the consultant responsible for the deceased telephone me to complete the report.



It was with this new-found resolve that I took a call from a consultant a few weeks ago. Before one of the support staff put him through, she warned me that he was in a foul mood and had been abrupt with her. I determined to mention this to him with a request that he treat our staff courteously. The consultant explained that he had come straight from the operating theatre where he had been trying to repair an abdominal aortic aneurysm. Unfortunately, the patient had suffered a rupture and had just bled to death in front of him. I offered my sympathies, ordered a post-mortem, and decided against raising the issue of his earlier surliness.



The last six months have been a mixture of routine and new experiences. I attended a post-mortem examination and was profoundly moved when I discovered the deceased had been born within three days of me. I also reviewed a file of papers relating to a road traffic collision in a matter that would later become the first inquest I undertook. A youth, barely six months from passing his driving test, had collided head-on with another vehicle as he attempted an overtaking manoeuvre. The other driver’s wife of 50 years and her sister had been killed.



Every family that comes before a coroner’s court, whether they are of royal blood or common stock, will inevitably have had sadness visited upon them. The need to strike the right balance between sympathy and professional detachment is a constant requirement.



The position of deputy coroner is both demanding and interesting. Some of the decisions that need to be taken call for a serious degree of responsibility. It is a job that has its rewards and I have been surprised by the number of times that the family of someone who has died has thanked me at the end of an inquest. It is also, most definitely, not a job for the faint-hearted. I wish Lady Butler-Sloss well.



Andrew Cox was a personal injury solicitor for more than a decade. He was appointed deputy coroner for Cornwall in 2006