A review of coroners’ practices is long overdue – as a recent case has shown.
The little-noticed review of coroners’ services announced by the Ministry of Justice last month is long overdue. Not much has changed since the first coroners were appointed to investigate sudden, violent or unnatural deaths more than 800 years ago.
The review has become all the more urgent because of shortcomings exposed by a recent High Court decision. Ministers seemed surprised to discover that some coroners act as if they are a law unto themselves. But the obvious solution – to bring coroners within the established judicial hierarchy – may cost the government more than it is willing to pay.
Coroners have been appointed locally since the 12th century. In 2003, a report commissioned by the Home Office recommended that they should be appointed and funded centrally, in the same way as other judges. But this proposal was rejected, presumably because it would have increased the cost to central government. So coroners are still appointed and paid by local authorities, although the lord chancellor and chief coroner can now veto appointments.
One of the ‘key areas of change’ introduced in 2013, according to the government’s new consultation paper, was a ‘requirement that coroners be available at all times to address matters which must be dealt with immediately’. Another question on which the government is seeking views is whether coroners are willing to grant requests for less invasive post-mortem examinations. A traditional autopsy is against the religious beliefs of many Muslims and Jews, who regard it as desecration of a corpse.
But neither of those requests cuts much ice with the coroner whose district includes the largest number of Jews in England and Wales – as well as many Muslims. Mary Hassell, the senior coroner for inner north London, apparently sees no reason why families who seek, where practicable, a non-invasive autopsy or immediate burial should be treated any differently from those who do not have these religious requirements.
How else are we to explain what happened last year in the case of 86-year-old Sarlotta Rotsztein, who died six hours after being admitted to a London hospital with very low blood pressure. Her GP concluded that she had suffered a heart attack but hospital doctors could not rule out an infection as the cause of death. They informed the coroner – who ordered an invasive autopsy.
Rotsztein’s five children knew she would have been horrified by the prospect. They offered to pay for a highly regarded pathologist to perform a non-invasive CT scan and coronary angiography. Hassell refused to authorise this and then went home for the night, refusing a request for out-of-hours contact details. The family were left with no option but to obtain an emergency injunction. Two days later, after several requests from their solicitors, the coroner released the body for a non-invasive post-mortem. This confirmed the cause of death as cardiac failure and enabled the funeral to go ahead.
So, too, did the family’s case against the coroner. They argued that she had adopted the wrong test when considering whether an invasive autopsy was required. Their claim was upheld by Mr Justice Mitting at a hearing in July. He said the coroner should have put off an invasive post-mortem for a day or two to see whether non-invasive procedures would prove conclusive – as indeed they did. The family also claimed, as a subsidiary ground, that Hassell had failed to take account of the chief coroner’s guidance. That part of the claim failed because the guidance does not say when non-invasive procedures should be used.
Hassell, a solicitor, was therefore ordered to pay 90% of the family’s legal costs as well as the costs of instructing her own lawyers to fight the case. Those bills, estimated at over £200,000, will be paid by council tax payers in north and east London (of which I am one).
Nobody is suggesting that coroners should work 24 hours a day, seven days a week. But according to Trevor Asserson, solicitor for the Rotsztein family, most coroners make themselves available by email or telephone so that a religious funeral can be held outside office hours. ‘It’s a phone call to release the body to the pathologist and another call to release the body for burial, which can be done in five or 10 minutes,’ he says. ‘It’s very, very minimal.’
The Rotsztein family were able to obtain an out-of-hours injunction because there is always a High Court judge on duty to hear urgent applications. And that, in turn, is possible because the High Court operates nationally rather than locally. If we are to avoid unnecessary anguish for newly bereaved families and unwanted bills for local taxpayers, we must have the consistency and uniformity that only a national coroner service can provide.