The BBC’s File on 4 broadcast a programme on 15th November entitled
Coroners under scrutiny. The programme questioned whether families are getting justice in the coroner’s courts and raised concerns about the variation in the behaviour of coroners and the rigour of their investigations. The programme found that coroners have very wide discretion over how to conduct inquests, which witnesses they call to give evidence, and do not routinely examine medical records. Following the unexplained death of Stanley Mack in a Birmingham hospital, the hospital put forward the witnesses it chose, rather than the coroner automatically asking the medical staff closely involved in the care of the dead person to explain what had happened. At Mr Mack’s inquest a consultant who had not seen him in the 12 days before he died was the medical professional who gave evidence. His family wanted his death investigated after discovering vital drugs had not been given and routine observations missed.
Some families, who are relying on an inquest to deliver a verdict that identifies neglect as a reason for the deaths of their loved ones, are left frustrated and bewildered when coroners do not choose to hear evidence from the people most intimately involved in the care of their relations, or examine the relevant medical records.
Lisa O'Dwyer, head of the inquest project at Action against Medical Accidents, said:
"If a coroner isn't going to look at those records, then it is very difficult for a family to feel anybody's got to the bottom of what has gone on in the events leading up to their loved one's death."
The government is planning a
national charter for the coroner service to bring more consistency to the level of service
Leigh Day and inquests
Leigh Day & Co specialist
personal injury,
clinical negligence and
human rights solicitors regularly attend inquests with the families of people who have died because of hospital errors, in car and cycle crashes, whilst resident in care homes or whilst detained under the Mental Health Act or in custody. For many of our clients a verdict from a coroner that identifies neglect or substandard or negligent care as one of the reasons for their loved ones’ death is the first step towards recovery following a traumatic and stressful event.
Alison Millar, human rights partner, says:
"When someone has died in contentious or unexpected circumstances, it is vital that there is an inquest process that enables their family to seek answers and through which lessons can be learned to protect other lives. For too long, however, it has been beset with inconsistencies and unacceptable delays. This programme highlights the difficulties families often face battling with the current, archaic system and the need for reform, in particular the appointment of a Chief Coroner to provide national leadership."
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