Constitutional Affairs Committee

Press notice No. 36 of Session 2005-06
31 July 2006


The Commons Constitutional Affairs Committee today says Government risks “wasting a golden opportunity” to reform the system of death certification and investigation in England and Wales, which dates partly from Victorian times and partly from much earlier.

The Committee’s report on “Reform of the Coroners’ System and Death Certification”, published today, Tuesday 1 August 2006, says that although the Government’s recently published draft Bill on Coroners Reform will do much to improve the coronial system, it will do nothing to remedy the “critical defects in the death certification system”. Dame Janet Smith, chair of the Shipman Inquiry, said in her evidence to the Committee that the reforms proposed in the Bill “would go no way at all towards remedying the defects that failed to detect or deter Shipman. If these reforms go through - and they are good in themselves and I have no criticism of them in themselves - there could still be a Shipman out there killing patients”.

The Committee concludes that, because neither DCA nor the Department of Health is taking responsibility for death certification, “if anything specific is being done at all, it amounts to tinkering at the edges of a system which has already been deemed unsafe and unsatisfactory by two Government-commissioned reviews”.

The two reviews, published in 2003 - the Shipman Inquiry and the Luce Review - both found the systems for certification and investigation of death in England and Wales to be “unfit for modern society”. The Committee concludes that “coroners undertake their statutory function in a fragmented and localized system that has remained largely unchanged since the time of Queen Victoria. The current system is ill equipped to deal with the modern expectations of society”.

 The Committee urges Government to revise its policy to not reform death certification, saying it should return to the proposals put forward by the Home Office in 2004, and ensure that they are supported with sufficient resources. At least, Government should introduce a clear system of duty for doctors to refer certain categories of death to the coroner and ensure all doctors understand these. At present there is no statutory duty on doctors or police to refer deaths to the coroner, and it can be difficult for them to know in which cases they should. 

The Committee also recommends that the Government adopt a strategy for reducing the number of post-mortem examinations performed. This may include abolition of the “14-day rule” where the doctor who signs the death certificate must have seen the patient within 14 days of their death - this is increasingly less likely with changes in general practice and out-of-hours care. Provision of detailed information to the coroner and pathologist, and adoption of written sudden death reports by the police could also reduce the number of post-mortems.

The Committee also argues that the coronial system lacks national direction, with wide variations in regional practice, and that under the reforms proposed in the draft Bill the coronial system remains essentially locally resourced. The legal framework for the functions of a coroner is by no means clear. “The police and local authorities provide varying degrees of financial and administrative support for the coronial system, there are also hidden subsidies, the magnitude of which is almost impossible to calculate. The system is beleaguered, with insufficient training for coroners and their staff, inadequate funding, a lack of facilities and uneven distribution of resources, leading to inconsistent levels of service across England and Wales.”

The Committee recommends that the Government create a national service with central and adequate funding so that all coroners are able to work to the same high standards. “The proposed reforms lack detail and fail to tackle adequately the resource and structural problems currently facing the existing, outmoded coronial system. A national service would almost certainly involve significant extra cost, but the failure to introduce one will mean that the current inequalities of resource will continue.”

For example, the Committee welcomes the Government’s draft Charter for Bereaved People, but notes that it may lead to severe disappointment for the bereaved where variable standards in service are likely to persist. The Committee is also concerned that the discontinuity involved in complex reforms and changes to jurisdictional boundaries proposed in the draft Bill could mean that many existing coroners, coroners’ officers and administrative staff, and valuable skills and experience, will be lost to the system. They may also create enormous geographical areas which one person has to cover, making access to the coroner more difficult. The Committee says that Government needs to make explicit in the Bill how their proposed system is intended to function in scattered and remote areas.

Chairman of the Committee, Rt Hon Alan Beith MP, said: 

The system of coroners and death certification is in urgent need of reform on at least two counts: there is enormous variation in standards, and the system failed to detect a major serial murderer. This is therefore an opportunity not to be wasted: we must strongly recommend that the Government rethink its plans, and that it incorporate reform of death certification. Attempting to reform the system without reforming the way it is funded likely to prove a failure. There is also a danger that bereaved families in some areas may have to deal with a less accessible and more remote service.


1. The report is available on the Reports and Publications page of this website

2. Committee Membership is as follows: Rt Hon Alan Beith MP (Chairman), James Brokenshire, MP David Howarth MP, Siân James MP, Mr Piara S Khabra MP, Jessica Morden MP, Julie Morgan MP, Mr Andrew Tyrie MP, Keith Vaz MP, Dr Alan Whitehead MP, Jeremy Wright MP