|
18.6 |
Professor Stephen Cordner, Professor of Forensic Medicine and Director of the Victorian Institute of Forensic Medicine, attended the seminar and described the system in Victoria. |
Background and Structure
|
|
18.7 |
The coronial and death certification systems differ from state to state in Australia. The eight systems all operate along broadly the same lines, but with differences of detail. All the systems are derived from that in England and Wales. |
|
18.8 |
The population of Victoria is approximately 4.8 million. The number of deaths is about 35,000 each year, of which about 10% are referred to the coroner. Autopsies are performed on behalf of the coroner in around 3000 of those cases. Toxicology is undertaken in around 2000 cases and, in about 1500 of those cases, toxicological testing extends beyond testing simply for the presence of alcohol. |
|
18.9 |
The Victoria State Coroner, who is legally qualified, has responsibility for the coronial system as a whole. He is based, together with four full-time coroners, at the Coronial Services Centre in Melbourne. The Institute of Forensic Medicine ('the Institute') operates out of the same building and works closely with, but independently of, the coronial system. The Institute is an independent statutory authority, as well as a University Department. Professor Cordner observed that its functions complement each other. Its coronial service obligations inform its teaching and research functions; those functions in turn support its service obligations. Autopsies for deaths occurring within the city of Melbourne are performed at the Institute. The quality of its forensic pathology services, and the way in which they work in close partnership with the coronial service, are particularly strong features of the Victoria death investigation system. Outside Melbourne, all magistrates, who in Victoria are legally qualified judicial officers, act as coroners. If a contentious matter arises in a country area, a full-time coroner may be sent to deal with it. In those areas, because of the large distances involved, autopsies are carried out by local pathologists, acting as agents of the Institute. |
|
18.10 |
Professor Cordner referred to the advantages of having a single individual, the State Coroner, responsible for the coroner system. Before that arrangement was introduced, there was considerable variation of practice between different coroners. Now, there is consistency and reliability of outcomes within the jurisdiction. The State Coroner is appointed from the magistracy for three years. He or she may be re-appointed but, if not, returns to the magistracy. As well as the leadership provided by the State Coroner, Professor Cordner also provides advice and guidance to support and assist those working in the fields of death investigation and certification. |
Statutory Framework
|
|
18.11 |
Model national legislation was introduced in Australia in the mid-1990s in an attempt to bring national uniformity to coronial law and practice. That legislation has been implemented to varying degrees across the eight states. In Victoria, the Coroners Act 1985 (as amended) remains in force. The Act established the office of the State Coroner. It also defined the categories of death to be reported to the coroner, and the procedure to be adopted by the coroner in the investigation of death and the holding of inquests. The procedure for the registration of deaths is set out in the Births, Deaths and Marriages Registration Act 1996. |
Objectives
|
|
18.12 |
The modern emphasis of the coroner's role is on death and injury prevention. It has been recognised in Victoria that there is an important public interest in learning lessons from preventable deaths. |
Deaths Not Reported to the Coroner
|
|
18.13 |
Deaths that are 'not unexpected' are not reported to the coroner. Where the death is not to be reported to the coroner, the doctor must give notice of death and cause of death to the registrar and the funeral director within 48 hours of the death. The registrar is notified by post and the family need not take any further steps to register the death. There is no requirement for the family to visit the registration authorities. Any registered doctor has the authority to certify the cause of death, regardless of experience or seniority. The standard of confidence that a doctor should have when diagnosing cause of death should, Professor Cordner said, be the same standard used by that doctor when making a good diagnosis in clinical practice. |
|
18.14 |
The model national legislation widened the category of doctor authorised to certify the cause of death beyond the treating doctor. It now includes partners in a group practice and any doctor, who may or may not have had previous contact with the deceased, but who has had access to the medical records. Any doctor who has seen the body after death has the authority, at least in theory, to certify the cause of death. In practice, doctors are told not to certify on the basis of an examination of the body after death without a reliable history, including a history of the circumstances of death. |
|
18.15 |
Like the system in England and Wales, the certification system in Victoria is wholly dependent on the integrity of the certifying doctor. There is no audit or quality assurance of certification. Professor Cordner observed that, in Victoria, as elsewhere, the completion of medical certificates of cause of death is flawed. He referred to the lack of training in the subject and the lack of enthusiasm for it amongst medical students. |
Deaths Reported to the Coroner
|
|
18.16 |
The categories of death requiring referral to the coroner differ from state to state but, in general, include violent, unnatural and sudden deaths, together with certain other specific categories of death. Those categories of death also include deaths in custody and deaths where no medical certificate of cause of death has been signed. The coroner's jurisdiction is limited to reportable deaths and does not extend to all deaths within the geographical jurisdiction. The statutory duty to report a reportable death is broad and extends to any person with knowledge of the death who has reasonable grounds to believe that the death has not already been reported. A criminal sanction for failure to report exists but is never imposed in practice. Professor Cordner said that there was not a high degree of awareness among the public of the duty to report. One perceived weakness of the system is its reliance upon persons reporting deaths to the coroner. Also, Professor Cordner observed that a particular emphasis is placed on the need to report deaths that are immediately identified as unnatural, with less emphasis being placed on the need to report and investigate sudden deaths which are thought to have a natural cause. |
|
18.17 |
The State Coroner's Office in Melbourne is staffed by coroner's clerks. The clerks are the first point of contact for a doctor telephoning to report a death or to make an enquiry as to the need to report. They are administrators who commonly have worked as court clerks and receive no formal training in legal or medical issues. In country areas, the magistrate's court staff will act as coroner's clerks. When a doctor telephones to report a death, the clerk may, in some circumstances, give advice as to whether or not a doctor should report the death, or may advise the doctor to certify the cause of death. That advice might be given without formal reference to the coroner. |
Death Investigation
|
|
18.18 |
Once a death has been reported to the coroner, investigations are undertaken by the police, acting as agents of the coroner. A small team of five police officers is seconded to the State Coroner's Office in Melbourne. Those officers oversee investigations carried out by the local police force. They also carry out investigations into particular types of death which require specific expertise and knowledge. For example, they might investigate a small plane crash or scuba diving accident. Outside Melbourne, coroners are entirely dependent on local police officers to investigate deaths. Coroners have powers to enter and inspect premises and to seize documents and other material in the course of their investigations. |
|
18.19 |
The decision as to whether an autopsy should be performed is made in the first instance by the coroner. The pathologist will then form his/her own judgement as to whether an autopsy is required or whether s/he can certify the cause of death without carrying out an invasive examination. In reaching that decision, the pathologist will have an opportunity to examine the body externally and will also have available to him/her the police report containing information about the circumstances of death. Medical records are not generally available at that stage, unless the death occurred in hospital. The treating doctor will rarely be contacted unless the pathologist wishes to enquire why the doctor feels unable to certify the cause of death. If a decision is taken not to carry out an autopsy, Professor Cordner said that there will usually be some consultation with the family to ensure that they are happy with the decision. |
|
18.20 |
Where it is decided that an autopsy should (or should not) be carried out, relatives have a right to object. The coroner's decision is subject to a right of appeal to the Supreme Court of Victoria; in practice, that right is rarely exercised. |
|
18.21 |
Extensive toxicology, designed to identify any one of a long list of drugs (including morphine), is carried out in approximately half of the autopsy cases in Victoria. The cost of toxicology in an individual case is approximately £250. |
|
18.22 |
At the end of an investigation, whatever the outcome, the family has access to a document setting out what is known of the circumstances of their relative's death. Documents arising out of the investigation are entirely public. |
|
18.23 |
The process for the investigation of deaths potentially caused by adverse medical incidents is undergoing reform. In a recent article on the investigation of deaths caused or contributed to by adverse medical incidents, Dr David Ranson, the Deputy Director at the Institute, noted that a large number of such cases go unreported and those that are reported have traditionally been investigated in the same way as all other deaths investigated by the coroner. The investigation consists of the police taking statements from doctors involved in the provision of treatment, and from other witnesses. Also, a pathologist will carry out an autopsy, on the basis of the information obtained by the police. Dr Ranson observed that the police have little direct experience or knowledge of the specialist medical issues involved in such a death. A potential problem might be missed because the doctors who are interviewed may not be forthcoming in identifying system failures. He also observed that the issues might not be picked up by the coroner's pathologist, who is unlikely to be aware of current practice issues in the entire range of specialist areas. |
|
18.24 |
A medical death investigation team has recently been established in Victoria. This adopts a very different approach to the investigation of deaths occurring in a medical setting. Cases are first screened by nursing staff against a set of diagnostic criteria and audit filters, to identify cases where there is a high likelihood that an adverse medical event has occurred. The information from the screening process is then passed, with the medical records, to the forensic pathologist conducting the autopsy. Once the results of the autopsy are available, the death will be reviewed by two clinical medical specialists from different clinical disciplines, who are employed on a part-time basis at the Institute. The specialists evaluate the records and identify areas where it would be prudent to obtain relevant witness statements. The specialists also draft specific questions to be put to witnesses and, if required, to an independent medical expert. The new investigative approach is still in its infancy but it is hoped that, in time, the process will lead to improvements in the safe delivery of healthcare. |
Judicial Investigation of Death
|
|
18.25 |
The majority of inquests in Victoria are held at the coroner's discretion, usually because there is a matter of public interest to be investigated. There are certain limited categories of mandatory inquests in cases of homicide, deaths where the deceased person is held in care and cases where the deceased is unidentified. Inquests into suicides are rare, as are inquests into deaths sustained in road traffic accidents, unless an issue of public safety and death prevention arises. Deaths that occur in the workplace commonly result in an inquest because of the potential for learning from the death and preventing future accidents of a similar nature. The views of the family are an important factor when taking a decision whether or not to proceed to an inquest. Inquests in Melbourne are presided over by full-time coroners. Outside Melbourne, magistrates sit in non-controversial cases. There is provision in the legislation for juries to sit on inquests, but no jury has sat for many years. Verdicts following an inquest are descriptive. Recommendations may be made, particularly if a number of deaths have occurred in similar circumstances. In some states, although not in Victoria, the appropriate authority is under an obligation to respond to recommendations made. |
Cremation
|
|
18.26 |
If a death is reported to the coroner, the coroner will authorise cremation. Otherwise, a cremation form is completed by the medical practitioner who was responsible for the deceased's medical care immediately before death. A second doctor and the crematorium medical referee must also complete cremation forms. The second doctor is required to examine the body, but will rarely contact the deceased's relatives or carers. Professor Cordner observed that his impression was that any independent enquiry by a second doctor in a cremation case was a rarity. |
National Coroners Information System
|
|
18.27 |
The National Coroners Information System (NCIS) is a computer database, which was established in 2000 and is based at the Monash University National Centre for Coronial Information, Melbourne. The NCIS receives and records information on the 18,000 or so deaths reported to coroners in Australia each year. Prior to the introduction of NCIS, the collection and analysis of coronial data was a slow process. For example, a Commission set up in 1989 to look at work-related deaths spent six years visiting each of the eight states collecting data, much of which was outdated by the time the Commission reported in 1998. Professor Cordner said that the NCIS has transformed the way in which such information can be obtained and studied. |
|
18.28 |
The database provides coroners with information about deaths occurring in other parts of the country. It allows coroners to identify patterns in preventable deaths which, on the basis of the limited information within an individual coroner's jurisdiction, might otherwise go unnoticed. The database also reduces repetition of work. For example, one coroner might not hold an inquest into a particular type of death if s/he knows that a coroner in another state has already investigated that type of death in detail and that the lessons in terms of death prevention have already been learned. |
|
18.29 |
Data from the NCIS is made available, not only to coroners, but also to Government agencies and other public sector organisations, particularly those involved in health policy. They use the NCIS to monitor particular types of death and identify health and safety issues. |
Detecting Shipman
|
|
18.30 |
On the basis of the summaries describing the circumstances of four of Shipman's unlawful killings, Professor Cordner formed the view that Shipman's activities would not have been detected by the Victoria system. In relation to the case of Mrs Kathleen Grundy, he said that there would be an issue as to whether the death could properly have been certified as due to 'old age'. This cause of death might or might not have been queried by a registrar. However, if the death had been reported to the coroner, the coroner's clerk might well have encouraged the doctor to certify the cause of death, on the ground that, even though the death was possibly unexpected, it was apparently (on the doctor's account) natural. If an autopsy had been carried out, so long as there was sufficient coronary artery disease to account for death, further investigation would probably not have been ordered. In the absence of heart disease, histology would have been ordered and samples for toxicology taken, to be analysed only in the event that the cause of death was not established by histology. |
Comments
|
|
18.31 |
The modern role of the Victoria coroner system in the field of death and injury prevention is one which, in my view, the system in England and Wales should also embrace. In order for that to be done, a system such as the NCIS is plainly necessary. |
|
18.32 |
The evident quality of the independent forensic pathology services in Victoria, their position at the centre of the death investigation and certification system and the close working relationship between the coronial and forensic pathology services are all important features of the system in Victoria. They provide a model which could, with benefit, be adapted for use in England and Wales. |
|
18.33 |
I was also most interested in the proposals for the identification and investigation of deaths associated with medical care. I shall recommend that similar measures be considered for the investigation of that type of case in England and Wales. |
|
18.34 |
I was also impressed by the evidence of leadership offered by both the State Coroner and by Professor Cordner, as Director of the Institute with responsibility for forensic pathology. It is clear that the leadership which they offer is of great benefit in achieving consistency, as well as in encouraging good practice and in supporting the work of those with day-to-day responsibility for the operation of the coronial and death certification systems. |
Introduction
