The role of Medical Examiners and the coronial system
I have been involved in the care of the dying and supporting the bereaved for more than twenty five years, first as a doctor in many guises, then expert witness, specialist advisor, and medical examiner. Understanding the needs of the bereaved has changed considerably, undoubtedly for the better, yet not without scope for improvement.
Following several high-profile incidents and enquiries, legislative changes reformed the coronial system in England and Wales and introduced the role of medical examiners. Many assumed fewer inquests would be necessary. However, the sad truth is that many deaths in the modern age are not straightforward - death is rarely a simple linear sequence of events and cases being referred to coroners have undoubtedly increased in complexity.
The role of a medical examiner is to conduct proportionate scrutiny of, but not to investigate, a death. Many mistake our role for that of similarly named forensic pathologists in US crime dramas. A cause of death can usually be determined but sometimes remains unclear; circumstances may be identified that make it ‘unnatural’ according to the Notification of Deaths Regulations (which might be comprehensible to medical examiners and coroners but not to the bereaved); or the cause of death may be clear but, despite reassurances, the bereaved consider that other issues in the deceased’s life were contributory. Such cases are referred to a coroner for investigation and resolution can sometimes be incredibly difficult. In practice, many options exist for the bereaved to understand the death of their loved one but explaining the nuances in the highly emotional context of a recent death is seldom easy. Empathy and good communication are paramount.
The bereaved are central to coronial proceedings but share the space with others, including the purpose of the courtroom. The bereaved are vulnerable in that space especially if exposed to stark legal processes and poorly managed expectations. In my experience, the public rarely understand the inquisitorial role of the coroner in establishing the facts relating to a death. The bereaved tend to expect more from an inquest than it can achieve, notably they may not recognise that coroners cannot determine guilt or liability. Inquests can potentially offer resolution to uncertainties but may also exacerbate grief and emotional trauma, which leads to enmity and resentment. Wide-ranging issues in the days, months or years before a loved one dies can be hugely important for the bereaved but may not be within the remit of the coroner to investigate if they did not contribute to the death. Poor communication, lack of empathy, and unreasonable delays, which are increasingly due to constrained local authority resources rather than a lack of understanding of what the bereaved need, usually lie at the heart of any discontent.
Thankfully, the vast majority of deaths are not investigated by a coroner and most of those that are referred have straightforward inquests. The system has certainly become more collaborative in the last few years and collective projects such as ‘Voicing Loss’ are raising awareness of lingering unresolved issues that still need to be tackled.