Nationwide disparities of deaths reported to coroners

A leading detective turned university researcher has discovered huge nationwide disparities in the numbers of deaths reported to coroners. It could mean that in some areas, inquests into unnaturaldeaths are not being conducted when they might have been deemed necessary elsewhere. Also, it has emerged that deaths of women are less likely to be reported and go to inquest. And when they do, they are less likely to result in a verdict of unnatural death.

Findings from the exhaustive research project have led former Detective Chief Superintendant Max Mclean, the ex-Head of West Yorkshire CID, to brand the 800-year-old coroners' system in England and Wales a "postcode lottery". He calls for a national Coroners' Service with the power to iron out inconsistencies.

Now retired from the force, Mr Mclean is undertaking a PhD at the University of Huddersfield.

Mr Mclean's findings have been published in an article, co-authored with the University of Huddersfield's Dr Jason Roach and Dr Rachel Armitage, that appears in the Journal of Clinic Pathology. The massive exercise in data collection and statistical analysis was designed and conducted by Mr Mclean. "It was significant data crunching!" he said.

By working out how many deaths had taken place in coroners' areas of jurisdiction and how many had been reported to the coroner, Mr Mclean was able to work out the reporting rates for each district.

"We found that between the years 2001 and 2010, the reporting rates in the 114 jurisdictions ranged from 12 per cent to 87 per cent and were consistent over time. My work has demonstrated that this variation is a product of the coroner's working practice," said Mr Mclean.

He argues that because coroners remain in office for long periods and have a large amount of autonomy, their attitudes and working practices are likely to become entrenched and have a powerful influence in their jurisdiction.

He found that there was a mean reporting rate of just under half of all deaths.

"That feels right and the mean figure of 45 per cent has been reasonably consistent for a number of years," he added.

Mr Mclean intends to conduct further research into the gender disparity. In the meantime, he comments: "The extreme hypothesis is that women's deaths are not considered as important to society as those of men. And that the traditional short form verdicts available to the coroner's inquests serve the needs of men more than women – in cases of industrial disease, for example."

More information: The article, Local variations in reporting deaths to the coroner in England and Wales: a postcode lottery?, by Maxwell Mclean, Jason Roach and Rachel Armitage has been published in the Online First edition of the Journal of Clinical Pathology.

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