New research shows huge disparities between the decisions made by coroners

April 7, 2014, University of Huddersfield
Credit: University of Huddersfield

Government plans to overhaul the centuries-old coroner system in England and Wales have been bolstered by the findings of a leading police officer who has become a PhD researcher at the University of Huddersfield. Detailed analysis by ex-Detective Chief Superintendent Max Mclean has shown that there are huge disparities between the decisions made by coroners in differing districts, with the troubling discovery that the deaths of women are considerably less likely to be investigated at an inquest.

The result is a "postcode lottery", claims Mr Mclean, who calls for a fully-fledged National Coroners' Service, overseeing a reduced number of districts, headed by fully-professional coroners. This means that he backs an announcement made by the Justice Minister that the coroner system will be reformed, with new national standards drawn up, but feels the reforms could go further. His statistical analysis – now the subject of two academic articles - will reinforce this process.

Mr Mclean – an ex-Head of West Yorkshire CID – acknowledges that there is a tension between retaining the independence of those who administer justice and the need for greater consistency between districts.

"But from my research is reasonable to infer that a bereaved family would receive a different outcome in two different coroner areas, where their loved had had died of identical facts presented to each coroner," he said.

Coroner consistency – The 10-jurisdiction, 10-year, postcode lottery?

Mr Mclean has published a new article in Medicine, Science and the Law, which is the official journal of the British Academy for Forensics Sciences. Entitled "Coroner consistency – The 10-jurisdiction, 10-year, postcode lottery?", it builds on findings reported in an earlier article - in the Journal of Clinical Pathology - based on data collected from the Ministry of Justice that detailed all inquest verdicts for the past 15 years and all deaths reported to coroners over a ten-year period.

This earlier research showed massive disparities between the 144 jurisdictions in England and Wales. The rate of deaths reported to coroners by medical practitioners ranged from 12 per cent to 87 per cent. Mr Mclean attributes this to the varied attitudes and working practices of coroners plus traditions entrenched in different jurisdictions.

Now Mr Mclean, for his latest article, has refined his research by concentrating on ten coroners' districts in England, all which have near identical caseloads and numbers of inquests. The districts vary demographically – ranging from Norfolk to South London - but Mr Mclean, having considered population and deprivation figures, does not believe that this is a factor in his findings.

He discovered that between the ten districts, over the course of ten years, there were substantial variations in reporting rates to the coroner. The proportion of deaths reported varied from 34% to 62% . Also, when cases did proceed to inquest, there was considerable variations between the districts in the range of verdicts – such as accidental death, death from natural causes, suicide or narrative verdict.

"The chief cause may be the different viewpoints of coroners, leading to different outcomes" said Mr Mclean. "Coroners will choose different verdicts according to local practice, so in some areas what might be deemed an accidental death might be death from natural causes elsewhere. A near identical caseload is no guarantee of similar decision making."

Personal viewpoint of coroners

Mr Mclean also found evidence that coroners would, to varying extents, record narrative verdicts as a substitute for suicide verdicts, leading to a confused national picture of suicide.

The only area of consistency discovered by Mr Mclean was that in all of the ten jurisdictions, male deaths were more likely to be reported to the coroner – 48 per cent as opposed to 37 of female deaths. Also, more reported male deaths proceeded to inquest – 16 per cent as opposed to nine percent - and more men were deemed to have died unnaturally (six per cent male, two per cent female).

More research is needed to explain this disparity, says Mr Mclean. A possible factor is that national statistics do not include an analysis of age in relation to death.

"Women do, on average, die older than men. However coroners are at least vulnerable to the suggestion that the deaths of women are not perhaps investigated as thoroughly as those of men. This may be because of the ancient nature of the coroner's jurisdiction and the way in which investigative techniques have developed in the coronial system.

" There is also some evidence that coroners individually favour particular verdicts according to whatever sex the deceased person is," added Mr Mclean.

His new article argues that services such as the criminal courts or the Crown Prosecution Service are subject to extensive national guidance in order to constrain idiosyncratic decision making, so there is no reason why this should not apply to the process of death investigation and classification.

This leads Mr Mclean to support moves towards a reformed coroner system, building upon that announced in 2013 by Justice Minister Helen Grant, with a goal to place the needs of bereaved families at the heart of the system.

Explore further: Nationwide disparities of deaths reported to coroners

Related Stories

Nationwide disparities of deaths reported to coroners

November 1, 2013
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 ...

Female deaths much less likely to be reported to coroner in England and Wales

July 29, 2013
Doctors in England and Wales are much less likely to report a woman's death to a coroner than they are a man's, reveals research published online in the Journal of Clinical Pathology.

Concern over accuracy of suicide rates in England and Wales

October 7, 2011
The increasing use of "narrative verdicts" by coroners in England and Wales may be leading to greater underestimation of suicide rates, warn experts in the British Medical Journal today, based on ongoing research part funded ...

Inquests more likely for younger people and deaths from medical care complications

January 30, 2012
Coroners are more likely to hold inquests for deaths involving younger people or people who died of fatal complications from medical care, according to a study published in CMAJ (Canadian Medical Association Journal).

Changes in coroners' practice may be compromising quality of suicide statistics

November 1, 2013
Assessment of official suicide statistics found that between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost seven per cent, largely because ...

Recommended for you

Women run faster after taking newly developed supplement, study finds

January 19, 2018
A new study found that women who took a specially prepared blend of minerals and nutrients for a month saw their 3-mile run times drop by almost a minute.

Americans are getting more sleep

January 19, 2018
Although more than one in three Americans still don't get enough sleep, a new analysis shows first signs of success in the fight for more shut eye. According to data from 181,335 respondents aged 15 and older who participated ...

Wine is good for you—to a point

January 18, 2018
The Mediterranean diet has become synonymous with healthy eating, but there's one thing in it that stands out: It's cool to drink wine.

Sleep better, lose weight?

January 17, 2018
(HealthDay)—Sleeplessness could cost you when it's time to stand on your bathroom scale, a new British study suggests.

Who uses phone apps to track sleep habits? Mostly the healthy and wealthy in US

January 16, 2018
The profile of most Americans who use popular mobile phone apps that track sleep habits is that they are relatively affluent, claim to eat well, and say they are in good health, even if some of them tend to smoke.

Improvements in mortality rates are slowed by rise in obesity in the United States

January 15, 2018
With countless medical advances and efforts to curb smoking, one might expect that life expectancy in the United States would improve. Yet according to recent studies, there's been a reduction in the rate of improvement in ...

1 comment

Adjust slider to filter visible comments by rank

Display comments: newest first

Dichotomy
not rated yet Apr 07, 2014
I have to wonder whether similar findings would be discovered in other countries.

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.