Report of a Fundamental Review 2003 - Review of Coroner Services: No. 5831 (Command Paper) - Softcover

The systems for certification of most deaths by doctors and the investigation of others by coroners have been seriously neglected over many decades. Both have come under increased scrutiny because of important failings, identified by the murders of patients by Dr Harold Shipman and cases calling into question the operation of coroners' inquests - the Allitt case, the Bowbelle/Marchioness disaster, the Bristol inquiry into child deaths after paediatric surgery, and Alder Hey Hospital's retention of organs from dead children. This review makes recommendations in six areas of major change: the coroner service should become a service of predominantly full-time legally qualified professionals appointed, trained and supported to modern judicial and public service standards; consistency of service to families, backed by a Family Service Charter; the service should deal effectively with legal/health issues across a full range of public health and safety, and support and audit the death certification process; a "two-tier" certification system to apply to all deaths equally whether the body is buried or cremated; more informative and accessible outcomes to coroners' death investigations; and proper recognition of the work of coroners' officers. The services also need statements of fundamental objectives and their service values.