What is it about?

Ten coroner areas in England, with almost identical inquest numbers in 2011, were examined for patterns in their rates of reporting deaths to the coroner, rates of advancing reported deaths to inquest and comparative use of verdict types. Despite very similar caseloads, substantial area variation was found in reporting rates and in the rate of advancing reported deaths to inquest, consistently applied. Likewise, only two of the ten areas shared the same ranking of proportions in which the six common verdicts were reached. A similar caseload is no guarantee of a similar approach to reporting a death, advancing to inquest and choice of verdict.

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Why is it important?

There are local differences in coroner investigation with no obvious evidential underpinning. Unless and until the variation can be attributed to either case-relevant factors not captured in the statistics or non case-relevant factors not routinely captured, the official process and outcomes consequent upon a death are vulnerable to the criticism that they represent a 'postcode lottery'.

Perspectives

Interestingly, the ten coroners were found to agree on one thing; the sex of the deceased makes a difference to eventual outcome. Deaths of men were more likely to be reported than women (47%/37%), more likely to advance to inquest (16%/9%), and more men were thought at inquest to have died unnaturally (6%/2%). One case relevant factor not captured in the routine analysis of the three stage process described in this paper (reporting, advancing to inquest and choice of verdict) is the age of the deceased and this is thought likely by the author to co-vary with the sex of the deceased i.e. women on average die older.

Mr Maxwell Mclean
University of Huddersfield

Read the Original

This page is a summary of: Coroner consistency – The 10-jurisdiction, 10-year, postcode lottery?, Medicine Science and the Law, March 2014, SAGE Publications,
DOI: 10.1177/0025802414526711.
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