Clinical governance and the coroner

In the face of public expectation of uniformly high standards of medical practice and of open accountability, we suggest that the public interest would be served by a system of transparent, informed and independent scrutiny of those deaths that follow medical treatment, either in hospital or in the community. We do not believe that such a system operates at present in England and Wales or, indeed, that best practice may be achieved within current financial or legislative constraints. However, we suggest that the existing law allows greater involvement of the coroner in the investigation of deaths following medical treatment, should there be the professional desire for self-scrutiny and the political will to release resources to support that desire.