A review of the coroner system in England and Wales: a commentary

The certification of deaths and their investigation is flawed and has not been subject to comprehensive revision for many decades; the current system is fragmented. Despite its historical 'stability', it is poorly understood by many who have to use it and the lack of supervisory structures within the system means that there is no leadership, accountability or quality assurance. No formal linkage to or communication with other public health services and systems exists, minimising its epidemiological value. There is a lack of clear participation rights in these processes for bereaved families. The standards for the treatment and support of the bereaved are woefully inadequate and have contributed in a major way to certain causes celebres. A report in 2003 suggested that death investigation should be a service that is consistent and professional, able to deal effectively with legal and health issues, work across the full range of concerns about public health and public safety and support, and audit the death certification process. The role of those supporting the current system must be properly established in a framework of accountability.