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Contradictory coroners? Decision-making in death investigations
Journal of Clinical Pathology
|April 12, 2017
Summary
Coroner decision-making varies significantly, with identical cases yielding different conclusions due to personal attitudes. National consensus is needed for consistent inquest outcomes.
Area of Science:
- Forensic Medicine
- Legal Medicine
- Public Health Policy
Background:
- Coroner data reveals disparities in death investigations and conclusions across England and Wales.
- Variations exist in how coroners approach reported deaths and record findings.
Purpose of the Study:
- To investigate the decision-making processes of coroners.
- To determine if identical case information leads to consistent conclusions.
Main Methods:
- Senior coroners received three clinical scenarios via a web-based 'Decision Board'.
- Participants provided inquest conclusions and comments, with information access logged by software.
Main Results:
- Thirty-five coroners responded, showing little consensus on conclusions across scenarios.
- Despite diverse outcomes, decision-making processes were similar, influenced by personal attitudes.
Conclusions:
- Coroners reached widely different conclusions from identical case information.
- Disparities in outcomes stem from differing personal attitudes among coroners.
- Urgent need for national coroner consensus on evidence interpretation.
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