Coroner consistency – The 10-jurisdiction,10-year,postcode lottery?

Abstract

The investigation and classification of deaths in England and Wales relies upon the application by medical practitioners of diverse reporting standards set locally by coroners and thereafter upon the effectively unconstrained decision process of those same coroners. The author has conducted extensive comparative analysis of Ministry of Justice data on reports to the coroner and their inquest and verdict returns alongside Office of National Statistics data pertaining to the numbers of registered deaths in equivalent local jurisdictions. Here, he analyses 10 jurisdictions characterised by almost identical inquest return numbers in 2011. Substantial variation was found in reporting rates to the coroner and in the profile of inquest verdicts. The range of deaths reported varied from 34% to 62% of all registered deaths. Likewise only 2 of the 10 jurisdictions shared the same ranking of proportions in which the six common verdicts were reached. Individual jurisdictions tended to be consistent over time in their use of verdicts. In all cases, proportionately more male deaths were reported to the coroner. Coroners generally seemed prima facie to be ‘gendered’ in their approach to verdicts; that is, they were consistently more likely to favour a particular verdict when dealing with a death, according to the sex of the deceased. The extent to which coroners seemed gendered varied widely. While similar services such as the criminal courts or the Crown Prosecution Service are subject to extensive national guidance in an attempt to constrain idiosyncratic decision making, there seems no reason why this should apply less to the process of death investigation and classification. Further analysis of coroners’ local practices and their determinants seems necessary.