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The BBC's Niall Dickson
"Post mortems are a matter of chance"
 real 28k

Tuesday, 24 October, 2000, 08:55 GMT
Post-mortem 'lottery' challenged
Coroners investigate unnatural deaths
Many coroners are failing to examine the deaths of patients who have died in hospital or individuals who have died at home, a BBC investigation has found.

There are huge variations in the proportion of unnatural deaths investigated by coroners across England and Wales.

In West Manchester and Lowestoft, 90% of deaths reported to the coroner result in a post mortem. However, just one in three are investigated in Boston and Spalding in Lincolnshire and the Wirral in Merseyside.

The variations have led to fears that some deaths which may have been caused by poorly-performing doctors or as a result of euthanasia are not being investigated properly.

It is in dire need of reform as quickly as possible

Ian Walker, personal injury lawyer

The BBC has learnt that it is a matter of chance whether a post mortem is carried out into unnatural deaths in different parts of England and Wales.

Dr Freddie Patel, a pathologist at Hammersmith and Fulham mortuary, said the variations did cause him concern.

"Now and again one assumes there is a natural cause of death but a post mortem examination may find that it may be a case of mercy killing, they may have been given an overdose of drugs or taken an overdose themselves."

Some of the variations are suspected to be because some coroners do not investigate deaths that occur in hospital.

But a spokesman for the charity Action for Victims of Medical Accidents expressed concern with the figures.

"There must be an enormous temptation on the part of a doctor that if something has gone wrong or even if it is suspected that something has gone wrong that they put it to the coroner in the best way possible so that the coroner doesn't take it forward," he said.

'Not worried'

Wirral coroner Christopher Johnson said he was not worried by that fact that his post mortem rates were among the lowest in the country.

"That doesn't worry me simply because doctors are consulted, families are consulted, and if the criteria for self-certification are fulfilled that is the way it should be."

He said he did not investigate all deaths in hospitals in his area because he had "a very good relationship" with his hospital.

"I believe hospitals and doctors are very open and frank with me," he said.

The Coroners' Society says the nature of the work means variations should be expected.

Its president David Sergeantson, said: "They are individuals trying to do an individual job without reference to anyone else.

"They must necessarily therefore at times arrive at different conclusions."

But Ian Walker, a leading personal injury lawyer, has called for reform of the system.

"It is in dire need of reform as quickly as possible. You have coroners throughout the length and breadth of the country acting completely independently with no real supervision from the centre."

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