Coroners reform to prevent 'new Shipman'

The coroner in the case of the Marchioness boat disaster was criticised

Measures to offer patients greater protection following the case of serial killer doctor Harold Shipman have been announced by the government.

The Independent Review of Coroner Services called for closer monitoring of the death certificates issued by doctors, to prevent any exploitation.

The review, which took two years to complete and covered England, Wales and Northern Ireland, was set up following numerous complaints from families about the current coroners system.

It also concluded that there should be fewer post-mortem examinations and that more inquests should be carried out in private.

'Huge hole'

The inquiry looked at complaints from the relatives of the victims of Shipman, who was found by judicial inquiry to have killed 215 patients over 23 years.

Shipman signed the death certificates of his victims

According to the report, Shipman was able to avoid detection due to the lack of policing of the death certification process.

Tom Luce, who led the review team, said: "We are suggesting that there is a huge hole in the arrangements around the death certification process.

"No public authority is responsible for ensuring that doctors do it as they should, and in particular no public authority is responsible for helping them do it."

At present, when a body is to be cremated, the second doctor to sign the death certificate can be a colleague of the doctor who treated the patient.

Independent

Mr Luce said the Shipman inquiry was told that it was by duping a colleague that the Greater Manchester GP was able to hide some of his crimes

He said the second doctor should be independent and accredited by a statutory medical assessor, with a position of advisor to the local coroner to be established.

The coroner's officer and the new medical assessor would have responsibility for looking at the certification of patients of each doctor, practice and hospital, to see whether there was anything strange.

'Transparent approach'

Other cases to have raised concerns included that of nurse Beverley Allitt, who was convicted of murdering four children in her care, and the handling of the Marchioness disaster.

We are concerned at the suggestion that there are going to be less jury inquests. Deborah Coles of Inquest

Fifty-one people died on board the Marchioness in August, 1989, and the coroner was criticised for ordering the removal of the hands of 21 of the victims to help identification.

Among the 122 recommendations in the report is a call for fewer inquests to be held, and a "more consistent and transparent approach".

Other proposals include a family charter with rights for the bereaved to request a review of certain decisions made by the coroner.

It also called for "more consultation and involvement of families" in relation to post mortems, which should only be held in specific circumstances.

A national jurisdiction, making most coroners full-time and reducing the number of coroners' districts, should be loosely based on police authorities, the report says.

'Proper scrutiny'

The Coroners' Society gave a cautious welcome to the proposals, particularly the discretion to avoid public inquests "if neither the family of the deceased nor their community need it".

But it said plans for better family access to, and input of, information would only work if additional staff and resources were provided.

It also raised concerns about plans to allow bereaved relatives to meet individual coroners, suggesting that many would not have enough time.

The Society's secretary, Victor Round, said that without serious commitment to finding proper resources and implementing reforms, the changes will "simply not happen".

Deborah Coles, co-director of pressure group Inquest, said: "We are concerned at the suggestion that there are going to be less jury inquests.

"What we want to ensure is that there is thorough and proper scrutiny of any cases that raise public interest questions."