The coroner's system in England and Wales should be radically reformed with non-suspicious deaths investigated, the judge heading the Shipman Inquiry has suggested.
Dame Janet called for coroners to be trained
In the inquiry's third report into the circumstances surrounding the UK's worst serial killer, Dr Harold Shipman, Dame Janet Smith said a "complete break with the past" was needed so the coronial system could detect cases of homicide, medical error and neglect.
The latest report focussed on death certification and the investigation of deaths by coroners.
The report said that Shipman, through the issuing of death certificates stating natural causes, was able to evade the coronial system altogether.
"A way must be found to ensure that all deaths receive a degree of scrutiny and investigation appropriate to their facts and circumstances," said Dame Janet.
"The coroner or member of the coroner's staff takes what the doctor says completely on trust.
"In general, no attempt will be made to verify the accuracy of the information given by the doctor from any other source."
She recommended that information provided by the person reporting the death should be cross-checked with a member of the deceased's family or some other person with recent knowledge of the deceased.
If appropriate, other inquiries should then be made.
Dame Janet said new role needed to be made to investigate non-suspicious deaths and said this should be a specifically trained person.
The new role would be part of a complete overhaul of the system.
Shipman killed at least 215 of his patients in Hyde and Todmorden
"The coronial system should be retained, but in a form entirely different from at present," she said.
"There must be radical reform and a complete break from the past, as to organisation, philosophy, sense of purpose and mode of operation."
Dame Janet concluded there was "virtually no training for coroners".
Many, especially part-time coroners, operate in isolation and have little contact with colleagues, which creates a "considerable variability of practice and standards in different coroner's districts".
"There is, in my view, an urgent need for a more focused, professional and consistent approach to coroners' investigations; this is needed from the time that the death is reported, right up to the verdict at inquest," she said.
Coroners should bear in mind that a non-suspicious death could be caused not just by natural causes, but by homicide, neglect, accident or medical error, she added.
"Otherwise the expectation that the death will be 'natural' may become a self-fulfilling prophecy."
The British Medical Association's medical ethics committee chairman, Dr Michael Wilks, an expert on death certification, welcomed Dame Janet's recommendations.
"One of the glaring problems that was shown up by Shipman's activities was that a doctor can write a certificate, it can be accepted by those actually issuing the registration of death and there is very little questioning as to the doctor's veracity," he said.
"Having a medical coroner with powers to investigate deaths would be welcome as long as they had the resources and expertise."