For those short on time, here are my top six points to note from the Chief Coroner's Annual Report (published in December 2018):

  1. The Chief Coroner recommends that new Regulations are created, to introduce a new legal duty on doctors to report specific deaths to the Coroner, as already exists in New Zealand and Australia. Our current system relies on professional guidance, rather than black letter law.
  2. Despite falling numbers of pathologists and previous recommendations from the Chief Coroner, no Government department wants to take responsibility for the system to provide post mortem examinations across the country.
  3. Medical Examiners. The Chief Coroner says that the current plan for April 2019 (which will only review only deaths which occur in hospitals), won't address the concerns raised in the Shipman Report. He also raises questions about perceived independence, if Medical Examiners are employed, or used to be employed, by the hospital.
  4. The Chief Coroner suggests an amendment to the 2009 Act, so that some inquests can be completed without the need for a hearing at all (by just handing down or publishing the ruling or Record of Inquest.
  5. The Chief Coroner suggests a change to the law, so that the High Court can amend a Record of Inquest (not just quash the Coroner's decision and order a fresh inquest).
  6. The Chief Coroner's previous recommendations in relation to legal representation for families (when the State is represented) still awaits the outcome of the Lord Chancellor's Legal Aid for inquests review.

You can read the Chief Coroner's Annual Report in full here

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