Second report of the Departmental Committee appointed to inquire into the law relating to coroners and coroners' inquests, and into the practice in coroners' courts.

  • Great Britain. Committee on Coroners.
Date:
1909
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Licence: Public Domain Mark

Credit: Second report of the Departmental Committee appointed to inquire into the law relating to coroners and coroners' inquests, and into the practice in coroners' courts. Source: Wellcome Collection.

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    25 May 1909.] 6472. In other words, he was satisfied as to the actual cause of death, and he did not think it necessary to hold an inquest >—Yes. 6473. Then we may take it that the only cases of really uncertified deaths are those’ 891 cases ?—Those are the only cases in which no report or official inquiry lias been made. 6474-6. Strictly speaking, those are the only cases in which the deaths had not been certified P—You must distinguish “certified deaths” in the sense that inquiry has been made into them and “certified deaths,” meaning deaths certified by a registered medical practitioner, or by a coroner after inquest. 6477. Yes, but leaving on one side cases in which there is a medical certificate or a coroner's inquisition, there have been only 891 cases of absolutely uncertified deaths ?—That is so. 6478. Do you see any reason why all deaths for which there is no medical certificate should not be reported to the coroner and a similar inquiry made by him as he makes now in those cases in which he issues his pink or other certificate ?—In towns there would be little difficulty, but I think that in some of ;the wild districts of the country there would sometimes be a practical difficulty, in the mountainous districts of Wales, for example. 6479-82. Is it not a fact that in some towns as it is, all cases of uncertified deaths are reported to the coroner ?—In some towns there are so few uncerti- fied deaths that it is hardly safe to say. If there are only one or two in a year, they may be reported or they may not. ; 6483. The words “uncertified deaths”? would seem to convey to the public mind the fact that persons are buried without a doctor’s certificate and without some proper inquiry being made into them, would it not ?— I do not think “ uncertified death” is a very accurate phrase; it should be “uncertified causes of death” ; ’ but we are apt to clip our phrases. 6484. Do you not think that another description might be used which would clearly distinguish those cases which have passed through the coroner’s hands, from those which are from any cause uncertified deaths ? —That is done already. 6485.-But they are all included under the general description of uncertified deaths ?—They are all deaths of which the causes are uncertified. 6486. But in cases which have passed through the coroner’s hands the causes of death are ascertained P— Iam afraid not. The cause is not in all cases ascer- tained. It depends upon the coroner. Some coroners are particular to ascertain the cause, and put it on the pink or other certifivate; but other coroners consider their function to be only to decide whether any one is criminally responsible for the death, and they will say nothing more about the actual cause of death. 6487. But supposing you get a case of death from phthisis, and the coroner is satisfied that the death has so arisen, would you not be satisfied that the cause of death had been properly accounted for?—If the coroner put on his certificate that the cause of death was phthisis, we should classify the cause of death for statistical purposes as phthisis. 6488. But it would still be an uncertified death ? —Yes. - 6489. Might not a better description be given in your books in the future, so as to distinguish more clearly and unmistakably those cases where the coroner had, as it were, certified what he had ascertained fairly to be the cause of death, and those cases in which you get no certificate of death at all —It all depends upon what you mean by “your books.” In the register itself nothing can appear except the cause of death, without anything to show on whose authority it appears. 6490. Let me put it in another way. Do you see any objection to a form being issued to coroners with a column in it for indicating whether he has been able to ascertain what the cause of death appears to be? —None whatever. In those cases that are reported by the registrar to the coroner there is a space on the form which the registrar sends to the coroner—not the pink form but the other form for what it stated to [ Continued. be the cause of death. The registrar reports to the coroner that the cause of death is stated to be so-and- so; the coroner inquires into it. 6491. And is probably satisfied in those cases that the cause of death indicated in the registrar’s report is the cause of death ?—He probably is. And he has an opportunity, if he thinks it was not the cause of death, of saying so. 6492. If he thought it was not the cause of death, he would hold an inquest >—Yes, but he might think it was not the cause of death, and yet not hold an inquest. 6493. Have you come across many cases in which he does not P—I cannot say that I have. I only say that it is quite possible. The cause of death might be stated to be bronchial pneumonia, and the coroner when he comes to inquire into it may be of opinion that the bronchial pneumonia resulted from measles or whooping cough. 6494. But the one might follow the other ?—Yes. 6495. Then he would put bronchial pneumonia— following measles P—Yes. 6496. So that bronchial pneumonia would still be the correct cause of death P—No; measles would be the correct cause of death. As we classify deaths, bronchial pneumonia would be the secondary cause and measles the primary cause in that case. 6497. All this, of course, is technical ?—Yes. 6498. What I want to get at is this: that really and truly there are very few cases of deaths of persons for which you do not get either a medical certificate or some satisfactory inquiry made by the coroner ?— Of course one is assuming a good deal in saying a satisfactory inquiry by the coroner. 6499. Well—some inquiry at any rateP—I know that the inquiries by some coroners are personal and satisfactory ones; but one does hear that in some cases the inquiries are only made by policemen (I do not know what amount of truth there is in it), and the coroner does nothing more than sign his name to the opinion of the policeman. 6500. Then, if the coroner had power to order a post-mortem examination without holding an inquest, much of that difficulty might be got over?—Yes; in that case, of course, the coroner would get an expert opinion as to the cause of death. 6501. And a medical certificate P—No doubt. 6502. But going back again to your pink certificate, in which there does not appear to be a column as to the cause of death, might not that pink certificate be altered so that the coroner might have an opportunity of filling in the probable cause of death ?—I quite agree ; I think it would be an improvement. I am not sure that all coroners would use it; there are a few coroners who might object. 6503. But it would give them an opportunity P— Yes ; the certificate would be improved by inviting the coroner to give that information. 6504. In the country, in mountainous districts and so on, under what circumstances are bodies buried when there is no doctor’s certificate or when the coroner does not hold an inquest —If they are. buried in a churchyard in the ordinary way, the minister who notify the burial to the registrar within seven days. 6505. How do you get the certificate of death in those cases P—AIl you can do is to take whatever state- ment the informant makes. 6506. That is not satisfactory P—No; those are the ordinary uncertified cases. Of course they are not satisfactory. The informant possibly gets the informa- tion in some cases from an unregistered man, more or less skilful, and in some cases of young children from midwives; in other cases the deceased person has been attended at some time by a medical man, for chronic heart disease or bronchitis, and the medical man informally states that as the probable cause of death. I may state that, of those 891 cases not reported to the coroner, 507 were infants under one month old and 157 were persons of 65 years and upwards. There are 664 cases out of the 891 in which the cause of death was probably fairly well known, either atrophy or debility, or premature birth or convulsions. That, however, is not satisfactory.