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.

    46/232 (page 16)
    8 June 1909.] Mr, “A.. ©. WATERS. [ Continued. ‘instructions to his own officials not to accept? “ (A.) Yes, that would meet the point. (Chairman.) “ T take it that any representation from you or any “ other authority on the subject would receive con- “ sideration? (A.) Very probably; but I think that a “ yule for the guidance of the registrar might be ‘‘ advisable. As medical referee such cases come before * me, I have had two recently which were both rather “ flagrant. (Q.) What was the cause of death? (A.) It * was alcoholism, no doubt. (Q.) But what was the “ cause of death certified? (A.) I think pneumonia. I “ have not got the certificate before me. (Mr. Bramsdon.) “ Do I rightly gather that in those cases that you have “ reported to the coroner, you have had a certificate “ from the registrar? (A.) Yes. The certificate of “ registry of death. (Q.) Then they have gone through “ the registrar’s hands before they get to you? (A.) Yes, “ death. (Q.) Notwithstanding that, you have still * reported 11 cases to the coroner? (A.) Yes; but I * did not report all these on account of alcoholic “ habits; the reasons for reporting were various. * (Q.) And in seven there has been an inquest ? *“ (A.) Yes. (Q.) Which would look, upon the face of “ it, as though the information that you obtained “ through the registrar had not been quite sufficient ? “ (A.) It is very unsatisfactory. (Q.) When were those * cases; have they been recent ?—(A.) Since the year “ 1903—five and a half years ago. (Q.) I do not know * whether you know that some more stringent regula- ** tions have been issued by the Registrar-General to * his officials within recent years. Would it be before “ or after that? (A.) I do not know when they were * issued. I have had one case within the last six *“ months December 1908. (Chatrman.) But your ** present point is important as bearing on the law of * death certification rather than on the law of coroners. “ (A.) I think it bears on both.” Have you anything to say upon that evidence ?—With regard to each of those cases, I should like to know in the first place how the cause of death was certified. One I note was certified as pneumonia. The registrar has not an oppor- tunity of examining the body, and in fact generally he he would not be skilled enough to find out anything by examining it; but if the cause of death is described as pneumonia in the medical man’s certificate, the registrar would have no reason for reporting that to the coroner. He is instructed that if any suspicious circumstances connected with the death come to his knowledge, he should report it; but every suspicious circumstance does not necessarily come to his knowledge. 6596. What are the more stringent regulations referred to ?—Registrars are instructed now to report to the coroner all cases of alcoholic poisoning. 6597. Does that work satisfactorily ?—I think so. The returns that come to our office are thoroughly examined, and in every case of alcoholic poisoning, where there is no evidence of its having been reported to the coroner, we write to the registrar to know whether he did report it, and if a registrar neglected to report a case of alcoholic poisoning he would be censured and told to do better in future. 6598. Then what is referred to here ought not to happen at the present time, that is to say, the cause of death certified as pneumonia, or some cause of that sort, the real cause being alcoholic poisoning P—Of course that ought not to happen, but the responsibility there is not with the registrar, but with the certifying medical practitioner. If the registrar were to go behind all medical certificates and make a kind of semi-judicial inquiry himself, there would be very great difficulty indeed, and it would embroil him with the medical profession. 6599. (Dr. Willcow.) You are entirely dependent on the medical man ? — Almost entirely. Occasionally something is said in the regigtrar’s office that leads him to report the case to the coroner. For example, in one case a man was described as having died of bronchitis, but something was said at the registrar’s office as to his having fallen into the fire. The registrar reported that to the coroner promptly, and the coroner decided not to hold an inquest, He took it that the fall into the fire had not accelerated death. My point is that it was not mentioned on the certificate, but that it accidentally came to the knowledge of the registrar by something that was said in his office; and that happens in a few such cases, but of course not in all. 6600. Chronic alcoholic poisoning would give rise to Bright’s disease or liver disease ?—Yes. 6601. Then the medical man would probably fill in the cause of death as Bright’s disease or kidney disease >—Some medical men would, and the registrar, of course, would have no power of going behind the certificate. 6602. (Chatirman.) In this particular case of Dr. Herring’s evidence, all the certificates are criticised by a competent authority who, as you say, has had an opportunity of examining the body; so that that dis- tinguishes the cremation cases from the ordinary cases ? —If I remember the Cremation Regulations correctly, two medical men have to certify the cause of death, and I think they actually see the body. I think, according to the Regulations, they must do so. 6603. (Dr. Willcox.) One of the main difficulties of Dr. Herring was that when the body of a person who has died abroad comes from abroad to this country, the cremation officer can generally get the two medical certificates as to the cause of death from abroad, but he is unable to get the certificate of registry of the death; and owing to that difficulty it is practically impossible to cremate bodies of persons who have died abroad and been brought over to this country. Have you any suggestion to make as regards that ?—I should think the Cremation Regulations might be amended. The registrar cannot register a death unless it occurs in his sub-district or unless an inquest is held in his sub- district by a coroner. If the death has occured abroad and the coroner holds an inquest in England, the death is there registered on the coroner’s certificate, because an inquest has been held. Otherwise, there is no registrar who can register the death; a registrar can only register deaths that occur in his sub-district. 6604. Do you think it would be practicable if the coroner were allowed to fill up a form entitling the body to be cremated in such a case, after making enquiry but without holding an inquest?—It is outside my direct province, but I can see no objection whatever to that. 6605. Do you consider that the coroner is the proper person to make such inquiry, owing to his experience in such matters and his judgment ?—I should think the coroner is the best person to do so. As things are at present he is the only official person who can do it. 6606. Do you think it would be desirable if the coroner were allowed to issue a form which would permit a body to be cremated ?—I see no reason why the coroner, after examining whatever papers are brought from abroad as to the cause of death, if he decides not to hold an inquest, should not give some certificate which would be accepted for cremation. 6607. And if he was not satisfied on the evidence before him, the coroner could hold an inquest with a jury, an ordinary inquest ?—Yes, that of course he can always do. Occasionally a coroner does hold an inquest on a body brought from abroad. 6608. In such a case could the body be cremated ? —A body can be cremated after an inquest. The registrar does not give a certificate of registry after an inquest. A certificate of registry is the authority for burial; but if the coroner holds an inquest the coroner gives an order for burial and there is no need for authority from the registrar. 6609. (Mr. Bramsdon.) Referring back to one small point, as to the signature by rubber stamp, you recognise that it is quite possible to conceive that some coroners or deputy coroners may be physically incapable of signing a certificate >—Yes. 6610. In which case it may be absolutely necessary for some substitution to be arranged P—Then I think somebody’s writing should be there, and that that person’s initials should appear,