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Comparative Coroner Programmes in Jurisdictions Across the World

United Kingdom Reforms Coroner System, Moves Towards Unified Death Investigation and Certification System

In March 2004, the Home Office published a position paper reforming the coroners' and death certification systems for England, Wales and Northern Ireland, following a fundamental review of the coroners' and death certification system it announced in 2001. The position paper retained the coroner system as of necessity, but with significant reforms, and indicated intent to overhaul the death certification system.

Some of the reforms adopted in the position paper include; rebasing the system on predominantly full time coroners, all legally qualified. (Hitherto, it was sufficient to have medical or legal qualification and seven years of professional experience to be appointed as a coroner. The position paper endorses the appointment of 40-60 full time coroners, as opposed to 127 or so coroners (mostly part-time) currently serving, all legally qualified, supported by part-time deputies); the appointment of an in-house medical examiner for each coroner's district to support the coroner and audit and support death certification by doctors; Limiting the use of juries; Appointment of a statutory Coronial Council to oversee the working of death certification and coroner services. The reforms will also see to the introduction of Coroners' Rules Committee and new more flexible procedures for inquests.

The position paper proposes the creation of an Advisory Coronial Council to harness relevant experience and expertise; requires fuller conclusions from inquests, with a stronger bias towards narrative and preventive findings; proposes a two-tier death certification process involving an independent certifier in every case.

The position paper supports verification of the facts of all deaths, certification of the cause of death by a doctor, scrutiny of all such certificates by a medical examiner in the coroner's office, and a referral to the coroner of all deaths that cannot be certified or which are unnatural.

These reforms will await the passage of an enabling legislation before they can be implemented. While not certain when this will take place, the position paper has stated that a White Paper and Bill would be prepared within 2004. The Coroner's Society of England has hailed the proposed reforms as truly radical and practical, applauding the aim to provide a unified, coherent system of death registration and investigation as providing the seamless and accessible process they had hoped.

In the U.S.A and Canada, Coroners Make Vital Contribution to Public Safety and Public Health Functions
The process of inquiring into deaths in the US and Canada is commonly called a death examination, which may be carried out by medical examiners, as coroners are called in some states or provinces in the US and Canada respectively, or by coroners. Coroners or medical examiners in both jurisdictions play pivotal roles in “the functioning of the judicial, public safety, and public health agencies of government.” Because they are responsible for providing accurate, legally defensible determinations of the manner and cause of these deaths, they provide vital collaboration with their respective Centers for Disease Control and Prevention (CDC) in the study of deaths arising from homicide, suicide, poisoning and drug abuse, motor vehicle collisions, and occupational and unintentional injuries. Other federal government agencies also collaborate with medical examiners and coroners in efforts to study various types of deaths that medical examiners and coroners investigate. Such collaboration facilitates the collection and sharing of information that assist in planning public health policy.
Coroner systems in the US and Canada both share a common law origin, but several reforms have introduced changes to the common-law models as several states and provinces in both countries have opted to introduce a medical examiner system while others have undertaken other far-reaching reforms. Both countries however regard the coroner institution as very relevant to their societies and have attached even more responsibilities to the coroner's office.

Until 1986, the Coroner's main function, in Canada, was crime detection. Today, the coroner's role has been expanded, with the coroner exercising greater responsibility in preventing deaths while leaving to the police the role of detecting crimes. Before this time, in Quebec, the coroner institution had come under criticism as obsolete, leading to a thorough study of the institution and a redefinition of the coroner's role. The study concluded that the Coroner's office in Quebec had to be given a new focus, namely; the prevention of situations likely to jeopardize human lives; efficient, complete detection of the causes and circumstances of death; and the distribution of clear, accurate information on deaths to those who require it, as well as to various officials involved in enforcing the law or having power to make changes that can save lives.

An Act Respecting the Determination of the Causes and Circumstances of Death was thereafter enacted in 1986, which adopted the outcome and recommendations of the study. The Act retained the office of the Coroner, but there were major reforms in roles, jurisdiction, function, organization and means of investigation of the Coroner. The Coroner's new defined role focused on two goals: preventing avoidable deaths by compiling, publishing and providing access to complete information on the causes and circumstances surrounding any violent or mysterious death in Quebec; facilitating the recognition of and exercise of rights and recourse following violent or mysterious death by preserving the evidence explaining the causes and circumstances of a death and making it available to those who require it.

Coroners in Quebec are guided in their duties by the Quebec Charter of Human Rights and Freedom, the above mentioned Act and a Coroner's Code of Ethics. The law also guarantees their independence by creating a Chief Coroner, who manages the institution and controls the resources. The principle of public disclosure enshrined in the statutory obligation on the coroner to publish findings fulfils a vital function. It sidetracks the rule of confidentiality associated with information obtained by government officials. It preserves, on the one hand, the public's interest in knowing the causes and circumstances surrounding violent or mysterious deaths of members of the community, and on the other, ensures that those responsible for correcting situations that endanger human lives take action.

In Georgia, Eastern Europe, Coroner's Role Undergo Important Changes
Georgian law defines as inquest as “an official judicial inquiry before a coroner and a coroner's jury for the purpose of determining the cause and manner of death.” Coroners have authority to hold an inquest on any case, but the law mandates one “When an inmate of a state hospital, or a state, county or city penal institution dies suddenly without an attending physician or as a result of violence” and “When ordered by a court.”

There have been tremendous changes in the duties and responsibilities of Georgian Coroners in the last two decades. By law, coroners perform investigative, judicial and administrative duties. The coronial process is regulated by Title 45 Chapter 16 of the Georgia Code, Annotated. In their capacity as investigative authorities, coroners investigate deaths that would be investigable in other Coroner jurisdictions, except that a peculiar situation is included: where death results after birth, but before seven years of age, if the death is unexpected or unexplained. This may possibly include inquiries to establish whether the child died of parental abuse, molestation or some form of neglect.

The basis of an investigative inquiry is to determine the cause and manner of the death. Investigative inquiries in Georgia help in resolving insurance liabilities and family and public health issues. It could also lead to legal consequences. Generally, the Coroner sits as a judicial officer whenever he presides over an inquest.

Coroners also sit on the Child Abuse Protocol Committee to review cases. They also sit on the Child Fatality Review subcommittee and review all child deaths regardless of cause to determine if the death meets the criteria for review by the committee or further investigations by the appropriate investigative agency. They are also responsible for proper documentation of deaths and their dissemination to the appropriate government agency.

The European Court Of Human Rights says Coroners Inquest is vital if Custody Deaths Occur

KEENAN v. THE UNITED KINGDOM (Application no. 27229/95)

FACTS: The applicant alleged that her son, Mark Keenan, had died from suicide in prison due to a failure by the prison authorities to protect his life, that he had suffered inhuman and degrading treatment due to the conditions of detention imposed on him and that she had no effective remedy in respect of her complaints. She relied on Articles 2, 3 and 13 of the Convention. The deceased was serving a sentence for assault on his ex- girlfriend. Mark Keenan was discovered by the two prison officers hanging from the bars of his cell by a ligature fashioned out of a bed sheet. On 25 August 1993, at the inquest before a coroner, the jury recorded a verdict of death by misadventure and that the cause of death was asphyxiation by hanging.

HELD: "Following the death of a prisoner and regardless of the cause, an inquest must be held pursuant to section 8(1)c of the Coroners Act 1988. Such inquests must be held with a jury (section 8(3)a). The coroner is the independent judicial officer charged with inquiring into deaths of various categories. His duties have been judicially defined;It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully, fairly and fearlessly investigated. He is bound to recognise the acute public concern rightly aroused where deaths occur in custody. He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity"