The College thinks the Ministry of Justice has missed an opportunity to invest in and reform the Coroner Service by not accepting key recommendations from the Justice Committee. Bereaved families will continue to experience a service that is fragmented, disjointed and inconsistent in its standards and delivery. 

The Justice Committee’s thorough investigation made a range of practical recommendations to strengthen the coroners’ service and ensure an adequate supply of pathologists to undertake post mortem work, including: 

The Ministry of Justice should immediately review and increase Coroner Service fees for pathologists, so they are enough to ensure an adequate supply of pathology services to the Coroner Service. (Paragraph 135)

In the medium term the Ministry of Justice should work with the Department of Health and Social Care so that pathologists’ work for coroners is planned for within pathologists’ contracts with NHS trusts. (Paragraph 136)

In the longer term, the Ministry of Justice should broker an agreement between relevant government departments and the NHS (in England and Wales) for the establishment and co-funding of 12–15 regional pathology centres of excellence. (Paragraph 137)

The College also recommended the following three key actions in our evidence to the committee:

• Clear ministerial oversight of the coronial service.
• Stronger governance powers for the Chief Coroner over the service and senior and deputy coroners – consideration should be given as to whether the Chief Coroner should be given responsibility/accountability for the quality of coronial post-mortems examinations.
• The introduction of a National Coroners Service to provide a consistent high-quality service and equity of access across England and Wales.

We are disappointed that many of these recommendations have not been accepted by the Ministry of Justice. The Chair of the Death Investigations Committee at the Royal College of Pathologists, Dr David Bailey, has raised a number of points for consideration: 

1. The Coronial service is fragmented with great unevenness and varying levels of delivery of service to bereaved families. The Government’s response to the report provides no reassurance that these major flaws in the system will be addressed.

2. The refusal to publish the 2015 post-implementation review on the basis that it will be six years old is insufficient reason not to publish. The system suffers from the same problems today that it did in 2009 with very little change seen on the ground.

3. Where recommendations have been responded to as “requiring further work”, no timescale has been included. Some of these changes require urgent implementation and this failure to provide any indication of the likely time to action leaves the service in limbo.

4. The refusal to implement changes to the Coroner’s rules relating to duty of candour means that there continues to be no legally binding requirement that forces public bodies or other individuals or organisations to reveal evidence to bereaved families.

5. Most of the committee’s recommendations that would have assisted the pathology profession in supporting the coronial service have been denied. 

Specifically:

• Whilst the low fee payable for coronial post mortems (which has not changed in decades) is not the only reason pathologists are giving up post mortem work, it is the main one. Our members tell us that, for pathologists who give up post mortem work, 62% cite poor remuneration as a major reason.
• We are relieved to see that the Government has accepted the recommendation that it should be made easier to integrate post mortem work into NHS contracts.
• Forming a much smaller number of specialised centres of excellence for carrying out post mortem work follows established good practice and policy in a number of other countries (e.g. Australia) where the policy has been remarkably successful. Accepting this recommendation and giving urgent impetus to the change would have given the profession in the UK the chance to establish itself as a world leader in this field. Instead, the recommendation has been relegated to the category of “further consideration” by someone else.

Professor Michael Osborn, College President, said:

‘There is a significant shortage of pathologists to carry out coronial post-mortems. This deficit has several causes. Coronial post-mortems fall outside of consultants’ hospital trust contracts and are rarely included in consultants’ job plans. This means that pathologists have to schedule post-mortems outside of their NHS work.

The current remuneration structure for coronial post-mortem practice is unsustainable in terms of maintaining the necessary level of service when trying to balance NHS and coronial work. The standard fees paid for coronial post mortems are far too low to attract pathologists to do the work, do not reflect the complexity of the work involved and have not been raised in any significant way for over two decades.

The shortage of pathologists to carry out post-mortem examinations has a direct effect on services for the bereaved and their relatives. It is vital that post-mortem services, and the accurate investigation and certification of death, are seen as part of the wider patient safety landscape.’

6. The Government’s refusal to consider implementing a single unified Coroner’s service on the basis of cost and difficulty fails to address the points above. The result is that bereaved families have to struggle on with the current flawed system that is doomed to fail.

7. The College was disappointed that the government’s consultation on coronial investigation of stillbirths has stalled and we are therefore pleased that the government has confirmed that a response will be published as soon as possible.