The UK’s most prolific murderer, Harold Shipman, would have been 70 this year had he not killed himself 16 years ago in Wakefield Prison. He managed to kill at least 250 women without alerting suspicion. The whistle was blown by a relative of one of the victims. So why wasn’t the case picked up by a coroner and how many more unnatural deaths are officially missed?

What do coroners do?

A coroner is an an independent judicial officer, appointed and paid for by the relevant local authority. He or she is usually a solicitor or doctor of five years standing, although all new appointments now have to be legally qualified. Their job is to investigate deaths that are violent, unnatural or of unknown cause with a view to determine who the deceased was, when and where they died and, crucially, how they died.

There are about 507,000 deaths every year in England and Wales, of which about 45% will be reported to coroners. And there are currently 96 separate local coroner areas, each with their own senior coroner.

Time for change

The failure of the coroner system in the Shipman case led to two reviews: one by Dame Janet Smith and one by Tom Luce. Both reviews found an inconsistent approach between coroner areas, and both advised the government that an independent national coroner service was needed.

Harold Shipman Reuters

But the advice was ignored and we remain stuck with the remnants of an 800-year-old fragmented system that has varied standards. Whether or not a death is investigated, how it’s investigated, whether or not an inquest is opened, and even how deaths are classified varies hugely from one jurisdiction to another. It’s important to have consistent standards because the process points up how our fellow citizens leave life in ways that are unusual and often preventable.

We should expect two things from the process: similar deaths in similar circumstances should be treated the same across coroner areas, and the categories into which deaths are placed should bear the closest possible relationship to the circumstances of their deaths.

Different conclusions

The coroner has three main decisions to make when a death occurs. First, should they accept the death for investigation? The general principles are that if the death was violent, unnatural or of unknown cause, it should be investigated. However, local reporting rules mean that what’s considered violent or unnatural varies from one area to another. I examined data for the ten-year period from 2000-2010 and found an incredible range of reporting deaths to the coroner, from just 12% of all deaths in some areas to 87% in others. It’s unlikely that this represents the natural variation in the proportion of violent and unnatural deaths by area.

Second, once investigated, the coroner must decide whether to open an inquest. An inquest is opened when the original reason for accepting the death for investigation – violent, unnatural, or unknown cause – still holds after initial enquiries. Data for the same period showed that deaths advancing to inquest ranged from 6% in some areas to 29% in others.

The third and final decision for the coroner is to determine the appropriate verdict for the death. There are six common verdicts (now known as “conclusions”): natural causes, accidental death, suicide, industrial disease, open verdict, and the increasingly used “narrative” verdict where the circumstances of the death are recorded in a brief story.

You might think that coroner areas would have a fairly similar profile of verdicts but, in fact, these too vary widely. For example, narrative verdicts for the period 2000-2010 ranged from almost zero in some areas, such as Carmarthenshire in south-west Wales, to 46% of all verdicts returned in another (Birmingham and Solihull). And in South Shropshire, just 3% of inquest verdicts were recorded as natural deaths, while that verdict accounted for an incredible 52% of all inquest conclusions in Sunderland. Suicide rates ranged from 4% to 27%.

The problem continues

Although my research examined data up to 2010, the latest government statistics reveal that inconsistencies in reporting continue. Local reporting rates for 2014 ranged from 24% to 96% of all deaths, and inquests ranged from 5% to 22% of all reported deaths. For the first time, the Ministry of Justice report shows evidence of local differences in the choice of verdict, showing that suicide rates for the year range from 4% of all verdicts (in Peterborough) to 31% (in East Sussex and in Ceredigion in Wales).

Does this matter? Widely varying outcomes across the country prove that not all coroner areas can be striking the appropriate balance between the needs of the state and the rights of the bereaved. Causes of death, informed by accurate classification and a consistent approach, are the starting point for setting priorities for preventative social policy and medicine. The bereaved, and our ability to prevent future deaths, are not being well served. Yes, it matters.