‘GPs aren’t getting the medical examiner system wrong – coroners are’

A source inside the coronial service responds to criticism of GPs using the medical examiner process, and argues that coroners must take more responsibility for safeguarding cause of death accuracy.

Like many who read in Pulse about a coroner criticising two GPs for ‘not understanding’ the medical examiner process, I felt frustrated. I have a lot of contact with coroners and have had concerns about death investigation in England and Wales for some time. This story pushed me over the edge and compelled me to speak out – albeit anonymously. 

The case in question involved two GPs who didn’t feel confident issuing the cause of death of a 94-year-old woman. The senior coroner questioned why, stating it was ‘overwhelmingly likely’ the cause was natural. But the law requires coroners to investigate where the cause is unknown, including where it is likely to be natural. The GPs, evidently unsure of what caused this lady to die, felt uncomfortable speculating and so referred them to the coroner, in line with their training. In my book, their reluctance to speculate is evidence of integrity, and I salute them.

Far from ‘failing to do their job’, these doctors were doing what they thought was right in a system that has become opaque, inconsistent, and intimidating. Although it may not be apparent, investigating where a cause of death is unknown and establishing what it was is one of the core functions of being a coroner. When they don’t do this, there can be catastrophic consequences.

I believe coroners must urgently be reminded that the law requires them to investigate where a cause of death is unknown, and the two reasons why doing so are important. The first is simply that once a cause is found, it may be unnatural – something like opiate poisoning.

The second is more subtle; the cause of death may be something that services should have diagnosed and treated but didn’t. Where that’s the case, the law considers the death to be unnatural and requires an inquest. 

It seems to me that coroners do not understand that recognising failures to treat the cause of death cannot be done if it isn’t known what the cause of death is. For this reason, it is vital coroners recognise where causes of death are unknown and authorise post mortems. If they do, it sets the tone for the area and causes doctors and medical examiners to follow their lead and safeguards cause of death accuracy. If they don’t, then it’s only a matter of time before a culture develops where unevidenced causes of death are issued. When doctors are pressured to issue speculative causes to help avoid autopsy for reasons of sensitivity/faith/wanting to be kind to the bereaved – and knowing they will not be criticised for doing so – then they will.

The coroner in this case criticised the two specific GPs, but also said that this was indicative of how his court had seen an increase in the number of GPs making ‘unnecessary death referrals’. A recent survey carried out by Pulse revealed that pressure on GPs to complete death certificates without knowing the cause.

But while GPs are criticised for referring too many deaths, I believe there is another problem at play with coroners. I have witnessed a growing attitude among coroners that post-mortems are something to avoid. It is seen as the ‘nice’ thing to do – the path of least resistance.

To me, there are a few reasons as to why coroners don’t always carry out post-mortems when they should: 

• They don’t have the medical knowledge to realise the issued causes of death are unsafe;
• They don’t feel the practical benefit of accurate causes as they don’t have the medicine to recognise if there was a missed opportunity to diagnose and treat it;
• It’s easier to acquiesce to the emotionally bereaved and not do an autopsy than go against their wishes and do the right thing;
• They don’t have to pay for the examination.

Yet there have been catastrophic consequences from failing to safeguard accuracy around cause of death:

1. The Shipman Inquiry showed inaccurate causes of death being accepted. Had safeguarding cause of death accuracy been done and autopsies held, he’d have been caught. There were 215 unlawful killings undetected.
2. The Gosport Independent Panel Report showed that people were referred pain-free, with no acute problems. They all died after infusions of opiates. The causes of death were put as bronchopneumonia, despite it having neither been diagnosed nor treated. It found 460 unnatural deaths undetected.
3. The Francis Inquiry into Mid Staffs showed a coroner’s office that undermined cause of death accuracy. Over 1,200 unnatural deaths missed.

In each of these cases, coroners did not do enough. And in each case, families, the public, and the profession all paid the price.

Part of the issue is systemic. Coroners are legally required to be lawyers, not clinicians. They receive no training on recognising medically unnatural deaths. At training events, I’ve heard coroners who do the fewest autopsies (and therefore have the least accurate causes of death) be commended. Senior coroners have been overheard saying: ‘be cautious of knowing too much medicine – we can’t be our own experts.’ As a result, many coroners rely heavily on doctors – particularly GPs – to offer a cause of death. But if those doctors are unsure, and the coroner is unwilling to investigate, accuracy falls through the cracks.

The current coronial culture sees low autopsy rates as a mark of success but I think it’s the mark of a weak coroner. Rather than deriding autopsies, I agree with pathologist Richard Shepherd who described them as ‘acts of love’. Given that they mean failures to prevent death are recognised, lessons learned, and killers are stopped, I agree. The only downside is doing them may cause distress to those who dislike them for reasons of religion, or sensitivity.

You don’t need to read far into the Coroners and Justice Act of 2009 before seeing that one duty of coroners is to investigate if the cause is unknown. Ergo, it is not enough to say ‘it is overwhelmingly likely it was a natural cause of death,’ and expect doctors to rustle something up that fits. 

Coroners urgently need to be trained why having a cause of death is important, and how to use a cause of death to identify missed opportunities to diagnose and treat disease. Only then can we be confident that the coronial service will not miss the next Gosport, Shipman or Mid Staffs type crisis. 

The author is a source inside the coronial service

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