Wednesday 21 April 2010

Reports reported

Most coroners are receiving an appropriate response, but that might not be the whole story

Where, after an inquest, a coroner believes that it might prevent other deaths, he can write to an appropriate authority, reporting the evidence he has heard. Any such report is sent under rule 43 of the Coroners Rules, and the coroner must copy it, and any response, to the Lord Chancellor. An analysis of those reports has just been published. Its contents might be seen as reassuring, but one or two significant concerns remain.

Statistics
In the six months from 1 April 2009, there were 164 inquests in which rule 43 reports were issued. A third of these concerned ‘hospital deaths’, and nearly a fifth, ‘road deaths’. Eight per cent, meanwhile, concerned work- or health and safety-related deaths, and a similar proportion, mental health-related deaths. The new analysis contains nothing, however, to indicate how these classifications were reached: was it according to the place or means of death or to its immediate cause, or to either the content or the recipient of the rule 43 letter? That deficiency is significant, for it might render the statistics unreliable. If, for example, someone were to die in front of a train, having absconded from the hospital where she had been receiving compulsory psychiatric treatment, would any rule 43 letter be classified as mental health-related; or as concerning a hospital death or one in custody; or as ‘railway-related’? This concern is compounded by the brief summaries provided in the new analysis, which suggest that some ‘deaths in custody’ actually raised distinct mental health concerns. Only one death, furthermore, was classified as ‘railway related’.

Wider implications
The new analysis provides details of some rule 43 reports that might have wider implications. In the ‘drug- and medication-related’ category, these include the death of a man who, believing it to be ecstasy, swallowed a substance used for de-worming animals. The coroner wrote to the Home Secretary and subsequently, the substance was brought within the Misuse of Drugs Act 1971. The analysis also mentions the unfortunate church warden, who died when he fell from his own bell-tower. After hearing that the man had not been wearing a safety harness, the Coroner wrote to the Archbishops’ Council, inviting it to take appropriate action. The Council, however, replied that as each parochial church council is autonomous, there was little it could do. It is only in this part of the analysis that we get a flavour of the responses coroners receive, but it is clear that recipients don’t always accept the content or the implication of rule 43 reports.

Coroners
In the period in question, rule 43 reports were issued in 61 of the 114 coroner districts. (The number of coroners that made no reports – 53 - is slightly down on the previous period’s figure). The most reports again came from the Greater Manchester South district, where ten reports compare with 18 in the earlier (and longer) period, but also from Brighton and Hove, which could only previously claim two reports. The City of Manchester, however, and Cardiff and the Vale of Glamorgan, are two coronial districts in which the number of reports fell considerably, to four and six respectively, from 12 and 15. The new analysis acknowledges that the highest-reporting districts are not representative of the whole. When they are discounted, the average number of rule 43 reports in the relevant six-month period is 1.06 per coroner district, or 1.98 per district making such a report.

Responses
Rule 43 now also requires recipients to respond to reports, and to do so within a specified period. On the face of it, the figures in the new analysis are encouraging, for they suggest that where a report was issued, no response was outstanding that was due within the same reporting period. That might not, however, be the whole story.

The format of the analysis allows to be listed as outstanding only responses to reports issued within the current reporting period. It provides no information about responses listed as outstanding in last report, and there were more than a hundred of those. Before April 2009, for example, the Manchester City coroner sent a rule 43 report to an electronics company. We know that the report concerned the maintenance of ‘cherry-picker’ machines and a response was outstanding at the end of the reporting period. What we cannot tell, however, is when, or even whether, that response was received.

Where organisations receive coroners’ reports, it seems most are complying with the amended rules. But they aren’t receiving them all that often. The official analysis suggests that on average, fewer than three rule 43 reports are made in each coroner district per year. And the limited scope of that analysis can itself minimise the embarrassment caused to those who persistently fail to respond.