The Coroner in England and Wales; Coronial Decision-Making and Local Variation in Case Outcomes

The investigation and classification of deaths in England and Wales relies upon the application by medical practitioners of diverse reporting standards set locally by coroners and thereafter upon the effectively unconstrained decision process of those same coroners. This research, using extensive analysis of Ministry of Justice (MOJ) and Office for National Statistics (ONS) data, presents comprehensive analysis of local variation in coronial outcomes across the three decision-making stages of whether to report the death, to advance to inquest, and the choice of inquest conclusion.
Substantial local variation was found in reporting rates to the coroner over time (12-87%) and in rates of advancing reports of death to an inquest (6-29%). The profiles of inquest verdicts varied widely between coroner areas with some verdicts more prone to varied levels of use. Individual coroner areas were consistent over time in their rates of reporting, advancing to inquest and use of verdicts. The gender of the deceased was a major factor with all coroner areas reporting proportionately fewer female deaths than male, and female deaths being overall half as likely as that of a male to proceed to an inquest. Once at inquest, a woman’s death was more likely to yield a verdict of natural causes than that of a man. Coroners seemed prima facie to be ‘gendered’ in their approach to verdicts; that is, they were consistently more likely to favour a particular verdict when dealing with a death, according to the gender of the deceased.
Decision Board Analysis (DBA), comprising three typical coroner case scenarios, was utilised to analyse the decision-making style of incumbent coroners. The DBA allowed for an examination of the way in which available case information was managed prior to coming to a conclusion, and free text respondent comments were captured.
Coroners were found to vary widely in their choices of outcomes yet they managed the available information in a similar way, reading concordant amounts of information and agreeing on the relative salience of the available information. Coroners sometimes robustly defended chosen outcomes against alternatives with dichotomous positions being taken. Variation in coronial outcome could not be explained by any variation in decision-making style. Further analysis of coroners’ local practices and their determinants seems necessary.