Evidence submitted by Mrs L H Lewy, Rigorous
Analysis of Iatrogenic Death (RAID)
The undersigned was greatly perturbed to hear
Dame Janet Smith's remarks on the subject of compulsory post mortem
examinations of all persons dying less than 24 hours after admission
to hospital.
Were such post mortems to be carefully and conscientiously
performed by highly qualified Pathologists there would be little
or no objection except possibly for Religious reasons.
But as is generally known and accepted in Mortuaries
out of sight of the bereaved public, these are carried out by
Mortuary Attendants (or, as they are now called, Assistant Pathology
Technicians) whose professional organisation has a website, but
does not reply to questions The ensuing "Report"—although
the body has NOT been examined either according to Medical or
Forensic criteria—may be (and frequently is) signed by a
Pathologist who may never have come within touching distance of
the Deceased.
Where such a "Report" purports to
state that Death was due to Natural Causes, the Family is adamantly
denied a proper Inquest.
It is a matter of great concern that only a
very few of the recommendations made in the Wassermann and Brodrick
Reports have ever been put into practice.
1. CORONERS HAVE
POWERS WHICH
THEY EXERCISE
WITH IMPUNITY
1.1 No one calls coroners to account or
scrutinises their behaviour. In many cases Coroners breach the
Human Rights of both the Deceased and the Next of Kin, yet their
decisions can only be challenged (usually without success) in
the High Court at enormous and disproportionate expense to the
bereaved Families.
1.2 They have the power to seize the bodies
of deceased people whether the body is lying or has arrived in
the area over which they exercise "jurisdiction."
1.3 They have the power to order post mortems
to be performed by mortuary attendants, and the power to accept
the ensuing reports even when signed by unqualified and even disqualified
"experts."
1.4 They have the power to make arbitrary
decisions, eg "natural causes" or "accidental death,"
which are often contrary to the experience and knowledge of the
Next of Kin, and the power to refuse to hold an Inquest when requested.
2. POWER WITHOUT
RESPONSIBILITY
2.1 Coroners proclaim themselves to be entirely
"independent." In fact they are local authority employees
in everything but name.
2.2 The erstwhile Lord Chancellor's Department
never exercised any jurisdiction over unsatisfactory coroners;
the Coroners Unit at the Home Office issues occasional Circulars
to Coroners but does not intervene in disputes between Coroners
and Families.
2.3 The "Luce Review" some years
ago made recommendations proposing various reforms. Not one of
them has yet been effectively implemented.
2.4 Another body under the aegis of the
Dept for Constitutional Affairs is currently reviewing Coroners
again, apparently intending to draft a Bill which may eventually
result in a new Coroners' Act (the current one being dated 1988).
3. WHO PAYS
FOR ALL
THIS?
3.1 Anyone asking about this will be given
only conflicting and inaccurate answers:
The answer is the Law-Abiding Citizen and Council-tax
Payer, that is, all of us!
3.2 Until very recently, no one fully appreciated
that local Authorities (Borough or Council) pay all the Coroners'
bills, and moreover pay them on request/demand: they are not examined
for justification, value-for-money or anything else.
3.3 One local authority's own Auditor told
a member of the public that such auditors "never looked at
any figure below a million pounds."
3.4 The District Auditor who was appointed
by the Audit Commission to Certify another Borough's accounts
informed a member of the public that the District Auditor is willing
to respond to "How Much?" type questions, but not to
"Why?"; he did not even mention "To Whom?"
Many people will consider that these questions
must ALL be asked, and asked EVERY TIME a single cheque is issued
for even the most trivial amount.
4. PROBLEMS WITH
CORONERS' OFFICERS
These individuals very often represent the recently-bereaved
Family's first contact with the Coronial system.
4.1 They are usually untrained and inexperienced
and ignorant not only of their duties but of the Human Rights
of the Deceased and of the Next of Kin.
4.2 The undersigned has had a prolonged
but unsatisfactory and inconclusive correspondence with the Judicial
Studies Board on this subject and will submit documentation on
the questions that have been repeatedly raised, and raised in
vain, by the undersigned.
Mrs L H Lewy
February 2006
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