1009RECOMMENDATIONS OF DEPARTMENTAL COMMITTEE ON CORONERS.

THE LANCET.

LONDON : SATURDAY, APRIL 9, 1910.

The Recommendations of the

Departmental Committee onCoroners.

THE Departmental Committee appointed by Mr. HERBERTGLADSTONE (now Lord GLADSTONE) in 1908 to inquireinto the law relating to coroners and coroners’ inquestsand into the practice in coroners’ courts has issued in

a second report its recommendations upon these subjects,of which a summary was published in THE LANCET

last week. 1 As our readers will have seen, some

very difficult and complex matters have been closelyconsidered, while one such-namely, the matter of

deaths under anæsthetics-will be made the subject of afurther report. The declaration of the views of the

committee upon this question, which was submitted for con-sideration as an afterthought, and with regard to which

evidence was heard simultaneously with evidence relating tothe law and procedure connected with inquests, is awaitedwith interest. The report, as a whole, is one which shouldbe regarded with satisfaction by the medical profession, forit recognises the importance of enabling the coroner to

obtain the best medical evidence reasonable of attainment

with a view of establishing the cause of death ; while inorder that the coroner’s position and authority may be

strengthened it recommends that the office should be con-fined to members of the medical and legal profes-sions. Those who read the opinions thus expressedside by side with the Act of Parliament now

governing their subject matter, the Coroners Act, 1887,are tempted to wonder how it came about that very littlemore than 20 years ago all provision for scientific evidenceof the cause of death in any but the simplest cases wasomitted. A scale of fees for medical witnesses was

’incorporated in the body of that Act which the committeerecognises to be causing great and justifiable dissatisfactionin the medical profession, and which in one instance (theinclusion of the chemical analysis of the contents of the

stomach - and intestines with the post-mortem examina-

tion) it characterises as ridiculous. To take another

instance of an anachronism not connected with the

progress of science, we need only refer to the retention

in the Act of 1887 of the condition that a county coronermust have "land in fee sufficient in the same county whereofhe may answer to all manner of people." We need not

discuss the usefulness of such a qualification in the reign ofEDWARD III. In more recent years it is said to have been

satisfied, if any notice has been taken of it, by the possession

1 THE LANCET, April 2nd, p. 942.

of a freehold grave in a cemetery, and the committee recom-mends that in future the requirement should be abolished andthat fitness acquired by training in medicine or law, or both,should be substituted. Perhaps the year 1887 must now be

regarded as having occurred during a period of transition, andthe date at which the future Coroners Act finds its place inthe statute book will come to be looked back upon byposterity as the one at which the medical profession founditself definitely established in a position but recently won.An important recommendation of the committee bearingupon the possibilities of future progress and development,not only in scientific discovery and medical science, is thatwhich advises the giving of powers to make rules for the

practice and procedure of the coroner’s court to a central

authority. No such power now exists, and the difficulty of

keeping pace with the times by means of fresh Acts of

Parliament is obvious.

In the summary of the report which we have published will be found many suggestions and recommendations affect-

ing the general usefulness of the coroner’s office, but not of

special interest to the medical profession. Among those,however, which are of medical as well as of public interest,by far the most important subject dealt with will be found in

paragraph 15. Hitherto the coroner has had to decide

whether he should hold an inquest or not without having the

power to order a post-mortem examination, the one method bywhich he could frame his decision with the least possible riskof error. The committee in advising that he should have this

power keeps in view the probability that inquests will therebybe diminished, and this recommendation lends weight un-

doubtedly to the one contained in paragraph 5, to the effectthat a coroner should be paid by salary in all cases and not byfees dependent upon the holding of inquests. It also adds

support to the contention, upheld constantly and strenuouslyin THE LANCET, that it is desirable in the interests of the

public that all coroners should have been medical practi-tioners, for a preliminary post-mortem examination may

convey little to the man without medical training. In advo-

cating the appointment of medical coroners, however, we havenever lost sight of the fact that the coroner’s court is a courtof law. Legal training and experience are both of very greatimportance in the exercise of the coroner’s duties, and nodoubt a combination of medical and legal training presentsthe most desirable preparation for the post. The need for

the coroner to be able to grasp, or shall we say conjecture,the medical aspects of a case without a post-mortem exami-nation to guide him has been combined in the past with the

desirability that he should be able to weigh and explainmedical evidence to a jury at an inquest. In future, if thecoroner should be allowed to order a post-mortem examina-tion as a precedent to an inquest he will have to call uponmedical knowledge in no less degree in order to understandthe fuller medical information at his command and to applyit to facts which will be in his possession, but which will nothave been before the pathologist. The latter will inform the

coroner of the physical conditions found in the dead bodythe potential subject of an inquest. The coroner will hava

to say whether those physical conditions, which may not bythemselves indicate any need for public inquiry, may renderan inquest desirable in combination with circumstances as

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to which he has learnt that evidence may be forthcoming.In other words, he will sometimes have to make up his mind

as to whether facts, in themselves not inconsistent with

natural death or perhaps pointing strongly to it, may intruth be attributed in some measure to criminal acts or

culpable neglect, or, at any rate, whether features mayexist in the case requiring elucidation. In doing so

he will have the advantage of his experience as a

coroner and of the information supplied to him as

such (part of which may emanate from medical men),but these in some instances might be rendered useless it

there were not medical knowledge on his part to supply thelink between the matters suggested by his official inquiriesand those established by the post-mortem examination. We

commend these considerations to the attention of those

who at some date, which we hope is not far distant, willundertake the promotion of legislation upon the lines of thecommittee’s report.The paragraphs in the report dealing with the calling and

remuneration of medical witnesses are highly important.Paragraph 29 proposes to do away with a power possessed bythe jury to select medical witnesses, which power certainlyseems inconsistent with the enjoyment by the coroner ofthat exclusive authority in his court which a judge shouldpossess. Under Section 21 of the existing Act a majority ofthe jury may insist upon the calling of additional medicalevidence, and may name the witness whom the coroner isthen obliged to summon. The curious point with regard tothis is that it has been the privilege of the jury only, andthat the coroner who is dissatisfied with medical evidence

has had no authority to obtain and pay for better, though nodoubt he may have been able to do so under the section with

the jury’s cooperation. The other paragraphs with regardto medical evidence will be found to recommend better pro- vision than now exists for the remuneration of those supplyingit, and the granting of power to the coroner to obtain in caseswhere such may be required the assistance of those highlyqualified witnesses who in the simpler everyday cases of thecoroner’s routine work would be out of place. The com-

mittee points to Scotland as furnishing an example of what

it holds to be more desirable than the present Englishsystem, and makes the important and commendable sugges-tion that" to give coroners a somewhat wider discretion asto costs-a discretion possessed by all other courts-would gofar to remove the friction which sometimes arises between

them and the medical profession, and would, on the whole, beconducive to the efficiency of inquests and the public interest." These words will be found in our summary already referredto, and are quoted from a paragraph in which the committee

expresses its views upon the question which has frequentlybeen discussed in these columns with reference to the

practice of a particular coroner in London in employing apathologist from outside his district for the making of all

post-mortem examinations. With regard to this we note thatthe committee points out that " clinical evidence may beessential to supplement the evidence as to the post mortem,’and adds : "The coroner is in a difficulty because,if the Act is strictly interpreted, he cannot pay

both the medical witness who gives clinical evidence

and the medical witness who makes and gives evidence

as to the post-mortem examination. Every coroner

should be empowered to call such medical witnesses as maybe necessary for the proper determination of the case."With this the medical profession is likely to be in agree-ment. The difficulty which has arisen in Westminster

during recent years has been due to the coroner employingon his own initiative, and in a manner not contemplated bythe Act of 1887, a pathologist whose evidence was not givenin corroboration of, but in substitution for, that of any othermedical evidence as to the death which might be avail-able. We contributed to the calling of attention to thiscourse, and if as a result a new Coroners Act renders the em-

ployment in special cases of an independent pathologist legal,without ousting the evidence of any medical witness who,

being summoned immediately before or after death, or beingotherwise acquainted with the condition of the deceased, hasvaluable evidence to give, the investigation of the coroner’s

jury will be made far more satisfactory than heretofore. Weiote that, with reference to the medical practitioner to be

selected for the making of the post-mortem examina-

tion, Mr. A. J. PEPPER, whose unrivalled experienceives weight to his words, said in his evidence before

the committee: "In the vast majority of cases the generalpractitioner is quite capable of conducting the post-mortemexamination and giving the necessary evidence." The same

witness also said : "I I think that any medical man, whether

he has attended the case previously or has simply known the

person, or has been called in at the time of death or imme-

diately afterwards, should always be called in," and headded that such evidence was undoubtedly essential,whereas to obtain information from a medical practitionerin such circumstances and then to refrain from summoninghim as a witness was "perfectly monstrous." Agreeingas we do with these opinions, we should suggest that the

enlarged discretion to be allowed under any new statute

to coroners in the summoning of medical witnesses mightusefully be governed by regulation? so as to ensure the

calling of all essential witnesses. Such rules framed by acentral authority would guide without circumscribing theexercise of the coroner judgment, and would prevent thereduction of medical evidence to a possibly dangerousminimum in order to save expense at the dictation of an

economically minded local authority.We note with satisfaction that the departmental com-

mittee is emphatic in its declaration that the deprivingof the officers of medical institutions of all fees in

respect of evidence given at inquests is inequitable andshould cease. Dr. F. J. WALDO in his evidence ascribed

this provision to the prejudice excited by the case of theinfamous body-snatchers and murderers BURKE and HARE.In any case, it is another instance of an anachronism which

found its way into the Act of 1887, and which has survivedto the prejudice of the public and to the injury andirritation of members of the medical profession for manyyears. That it so survives, in common with other relics

of machinery antiquated and obsolete in connexion withthe exercise of an important judicial office, is a furtherreason why the law and procedure affecting inquestsshould be renewed and amended with as little delay aspossible.