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The modern coroner as injury preventer
  1. David M Studdert
  1. Correspondence to Dr David M Studdert, Stanford Law School and Stanford University School of Medicine, 117 Encina Commons, Stanford CA 94305, USA; studdert{at}stanford.edu

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Our study1 of timelines in death investigations conducted by Australian coroners, published in this issue, suggests that lengthy delays have adverse consequences for public health. Delineating those consequences depends on a prior step: understanding the public health role of the modern coroner.

Coroners are public officials. General descriptions of their structure and functions are inherently difficult because, like the political-legal environments in which they are embedded, there is variation across and within countries. The USA has a particularly convoluted arrangement, with two divergent models of death investigation (coroner and medical examiner) located at multiple jurisdictional levels (city, county, district and state).2 ,3

Arrangements in the Commonwealth of Nations tend to be more homogenous. (Several Canadian provinces that have adopted a medical examiner model are notable exceptions.) Coroners are typically lawyers or doctors. They may operate from the judicial branch (as judges or magistrates) or from dedicated offices in the executive branch. Their primary function is to investigate the ‘who, how, when and where’ of unnatural and unexpected deaths. Deaths due to injury are normally categorised as unnatural, and thus reported to and investigated by coroners.

Evolution of the coroner

The office of coroner dates from mediaeval England, where coroners were county officials, charged with protecting the King's financial interests in various legal proceedings.4 The ancient coroner's remit included violent and unnatural deaths because the King often had a stake in them. In deaths judged to be due to the ‘crime’ of suicide, for example, the deceased's assets were forfeited to the crown.

Coroners' authority and importance waxed and waned for centuries until two developments converged in the 19th century to clinch their pivotal role in death investigations. One development was the advent of comprehensive systems of mortality surveillance and death registration. Driven by public health imperatives, these systems necessitated a …

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