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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}

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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 locus of reliable and consistent decision-making, especially for deaths whose causes and circumstances were not apparent. Given their traditional role in this area, coroners were a natural fit.

A second development was the maturation of forensic medicine in the late 19th and early 20th centuries. Scientific advances brought new understanding of the pathophysiology of death, strengthening the hand of pathologists, toxicologists and other clinical experts in death investigations. The choice between the medical examiner and coronial models partly reflects contrasting perspectives on whether such clinical information can essentially ‘explain’ death, or merely contribute useful data to be sifted and weighed alongside other evidence in solving a larger puzzle. In the latter conception, the coroner assumed the mantle.

A skew towards public health threats and injury

Coroners' field of vision is framed by rules specifying the types of deaths that must be reported to them. These rules vary. In the England and Wales, for example, the catchment is remarkably wide: nearly half of all registered deaths are reported to coroners;5 in Canada6 and Australia,7 by contrast, the proportion is 10%–15% of registered deaths.

Regardless of the share of deaths that fall within coroners' purview, their investigations home in on a selected sample. The 90-year-old woman who dies at home after a long battle with breast cancer is unlikely to trigger a coronial investigation; but unexplained deaths believed to be due to natural causes may, and automobile crash fatalities certainly will, as will deaths due to suicide, drowning, poisoning, assault and certain medical injuries.

Deaths due to external causes are a mainstay of coroners' caseloads. Although not necessarily the most common type of death reported and investigated, they dominate labour and resources. In Australia, for example, deaths known or ultimately determined to be due to external causes account for approximately 40% of all deaths reported to coroners. However, most other reported deaths prompt investigations that are short and relatively routine; they involve desk based investigations that are concluded within a few months. Inquests, on the other hand, are the most intensive form of coronial investigation, and two-thirds of them address external cause deaths.

The coroner's public health role

Until relatively recently, coroners' death investigations and public health activities were largely separate worlds, parallel enterprises at best. There were obvious points of intersection, but little or no explicit recognition of a shared mission. A discernible shift has occurred in the last 30 years.8 ,9 Led by progressive coronial systems—such as those in Victoria, Australia and Ontario, Canada—coroners have been refashioned as quasi-public health officials and their functions have been linked more explicitly to the protection of community health and well-being.

But again, generalisations oversimplify. In some jurisdictions, coroners appear to function much as their forebears of a century ago did (although with the benefit of superior forensic evidence). In other jurisdictions, the shift has been chiefly in outlook—both how the polity perceives coroners' and how coroners perceive themselves—without any substantive modifications to actual powers or functions. But in many jurisdictions the shift towards an explicit public health role is unmistakeable: it is manifest in both fresh mission statements and changes to statutorily prescribed functions.

The modern coroner's public health role plays out in four main areas.

Vital statistics

Mortality statistics are a backbone of public health systems. They remain the core measure of the health of a community. They also guide policy and priority setting, and enable a wide range of medical and epidemiological research.

Coroners contribute mightily to the production of mortality statistics by determining the manner and cause of death in a subgroup of deaths that is skewed towards cases of particular relevance to public health surveillance. This is an old function, not a new one. But the extent to which the accuracy and efficiency of coroners' work influences the integrity of vital statistics is more clearly understood today.

The recent controversy over mortality statistics in Australia provides an illuminating case study. A 2006 editorial in the Medical Journal of Australia celebrated a decline in the national suicide rate.10 This conclusion was immediately contested on the grounds that the official suicide statistics were flawed. A major source of the alleged problem was lags in cause-of-death determinations attributable to lengthy coroners' investigations.11 Attention focused on the counting protocols used by the Australian Bureau of Statistics (ABS), custodian of the official mortality index, which imposed a sharp cut-off date; deaths not certified by coroners before the cut-off date were at high risk of being permanently miscoded.

The revelation prompted a flurry of studies aimed at exploring and quantifying the problem.12–15 In general, these studies confirmed that lags in the certification of deaths led to non-trivial biases in a range of injury-related deaths, not only suicides. The ABS has implemented several reforms to try to address the issue, but lengthy coroner investigations remain a challenge for official death statistics in Australia.16 Other countries appear to have faced similar issues.17 ,18

Data for research

The importance of official mortality data to clinical and public health research is widely appreciated. Less well known is the research value of the store of information on deaths that is housed upstream—in coroners' courts and offices. Coronial information is usually more detailed and nuanced than what is available in the vital statistics repositories it feeds. These extra dimensions unlock new research possibilities.

Twenty years ago, using information sourced directly from coroners was a novel in public health research. That is not the case today. A cursory review of publications from the last year alone shows studies that have analysed coronial data to advance understanding of opioid deaths,19 intimate partner homicide,20 suicide among the elderly21 and deaths in nursing homes.22 We recently used coronial data to link the sharp decline suicide by motor vehicle exhaust asphyxiation with changes in emissions laws in Australia.23

The accessibility of coronial data remains a key challenge. Many coroners recognise the value of using their data to support public health research and are willing to grant access to approved researchers who have appropriate safeguards in place. However, harvesting the information of interest from administrative databases and hardcopy files can pose an insurmountable logistical challenge.

Coroners in a few jurisdictions have moved to rectify this problem and catalyse research interest in their data by developing research friendly, electronic data systems. The National Coronial Information System (NCIS), a collaboration among Australian coroners that was launched in 2000, has set the mark in this area.24 A recent systematic review25 identified 106 original studies that have used the NCIS as a primary source of data. Furthermore, analyses of NCIS data have reportedly prompted reforms aimed at preventing a range of injuries, including burns from unintentional cigarette fires, injuries due to collapsing vehicle jacks, slow vehicle run-overs of children and child strangulation by blind cords.26

Recommendations and warnings

Coronership inherited the predilection of judges and lawyers for particular sample size: n=1. Every case is different, and the administration of justice demands careful attention to the details of each one. This approach produces inward-looking findings, exquisitely matched to the case at hand but unlikely to have broader implications.

The most visible step past coroners' traditional death investigation functions and towards a more explicit public health role has been the move by a growing number of countries to vest coroners with authority to incorporate into their findings in specific cases general recommendations aimed at reducing risk and improving health and safety.8 ,27 Coroners in Australia, New Zealand, Ireland, the UK and most Canadian provinces now wield this power.

The change has not been welcomed in all quarters. Some critics have pointed to the unorthodoxy of conferring recommendation powers on judicial officers.28 Concerns have also been raised about the quality of coroners' recommendations.29

A small but growing body of research has begun to explore the efficacy of coroners' recommendations.28 ,30–33 Anecdotally, recommendations have been linked to a variety of successes,29 ,30 ,34 including countermeasures designed to prevent injury from heavy vehicle crashes, cooling fan fires, methadone overdoses, child drownings, ultralight aircraft crashes and medical injury. But establishing cause-and-effect here is extremely difficult. Innovative and successful public health reforms tend to be product of a confluence of forces, and disentangling the relative contribution of particular ones may be impossible.

One obvious threat to the efficacy of coroners' recommendations is that, even when they are well formulated and evidence based, the organisations to whom they are directed may simply choose to ignore them. In 2009, the state of Victoria moved to address this pitfall by mandating written responses from recipient organisations outlining what if any action they had taken in response to recommendations.35 The responses are publicly available. A recent evaluation of the regime by Sutherland et al29 analysed 164 coroners' recommendations made over a 3-year period to 159 organisations. The study found that about 40% of the recommendations were adopted, one-quarter were rejected and organisations pre-emptively adopted the rest (ie, before the coroner's findings were issued). The most common reason reported for accepting a coroner's recommendation was ‘prevention of future injury or death’. How generalisable this degree of responsiveness is outside Victoria is unknown; a jurisdiction with a mandatory response regime in force may well represent a high-water mark.

Treatment of the deceased's family

Many types of legal proceedings are stressful and emotionally charged occasions for participants, but death investigations surely rank among the most poignant. A coroner interacts with family members and loved ones of the deceased at a particularly vulnerable moment. The content of coronial findings can permanently mark lives; so can the process through which those findings are reached.

The scale of coroners' caseloads has the potential to transform these individual ‘micro’ effects into a larger policy issue. A typical coroner's court or office will investigate thousands of deaths each year. If the process is insensitive, highly inefficient or ill-equipped to meet the needs of grieving families, successive private tragedies may give way to a public health problem. In the language of public health, defective processes that exacerbate or fail to help remediate grief constitute the ‘risk’ and every living individual who comes into contact with them is ‘exposed’.

Customer service and consumer orientation are not foreign concepts. Many bureaucratic and legal systems have imported these models and aspirations from the private sector. But there is much less awareness and understanding of the potential for legal processes to do harm.36 The field of ‘therapeutic jurisprudence’ has emerged to grapple with the complex pathways through which legal processes, rules and actors may affect the health and well-being of those who use legal systems.37 Freckelton has noted the high potential for counter-therapeutic effects in the coronial setting.38

Reports from a number of recent national inquiries into coroners' services have underlined the importance of the interaction between coroners and families. Suggested reforms include better training of frontline staff and the establishment of inhouse grief counselling services. In the UK, the Ministry of Justice went so far as to draft a charter specifying standards and services bereaved families are entitled to expect from coroners.39


The Office of the Chief Coroner of Ontario has a catchy motto: ‘We speak for the dead to protect the living’. These words encapsulate an important shift that has occurred in many places over the last 30 years—in coroners' outlook, in coronial practice and in public expectations.

Coroners have entered the prevention business, and they are undeniably players in the injury prevention field today. The jury is out on their performance in this capacity. In particular, it is not yet clear how effectively coroners will be able to use death investigations as a vehicle for synthesising public health expertise, and then use their bully pulpit to drive adoption of effective countermeasures and policy reforms. It is a space worth watching.


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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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