The Role of the Coroner
The History of the Coroner
In order to examine the role of forensic medicine in death investigations, it is essential to understand the development of death investigation systems. Most death investigations are administrative and rely on a treating medical practitioner providing a death certificate that sets out what the doctor believes the patient died from. This certificate is provided to relevant government authorities such as the Registrar of Birth Deaths and Marriages who routinely compile the information for the public record. In the case of certain deaths in which the community may have a public interest such as unexplained deaths, non natural deaths or deaths from injury, a more sophisticated system of death investigation take over and this usually involves specialist death investigators. There are many such specialist systems in the world some rely upon police, some on medical examiners, and some on public judicial officers. In many countries that have inherited the “English Legal System” these death investigations are handled by a public official called the Coroner.
Coroners in Australia are lawyers and nowadays are mostly judicial officers. However, in other jurisdictions they may be doctors or elected members of the general community.
The office of coroner has its historial roots in England in early Anglo Saxon times. However it was following the Norman invasion of England, when death investigation was associated with important political and financial considerations, that it came to prominance. These early Coroners had responsibility for the collection of a number of fines and taxes that could be levied by the Crown in relation to certain types of deaths, treasure trove and royal fish.
Deodands comprised taxes paid to the Crown that were based on the financial value of the implement or object that had caused a person’s unnatural death, so that if a person was run over by a cart, the cart or its value was forfeited to the Crown as a tax and the coroner was responsible for ensuring that the tax was paid. Similarly, the fine of ‘Presentment of Englishry’ or ‘Presentment of Welshry’ was payable by a local community if the coroner found that a deceased person was not of English or Welsh blood.
The role of the early coroner in criminal matters relating to death was limited, although the coroner helped to ensure that potential criminal matters were recognised by authorities and brought within the criminal justice system.
One of the early coroner’s main function was to keep a check on the sheriff (‘Keeping the pleas of the Crown’) and to ensure that revenues such as fines relating to certain deaths were officially recorded and reached the Crown treasury. With regard to the prevention of deaths, the early coroner had little or no direct function, although some coroners made attempts to highlight hazards in the community and to reduce their impact.
Over time, the coroner’s role diminished and the office became an onerous one with the coroner having to pay many of the fees associated with the work out of their own pocket. Early English and Australian coroners were not necessarily medically or legally trained, and many of the early coroners’ appointments were essentially political rather than professional.
The Role of the Coroner Today
Today the focus of coroners in Australia differs from that of the ancient coroners in England and Wales. Much of the operation of the office of coroner or coroners courts in Australia is centred on injury and death prevention, with the coroner empowered to make recommendations on matters of public health and safety and judicial administration. Such an approach gives the coroner a dynamic function in contributing to the welfare of the community. As lawyers Coroners rely upon a range of specialist investigators to provide them with the technical expertise and evidence they need to discharge their responsibilities with regard to the death investigation. These agents of investigation include police, forensic pathologists, engineers, psychologists, physicians and surgeons amoungst others. Today the medical/pathological aspects of death investigations in Victoria, focused on the pathological examination of the deceased body, is carried out for the most part by full-time forensic pathologists from the Victorian Institute of Forensic Medicine.
Many people think that the Coroner is largely involved in the investigation of suspicious deaths that may have a criminal background such as suspected murders. This is NOT the case. Homicide investigations form a very small part of the work of Coroners perhaps only around 1% of the deaths they investigate. The other 99% of cases reported to a Coroner involve unexplained natural deaths and deaths suspected to be from direct or indirect trauma.
The importance of a Coroners’ investigation is that it can lead to a greater understanding of risks and hazards in our community as well as to improvements in public health and safety. By being empowered to hold a public court hearing (the Inquest) Coroners have a vehicle for raising in public the facts about how a person died and can use the inquest to raise awareness of hw that death could or should have been prevented. In conjunction with the work of the Coroner, other statutory agencies including the police, the Chief Medical Officer of Health and the Victorian Institute of Forensic Medicine form a group of ‘watchdogs’ who maintains a constant surveillance on potentially fatal hazards in our society and ensures that preventable deaths are recognised and brought to the attention of the relevant public and government agencies so that the issues surrounding them can be addressed.