Establishing Cause of Death

The Present Coronial System

The process of determining cause of death through the coronial autopsy has been a cause of concern amongst both coroners and pathologists for a considerable period of time. The Wright report (1936), the Broderick report (1971) and the Luce report (2003) all highlighted the problems before Dame Janet Smith called for rigorous reform to protect the public. The Luce report stated: “There is, indeed, a general lack of evidence about the utility and justification for coroner’s autopsies on the scale on which they are practised in England and Wales. If the 121,000 autopsies a year that are now performed were surgical procedures carried out on living people there would long ago have been an evidence base compiled to assess the utility and justification for the scale of intervention.” In its response to the Luce report, the Coroners’ Society of England and Wales noted that:6 “it hopes fervently that this report will receive the attention and implementation that its predecessor reports.”