How well do Regulation 28 reports serve future public health and safety?

Her Majesty's (H.M.) coroners issue Regulation 28 (Reg. 28) reports following inquests. These reports concern hazards which, if mitigated, might prevent future deaths, and have addressees who are best placed to take remedial actions. Since 2013, the reports and addressees' responses are copied to, and electronically published by, the Chief Coroner in non-exclusive demographic, aetiological or venue categories. Three of those categories were chosen so as to minimise the replication of unique cases - child deaths; alcohol, drugs and medications (ADM); and railways - with the most recent 50 reports in each category. A further ad hoc sample of neonates was taken after a finding in the first of these. The principal findings are: (a) H.M. coroners generate Reg. 28 reports at different rates (including 27 coroner areas with none at all; random variation probability p ≈ 10-6); (b) there is a large deficit of addressees' responses compared with Reg. 28 reports that are issued; (c) addressees from large organisations are more likely to respond than small ones; (d) substantive remedial actions appear in only a further subset of addressees' responses; and (e) there is a sex imbalance in Reg. 28 reports which is least explicable for neonates. It is concluded that the Reg. 28 report system is haphazard in many ways. As the only official publication from H.M. coroners' courts, Reg. 28 reports have a large scope for improvement, which might promote support from bereaved families and the wider public for the process of inquest. Suggestions for process improvement are made.

COVID-19 instigates resurgence of 'needless autopsies' issue in India.

COVID-19 has swamped the entire world and turned into a pandemic. Its high contagiousness compelled authorities to categorize all autopsies as 'high risk' considering the risk of exposure to the healthcare workers. In India, the Criminal Procedure Code authorizes investigating police officer to hold an inquest into suspicious deaths. The present article draw attention towards the 'needless autopsies' in times of COVID-19 and emphasizes on causes and recommendations.

Medicolegal Investigation for Cremation Clearance: How and Why?

This study on cremation clearance examines whether physical inspections detect more unnatural unreported deaths than medicolegal investigations without inspections. We reviewed all deaths reported to the medical examiner for cremation clearance during 2 distinct years and compared subsequent amendments of death certificates after 2 different investigative methodologies (1 with and 1 without physical inspection). Of 10,367 deaths in 2012, there were 86 deaths (0.83%) in which the investigation with physical inspection resulted in amendments to the death certificate. Of 11,906 deaths in 2016 without physical inspection, there were 153 that resulted in amendments (1.3%) including 2 homicides. For the detection of accidents, there was no statistically significant difference (χ = 0.8119, P = 0.367552). For cremation investigations, the work effort and costs of performing physical inspections do not appear justified given the similar detection rates (approximately 1%) for unnatural deaths among the 2 groups. Both methods, however, do detect unreported unnatural deaths.

Interstate and Overseas Deaths: Jurisdictional and Decision-Making Challenges for Coroners.

This editorial addresses the jurisdictional challenges for decision-making about which coroners should exercise jurisdiction over a dead body, when more than one has the potential to do so, including when a tragedy has occurred involving deceased persons ordinarily residing in diverse jurisdictions. It considers the criteria that are applied and should be applied by coroners to assumption of jurisdiction in relation to overseas deaths and reflects on considerations relevant to the exercise of such decision-making. It reviews significant cases, including appellate case law, in relation to coroners' investigations of overseas deaths and concludes by reflecting upon the need for consistent legislation throughout Australia and New Zealand on exercise of jurisdiction by coroners. It considers the expedient of a federal coroner for Australia.

Coroners court and directions to juries in Article 2 inquests.

Article 2 of the European Convention of Human Rights (ECHR) protects the Right to Life that is invoked in an inquest where the diseased has expired in circumstances of custody or control by an agency of state. The High Court in 2012 ordered the second inquest in the Hillsborough case where the correct directions to the jury were read as to when there is a breach of such a duty. The inquest findings resulted in criminal charges being brought against two former senior police officers, who were indicted linked to the disaster. This paper examines the inquest process where there is a jury and considers the framework of the Coroners Court in the context of Article 2 where death has occurred under circumstances of duress.

Interpretation of 'Unnatural Death' in Coronial Law: A Review of the English Legal Process of Decision Making, Statutory Interpretation, and Case Law.

The article examines the decision-making process for medical reporting of deaths to a coroner and the statutory basis for coronial decisions whether to investigate. It analyses what is published about the consistency of decision making of coroners and discusses what should be the legal basis for determining whether a particular death is natural or unnatural in English law. There is a review of English case law, including the significance of Touche and Benton and the development of 'unnatural' as a term of art, which informs what the courts have held to be an unnatural death. What case law indicates about multiple causes and the significance of the wording in the Coroners & Justice Act 2009 that triggers an investigation are considered. It highlights the importance of considering the medical cause of death and to what extent information other than the initial death report is required, before making the decision that the coroner's duty to open an investigation is triggered. The article concludes that a two-stage test is required. Firstly, is the cause of death medically unnatural? Secondly, whether the circumstances themselves are unnatural or such as to make a medically natural cause of death unnatural. If the coroner has reason to suspect the medical cause of death is unnatural per se the statutory duty to investigate will be engaged, regardless of the circumstances.

Variations in death notification of nursing home residents to Australian Coroners.

OBJECTIVES: To examine the impact of changes to the reporting requirements in coronial legislation on the nature and frequency of nursing home resident deaths reported to Coroners. DESIGN: National retrospective study of a population cohort of nursing home resident deaths. SETTING: Accredited Australian nursing homes between July 2000 and June 2013. PARTICIPANTS: Residents who died in nursing homes accredited by the Aged Care Standards and Accreditation Agency reported to Coroners. MAIN OUTCOME MEASURES: We explored three death-reporting models in the nursing home setting: comprehensive model, selective 'mechanism of death' model and selective 'age of death' model. These models were examined by manner of death subgroups: natural, falls-related and other external causes using the outcome measure of deaths notified to the Coroner per 1000 residents. We used an interrupted time series analysis using generalised linear regression with a negative binomial probability distribution and a log link function. RESULTS: The comprehensive model showed the proportion of reportable deaths due to natural causes far exceeded those from falls and other external cause. In contrast, the selective notification models reduced the total number of reportable deaths. Similarly, the selective 'age of death' model showed a decline in the reportable external cause deaths. CONCLUSIONS: Variation in the causes, locations and ages of persons whose deaths are legally required to be notified to Coroners impacts the frequency and nature of deaths of nursing home residents investigated by Coroners. This demonstrates that legislation needs to be carefully framed and applied to ensure that the prevention mandate of Coroners in Australia is to be achieved.

Improving medicolegal death investigative gaps of fatal elder abuse.

The purpose of this brief is to present several case vignettes that illustrate omissions in the investigation of elder deaths. These vignettes demonstrate the need for a standardized approach in the conduct of medicolegal investigations of fatal elder abuse. For each of the described oversights, a recommendation is offered to address the gap in investigation processes, which in turn could improve the determination of cause and manner of elder death. Inherent limitations of resources and practical realities of death investigation are discussed and recommendations are made for future research. Viewed broadly, deficiencies in elder death investigations can lead to the underreporting of elder abuse and the reduction of legal options for victims, which may reflect a systemic pattern of social injustice.

The Coroner's Role in the Prevention of Elder Abuse: A Study of Australian Coroner's Court Cases Involving Pressure Ulcers in Elders.

The prevention of elder abuse is a health priority around the globe. The Australian Law Reform Commission's 2017 report on Australian residential aged care facilities found that neglect may constitute elder abuse and that painful pressure ulcers (PUs) fall into this category. The purpose of this article is to examine deaths from PUs in elders 65 years and older. A database search of Australian cases identified four coroner's court cases. This article considers the role and potential of coroners' recommendations to prevent PUs. The origin and site of PUs, prevention, wound and pain management, quality of care and coronial recommendations were examined. Coronial recommendations were made in two of the cases. As judicial officers with a statutory public health function, coroners have the potential to play an important role in the prevention of deaths attributable to PUs. This article makes recommendations to harness the potential of the coronial jurisdiction to prevent PUs.

Legal Examination: Case Tests Lawsuit Immunity For Medical Examiners.

Case tests lawsuit immunity for medical examiners.

Procedural Fairness and the Coroner.

The hearing rule of procedural fairness applies to coroners' investigations and the findings made by coroners. Decisions by Australian and New Zealand appellate courts starting from the 1980s and early 1990s suggest that this will require interested parties to be accorded the opportunity to respond to any adverse findings, and probably comments, which a coroner is minded to make by being alerted in advance to what is proposed by the coroner. This editorial scrutinises decisions by the Victorian Supreme Court and Court of Appeal on the issue between 2016 and 2018 against the backdrop of appellate decisions in South Australia and New Zealand, as well as in the context of the development of modern administrative law in both Australia and New Zealand. It identifies conceptual challenges that exist as a result of the recent case law for coroners' courts, pointing to the uncertainty of what are "adverse" findings and comments for these purposes, a lack of clarity as to who is entitled to procedural fairness in the inquisitorial context of a coronial investigation, the uncertain parameters of reputation for such purposes, vagueness as to what is required for coroners to discharge their obligations, and the logistical difficulties that compliance with such obligations will pose for timeliness of coronial findings.

Process for Department of Veterans Affairs (VA) Physicians To Be Added to the National Registry of Certified Medical Examiners. Final rule.

FMCSA amends the Federal Motor Carrier Safety Regulations (FMCSRs) to establish an alternative process for qualified advanced practice nurses, doctors of chiropractic, doctors of medicine, doctors of osteopathy, physician assistants, and other medical professionals who are employed in the VA and are licensed, certified, or registered in a State to perform physical examinations (qualified VA examiners) to be listed on the Agency's National Registry of Certified Medical Examiners, as required by the Fixing America's Surface Transportation (FAST) Act and the Jobs for Our Heroes Act. After successful completion of online training and testing developed by FMCSA, these qualified VA examiners will become certified VA medical examiners who can perform medical examinations of, and issue Medical Examiner's Certificates to, commercial motor vehicle operators who are military veterans enrolled in the VA healthcare system. This rule will reduce the costs for qualified VA examiners to be listed on the National Registry.