Contradictory coroners? Decision-making in death investigations

National coroner data demonstrate differences in the rates at which coroners across England and Wales choose to investigate reported deaths and the frequency by which they record certain conclusions. This study sought to examine how decisions are made by coroners and whether they differed when faced with identical case information.

Three different clinical scenarios were circulated via a web link to all senior coroners. The case information was contained within a ‘Decision Board’ displayed on screen. Each scenario had nine consistent categories of information, such as the cause of death and the medical history. Participants were asked to indicate an inquest conclusion (verdict) using free text and to provide comments. The way in which participants accessed the case information (order, frequency, etc) was recorded by the computer software.

35 coroners responded. There was little consensus as to conclusion with scenarios 1 and 2 generating four different outcomes and scenario 3 generating an extraordinary eight different conclusions among respondents. Despite coming to widely different conclusions, coroners demonstrated very similar decision-making processes. Conclusions were robustly defended yet proffered alternatives were plentiful. The comments made indicated a difference in the personal attitudes of coroners towards case information.

Different coroners faced with identical case information arrived at widely different case outcomes ranging from no further investigation to finding numerous alternative verdicts. Disparity appeared to be a product of differing personal attitudes among coroners. National coroner consensus to achieve a shared inference from available evidence is urgently needed.