Sunday, 23 January 2011

The Coroner, the Pathologist's Report and the Death Certificate

This post has evolved following comments made by Felix on my last piece in which I wrote about the number of reports submitted by Dr Hunt to the Inquiry.  More specifically the concern relating to the delay between Dr Hunt writing his second report dated 25th July 2003 (now published on the internet) and when it was logged in at the Hutton Inquiry on 20th August, almost four weeks later.

Just recounting a bit of history for a moment: Dr Hunt completed his internal examination of Dr Kelly in the early hours of Saturday morning, the 19th July.  Later that day he writes up the report from which Lord Hutton quotes in his Opening Statement of 1st August.  That Dr Hunt types his report as soon as possible after the post-mortem seems perfectly sensible, at least as a draft.  Now my understanding is that the forensic pathologist is responsible to the coroner - do we assume that Dr Hunt faxed or personally delivered his report to Mr Gardiner on that day?  How, and at what time are the police informed about Dr Hunt's findings?  How the procedure works is a fascinating one, if there are any retired pathologists reading this blog I would love to be enlightened.

Logically, to me at least, I would think that the police need to know what the pathologist thinks as soon as possible but I would have thought that might be done verbally of for him to send a faxed copy of his draft with the emphasis that it is an interim report.  Felix makes the strong point about waiting for the toxicology report from Dr Allan, necessitating a delay of only a day or two in reality, so that in effect Dr Hunt can produce the one single report.  What has to be emphasised here I believe is that although Hutton had Dr Allan's report by 1st August, that is what it was - a report of Dr Allan's findings.  The conclusions about the co-proxamol so far as it was a factor in Dr Kelly's death was a matter for the pathologist to decide.

There would be no doubt in my mind, thinking about the laboratory tests that Dr Allan and his colleagues were going to carry out, that Dr Hunt would be confident about getting the results in a very short time.  The second report does make clear that he was informed verbally by Dr Allan of the results of his testing, as of course one would expect.  So should Dr Hunt have waited for just a day or two before sending his report to the coroner?

Now we come to the second (final) report to the coroner and dated 25th July 2003.  When Mr Gardiner received it he would surely have realised that it was a document that had to go to the Inquiry.  At that stage he didn't know that he would get the authority to briefly reconvene the Inquest so that he could take enough evidence from Dr Hunt to put the cause of death on the death certificate.  Why couldn't he have just photocopied the 25th July report for his own reference and sent the original of to Hutton?  I do wonder if Mr Gardiner was just being bloody minded at this juncture.  He would be quite angry in my opinion and was aware about how inferior the Hutton process would be compared with an inquest.  He had only just sent off the first report to the Inquiry after all.  I think that the day Mr Gardiner took the further evidence from Dr Hunt was the 14th of August and after then there was no reason for him to hang on to the second report.  perhaps he received a nudge from the Secretary to the Inquiry saying 'We would like that second report please'.  However one views it I think that the second report should have been available to Hutton for his Opening Statement.

Regarding the death certificate I have been severely critical of Mr Gardiner in the past.  My understanding is that it had the inadequate 'found at Harrowdown Hill' as place of death and wasn't signed by a doctor or coroner as it should be.  At this point its worth looking at the first two clauses of the Coroners Act 1988 Section 17A Clauses 1 and 2:

17A Adjournment of inquest in event of judicial inquiry.

(1)If on an inquest into a death the coroner is informed by the Lord Chancellor before the conclusion of the inquest that—

(a)a public inquiry conducted or chaired by a judge is being, or is to be, held into the events surrounding the death; and

(b)the Lord Chancellor considers that the cause of death is likely to be adequately investigated by the inquiry,

the coroner shall, in the absence of any exceptional reason to the contrary, adjourn the inquest and, if a jury has been summoned, may, if he thinks fit, discharge them.

(2)Where a coroner adjourns an inquest in compliance with subsection (1) above, he shall send to the registrar of deaths a certificate under his hand stating, so far as they have been ascertained at the date of the certificate, the particulars which under the 1953 Act are required to be registered concerning the death.   

Note in Clause (1)(b) the words "cause" and "adequately".  As we know the Inquiry was mainly focused on the politics surrounding Dr Kelly's death, the clause quoted is just about the cause of death.  Did Lord Falconer really consider the Inquiry procedure adequate - it turned out that it was a friendly chat across the table sort of affair with no rigour at all, if for instance a witness decided to lie well, that wouldn't be a problem. If witnesses produced conflicting testimonies so what?  It's clear that the Inquiry failed in respect of (1)(b).

On to Clause (2) and I concede that the coroner had a bit of a problem here.  He could argue that he was bound by the provisions of the Act to ascertain cause of death from the Forensic Pathologist and at least insert this information and then send the certificate, even if incomplete, to the Registrar.  We have to be clear that the cause of death is purely recording the physical cause of death as considered by the pathologist and not stating whether suicide or murder.  The trouble with Clause (2) I believe is that the drafter wouldn't have envisaged the way the Act would have been misapplied by the government.  Certainly you can see the logic when you think about one example where Section 17(A) had been used justifiably: the murder of over 300 people by Dr Shipman.  There it makes sense but as I say in the case of Dr David Kelly it doesn't in my opinion.     

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