1. THE NEED FOR PARTNERSHIP WORKING John S. Pollard John S. Pollard HM Coroner HM Coroner Greater Manchester South District Greater Manchester South District

2. HM Coroners --- Who are we? Doctors/Lawyers Doctors/Lawyers Minimum 5 years P.Q.E. Minimum 5 years P.Q.E. (REFORM – Coroners and Justice Bill 2008 -- Will all be lawyers) (REFORM – Coroners and Justice Bill 2008 -- Will all be lawyers)

3. WHAT DO WE DO? Investigate all sudden, unnatural or violent deaths Investigate all sudden, unnatural or violent deaths Natural/Unnatural? What is the difference? Natural/Unnatural? What is the difference? Natural -- “the normal progression of a natural disease” [condition?] Natural -- “the normal progression of a natural disease” [condition?] Unnatural -- “wholly or partly caused or accelerated by any act, intervention or omission other than a properly executed measure intended to prolong life” Unnatural -- “wholly or partly caused or accelerated by any act, intervention or omission other than a properly executed measure intended to prolong life”

4. FURTHER COMPLICATIONS R v. HM Coroner for Inner London North ex parte Touche R v. HM Coroner for Inner London North ex parte Touche “a wholly unexpected natural death that would not have occurred but for some culpable failure” “a wholly unexpected natural death that would not have occurred but for some culpable failure” Could apply to “Fire death” where c.o.d. is Myocardial infarction Could apply to “Fire death” where c.o.d. is Myocardial infarction

5. DUTY TO REPORT Statutory Duty --- Registrar Births and Deaths Statutory Duty --- Registrar Births and Deaths Doctors/nurses --- G.M.C. and G.N.C advice Doctors/nurses --- G.M.C. and G.N.C advice and 1998 C.M.O advice and 1998 C.M.O advice Remember all citizens have a duty to assist HMC. ( Reform -- Statutory duty on all doctors )

6. INQUEST,FORM A, FORM B? Decision as to which route is followed is that of HMC and only HMC Decision as to which route is followed is that of HMC and only HMC Administrative decision in office not in court Administrative decision in office not in court No right of Appeal (except J.R.) No right of Appeal (except J.R.) (Reform -- Right of Appeal against decision NOT to hold P.M. and as to whether inquest or not) (Reform -- Right of Appeal against decision NOT to hold P.M. and as to whether inquest or not)

7. SUSPICIOUS DEATHS (Including fire deaths) (Including fire deaths) HMC and police maintain co existent rights to investigate HMC and police maintain co existent rights to investigate Protect scene for crime investigation and coronial investigation Protect scene for crime investigation and coronial investigation Forensic Pathologist? Forensic Pathologist? Who can attend PM? -- Doctors, Chief officer of police, but not necessarily Fire Service. Who can attend PM? -- Doctors, Chief officer of police, but not necessarily Fire Service. Who gets PM report? -- HMC. (Can Fire service have a copy?) Who gets PM report? -- HMC. (Can Fire service have a copy?)

8. FIRE DEATHS Greater Manchester 25 years ago 55-60 p.a. Greater Manchester 25 years ago 55-60 p.a. “ “ 2007/2008 10 “ “ 2007/2008 10 Why the improvement? -- social changes: open fires, smoking, electric blankets, dietary changes e.g. chips (chip pans) etc Why the improvement? -- social changes: open fires, smoking, electric blankets, dietary changes e.g. chips (chip pans) etc Campaigns -- HMC/ G.M. Fire Service working together Campaigns -- HMC/ G.M. Fire Service working together Vulnerable people --- Alcohol, age, drugs, smoking, mental health etc. Vulnerable people --- Alcohol, age, drugs, smoking, mental health etc.

9. AN EXAMPLE (Thanks to Deon Webber GM Fire for these details) (Thanks to Deon Webber GM Fire for these details) 17 th December 2008, elderly lady (late 80’s) confined to ground floor of her home. Faulty gas fire—ignited by matches. Very dated and dilapidated electrical installation. Visited 4 times per day by carers. Numerous disabilities inc. dementia. Lived alone. Smoke alarms fitted by an “agency” but on top of the polystyrene tiles on every ceiling. Her death due at least in part to those tiles. 17 th December 2008, elderly lady (late 80’s) confined to ground floor of her home. Faulty gas fire—ignited by matches. Very dated and dilapidated electrical installation. Visited 4 times per day by carers. Numerous disabilities inc. dementia. Lived alone. Smoke alarms fitted by an “agency” but on top of the polystyrene tiles on every ceiling. Her death due at least in part to those tiles. Just one example of ill informed good intentions Just one example of ill informed good intentions Fire Service already acted, I will Issue R43 letter Fire Service already acted, I will Issue R43 letter

10. WHAT DOES HMC EXPECT OF FIRE SERVICE? Clear and consistent format of report Clear and consistent format of report Full details of actions of Fire Service Full details of actions of Fire Service Full details of the fire investigation Full details of the fire investigation Full details of the identity and status of the investigating officer Full details of the identity and status of the investigating officer Any recommendations clearly set out and the justification for them Any recommendations clearly set out and the justification for them (Remember r 37 Coroners Rules if report is good enough) (Remember r 37 Coroners Rules if report is good enough)

11. PREVENTION OF FUTURE DEATHS Fire service can instigate pre inquest e.g. as in slide 9 above Fire service can instigate pre inquest e.g. as in slide 9 above Pre inquest HMC can coordinate various agencies to examine fully any perceived “failings” Pre inquest HMC can coordinate various agencies to examine fully any perceived “failings” Post inquest R43 Coroners Rules applies (See Statutory Instrument 2008 came into force 17 th July 2008) -- extended powers of HMC to require response to r43 etc. Post inquest R43 Coroners Rules applies (See Statutory Instrument 2008 came into force 17 th July 2008) -- extended powers of HMC to require response to r43 etc. HMC is an independent judicial officer therefore to get involved in case conferences, de-briefs etc – not really a good idea HMC is an independent judicial officer therefore to get involved in case conferences, de-briefs etc – not really a good idea

12. TEAM WORK Time limits are vital -- not just for the amusement of HMC Time limits are vital -- not just for the amusement of HMC Accuracy is vital -- self evident Accuracy is vital -- self evident Relationships (inter agency etc.) are vital -- talk to people. Relationships (inter agency etc.) are vital -- talk to people.

13. THANK YOU Any questions Any questions