Role of HM Coronor & Procurator Fiscal
Coroners are independent judicial officers who enquire into those deaths reported to him or her. It is the Coroner’s duty to find out the medical cause of the death, if it is unknown, and to enquire about the cause of it if it was due to violence or otherwise appears to be unnatural. There are a number of occasions when a death will need to be reported to the Coroner or the Coroner’s officer (the deputy supporting the Coroner) by the hospital staff caring for the patient; where the potential donor has expressed the wish to donate, this will usually be done in collaboration with the Specialist Nurse – Organ Donation (SN-OD).
Reporting of deaths to the coroner in usually done by the medical staff and death should be reported to the Coroner if:
- The cause of death is unknown.
- Death cannot readily be certified as being due to natural causes.
- The deceased was not attended by a doctor during his last illness or was not seen within the last 14 days (28 days in Northern Ireland) or viewed after death.
- There are any suspicious circumstances or history of violence.
- The death may be linked to an accident (whenever it occurred).
- There is any question of self neglect or neglect by others.
- The death has occurred or the illness arisen during or shortly after detention in police or prison custody (including voluntary attendance at a police station).
- The deceased was detained under the Mental Health Act (in England and Wales) or the Mental Health Northern Ireland Order (in Northern Ireland).
- The death is linked with an abortion.
- The death might have been contributed to by the actions of the deceased (such as a history of drug or solvent abuse, self injury or overdose).
- The death could be due to industrial disease or related in any way to the deceased’s employment.
- The death occurred during an operation or before full recovery from the effects of an anaesthetic or was in any way related to the anaesthetic (in any event a death within 24 hours should normally be referred).
- The death may be related to a medical procedure or treatment whether invasive or not.
- The death may be due to a lack of medical care.
- There are any other unusual or disturbing features to the case.
- The death occurred within 24 hours of admission to hospital, unless the admission was for the purposes of terminal care.
- It may be wise to report any death where there is an allegation of medical mismanagement.
- The list is not exhaustive – if in doubt contact the Coroner.
In the situations described above, or if the clinician caring for the patient is unable to issue a death certificate, the SN-OD must gain permission from the Coroner for organ donation to proceed. This will be done in collaboration with the medical team caring for the patient.
It will often be the Coroner’s officer who the SN-OD will be liaising with. Outside of working hours some larger city areas may have an official on-call rota to aid contacting the Coroner’s officer, if this is not the case the local police station will be able to advise.
To help their investigation and to determine the cause of death the Coroner or their officer may place some restrictions as to what organs can be retrieved. This all needs to be agreed before donation can proceed. There may be certain circumstances when a home office pathologist may need to attend the retrieval procedure to document events and take photographs to help the Coroner with their investigation.
In England, the Coroner cannot give consent for organ or tissue donation but can agree to organ or tissue donation proceeding if she/he believes that donation will not interfere with their legal responsibilities to establish the cause of death.
However, in Scotland the Procurator Fiscal is required to give consent in writing which is usually faxed to the ICU. For both, the primary concern will be to establish whether there are any grounds for an inquest/fatal accident enquiry.
Coroner’s cases may require an autopsy, after retrieval has occurred therefore it is important that retrieval surgeons clearly document the all details of the operation and note any abnormalities. Occasionally blood samples will be required by the Coroner.
Role of the Procurator Fiscal
The Crown Office and Procurator Fiscal’s Service (COPFS) is Scotland’s sole prosecution authority and has five main objectives:
To deliver swift, effective justice, giving priority to serious crime, including sexual offending, serious violence, organised crime and drug trafficking. To work with the police, local communities and others to solve problems caused by persistent offending, helping people live their lives free from crime, disorder and danger. To ensure that all deaths reported to the Procurator Fiscal (PF) are investigated appropriately. To provide services that meet the information needs of victims, witnesses and nearest relatives, in co-operation with other agencies. To respect and protect diversity, and promote tolerance. (www.copfs.gov.uk)
The Procurator Fiscal (PF) is a lawyer employed within COPFS, which is part of the Scottish Government, and performs in the role of public prosecutor with a duty to investigate all sudden, suspicious, accidental, unexpected and unexplained deaths. He/she must also investigate deaths which occur in circumstances that cause serious public concern.
Scotland is divided into eleven geographical areas by COPFS and each area is headed by an Area Procurator Fiscal. Each area contains a number of district offices which are headed by a District Procurator Fiscal, with each district office having one or more Deputy Procurator Fiscal who can exercise all the powers of the Procurator Fiscal. The only exception to this is Glasgow, which is an area in its own right.
Responsibility for investigating a death rests with the Procurator Fiscal (PF) in whose jurisdiction the accident or event leading to death occurred. For example, if a person is injured in a climbing accident in Glencoe and is taken to the Southern General Hospital, Glasgow where he/she dies, the death should be reported to the PF in Fort William which is nearest to Glencoe (Death and the PF, COPFS, 2008). Certain areas, such as Glasgow, have centralised death units while other areas have local offices.
A protocol has been drawn up between COPFS and the Scottish Transplant Group (currently under review) with regards to organ and tissue donation. The most important points are: Where there is reason to believe that the death may be reported to the PF, no parts of a body will be removed without his/her prior consent The PF may object to removal of organs in a case which is likely to result in a charge of murder, or where, in the time available insufficient enquiry is able to be carried out to allow an informed decision. There are procedures available which will allow the PF not to object to transplantation of organs in cases of murder but early discussion with the PF is essential. The PF will normally permit removal of organs subject to the need to ensure that sufficient evidence is available for any criminal proceedings or Fatal Accident Inquiry (FAI) and the need to establish that the death has not been caused or contributed to by the retrieval operation. FAIs are held under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976. An inquiry must be held in cases of death in custody or as a result of an accident at work.
The purpose of an FAI is not to apportion blame for the death in either the civil or criminal sense. An FAI may be held in other cases of sudden, suspicious or unexplained death, or death in circumstances that give rise to serious public concern. Decisions on whether these discretionary inquiries are held are made by the Lord Advocate.
A FAI is essentially a fact-finding exercise carried out in the public interest. The rules of evidence and the standard of proof are as for civil cases in Scotland. The purpose of an FAI is to determine: Where and when the death took place. The cause of the death. Reasonable precautions whereby the death might have been avoided. The defects, if any, in any system of working which contributed to the death or any accident resulting in the death. Any other relevant facts relevant to the circumstances of the death. Procurators Fiscal investigates around 14,000 sudden deaths each year. There are usually around 50 or 60 FAIs in Scotland each year. FAI recommendations are made by sheriffs at the conclusion.
(Death and the PF, COPFS, 2008).