Coroners

Coroners have existed since the 12 th century when they were created to support itinerant judges and, thus, facilitate the levying of fines on people living in England and (following the Edwardian Conquest) those in Wales. Over the centuries, the medieval coroner lost this function and his descendants have, in spite of a long-standing lack of central guidance, been forced to reinvent the coronial identity and to discover a modern purpose. The coroner operates in the space between law and medicine. Consequently, the coroner has been forced to adapt to the development of medical science, the normalisation and codification of human rights, and the development of the theory and practice of public health. Recent scandals -most notably the inquiry into the crimes of Harold Shipmanhave highlighted the shortcomings of the office and have resulted in calls for reform.

This article critically analyses the present system of investigation of death in Sri Lanka and aims to identify its shortcomings and make recommendations for necessary reforms. Part 01 of the article contains a brief overview of the death investigation system in the ancient Sinhalese Kingdom, History of the English Coroners system and its introduction to our country. Part 02 lays down the statutory provisions and relevant judgments in relation to the inquest procedure, function and duties of an inquirer and government circulars and regulations in relation to appointment, payment, and conduct of the inquirer.  Shortcomings and the positive features of the present system as reflected by this study are discussed in Part 03. The recent developments of the Coroners system in England has been taken in to consideration in Part 04 in making suggestions for necessary reforms stated in Part 05.

Abstract
Coroners have always been associated with investigating death, but this ancient office has undergone considerable reform since its creation in twelfth century England. The original function of the office of coroner was linked to raising revenue for the King in the form of large fines. Over time this office began to focus on investigating violent, suspicious and unnatural deaths. It was this “modernised” English coronial institution that formed the foundation of coronial law and practice in Australia. Queensland adopted the English common law system from New South Wales upon separation in 1859. Consequently the office of coroner was also transplanted to the new colony. This thesis looks at the first one hundred years of the office of coroner in Queensland, discussing the factors that led to its transformation between 1859 and 1959. The resulting history provides a platform to examine how the institution was formed and how it evolved into the system we recognise today. The data collected revealed a picture of a parsimonious government that marginalised the office of coroner in Queensland legislation. The government undervalued the institution of the inquest as a forum for public scrutiny and an instrument of justice and accountability. This thesis presents an administrative and social history that fills a significant gap in the history of the coroner. It also contributes to aspects of colonial legal and medical history, drawing on previously untapped sources.

On behalf of the Los Angeles Civil Grand Jury (CGI), KH Consulting Group (KH) set up a Steering Committee composed of representative from the:
- County of Los Angeles, Department of Children and Family Services (DCFS)
- County of Los Angeles, Department of Mental Health (DMH)
- County of Los Angeles, Department of Public Health (DPH)
- District Attorney's Office
- Harbor-UCLA Medical Center
- Inter-Agency Council on Child Abuse and Neglect (ICAN)
- County of Los Angeles, Department of Coroner
- Los Angeles City Attorney’s Office
- County of Los Angeles, Sheriff’s Department – Special Victims Bureau
- Los Angeles Police Department (LAPD), Juvenile Division – Abused Child Section

KH facilitated a collaborative process with these participants to develop recommendations that would mitigate the number of children who die each year in the custody of the Department of Children & Family Services.  Besides a robust set of recommendations, new, cooperative working relationships were developed between these agencies that should bode well for future positive changes.

The scenario presented to the class was about child pornography. The case will be based on the certified reconstruction of computer usage, with the examination of remaining data, confirmed by that of the same data of computer forensics methodology or explanation of the technical distinctive part.

The forensic investigator’s job will most likely be completed in stages detailing the goal of finding child pornography on the computer’s hard drive of the perpetrator and identifying such by extracting all relevant data within the system.

The privilege against self-incrimination has a venerable history in the conduct of coroners' inquests. However, recent statutory reforms to the privilege in coroners' courts, which have had disuniform outcomes throughout Australia, have complicated the circumstances in which the privilege is extended to those claiming its protection. This editorial reviews the evolving law on the privilege generally and rulings that have been made in high-profile coronial inquests, as well as the modest volume of appellate litigation on this important issue. It identifies that the emerging law on the area prioritises amongst relevant factors for the coroner's discretion to exercise coercive powers over witnesses' objections to give evidence the fact that they are charged with serious criminal offences, and that the need for and utility of the evidence are also functioning as important considerations.

The entire legal profession – lawyers, judges, law teachers – has become so mesmerised with the stimulation of the courtroom contest that we tend to forget that we ought to be healers – healers of conflicts. 1 For more than a decade, analyses of coronial processes inspired by both therapeutic jurisprudence and restorative justice have identified the potential for maximising the therapeutic and public health benefits of the investigative functions of coroners' courts and minimising their counter-therapeutic potential. The focus of both scholarly literature and law reform proposals has been upon addressing deficits in respect of the role of families in coronial investigations and especially coroners' inquests. This has been a constructive contribution and has improved sensitivity to the risk that family members will be disenfranchised and alienated at a highly vulnerable time after they have been bereaved. This article chronicles the development in awareness of such issues. However, the potential for adverse effects on parties other than family members has been inadequately recognised in the literature, save for empirical studies conducted in 2011 for the Coronial Council of Victoria and another study published in 2014 in New Zealand. This article seeks to redress that imbalance. It argues that it is appropriate also to have regard to such potential in endeavouring to provide an approach to the work of coroners that is influenced by the sensibilities of therapeutic jurisprudence and seeks to reduce, so far as possible, counter-therapeutic outcomes for all parties, while at the same time prioritising accurate and robust fact-finding and formulation of constructive recommendations to avoid avoidable deaths. It calls for further empirical research on the impact of coroners' investigations on all affected parties and argues in favour of extension of improved funding to enable approaches to be informed by therapeutic jurisprudence and in particular to enhance eligibility for the counselling services attached to coroners' courts.

The problems of forensic pathologists’ court testimony leading to wrongful convictions in cases of infant death, especially where mothers are charged with the offence, and of this testimony possibly involving gross distortion of
scientific findings arise, in part, through a systematic misunderstanding by the law, and by judges and jurors, of forensic pathologists’, and especially coroners’, attitude toward their professional obligations. The law takes forensic pathological and coronial testimony to be ‘‘disinterested’’ scientific fact advanced purely for its inherent value in assisting the truth-seeking element of the trial process, and thus highly reliable as the basis of the exercise of the most coercive powers of government. Those delivering the testimony understand their task as part of a broader, long-standing public health and safety mandate to ‘‘speak for the dead to protect the living.’’ This clash of discursive frameworks has undermined the adversarial element of these trials, not just on a contingent case-by-case basis but over the courses of extended campaigns against child abuse and of professional forensic pathological careers.

Começo esta apresentação agarrando parte do próprio título, para emprestar um melhor contorno à expressão "iniciativas legais", aproveitando assim para explicitar que tenho por tal, todo o conjunto de actos que podem ser executados em conformidade com o sistema jurídico português. E já agora, acrescento que este sistema, integra, tanto os princípios gerais de Direito, como a legislação em vigor.

Research notes the broad complicity of white public officials in historical racial violence and repression. These discussions emphasize the role of criminal justice actors in perpetrating and enabling this repression. Extending this assessment, the authors examine coroners’ facilitation of white racial dominance through administrative performances constructing white innocence. Using cases from post-Emancipation South Carolina, the authors document race-related patterns of exculpatory effort, through the omission and curation of evidence amid the post-Reconstruction rise of white supremacist redemption. The authors theorize that these exculpatory efforts helped sustain an ideology of white innocence and institutional legitimacy by constructing a white “law-abiding” public. The authors argue that such coroner misconduct not only degrades the rule of law but has broader implications, including its corruption of the corpus of mortality and crime data. Finally, the authors suggest that these administrative performances persist in present-day coroner reporting, including in the exculpation of racist police violence.

This article explores the abolition in 1846 of the deodand – the object or animal declared responsible for death by an inquest jury – and its relationship with the family of the deceased.  Drawing on the works of Jacques Donzelot and Philippe Aries, it argues that the deodand brought contingency into the heart of law, and that its replacement with a legal right to compensation for dependents was a move to rationalise the investigation of death.  This rationalisation had consequences; limiting the place of the unruly community, centring and regulated the family, and disconnecting the inquest from the material of death.

Government intrusion into the homes of the working-classes gained momentum through the late nineteenth and early twentieth century. One hitherto unexamined piece of legislation that sought to regulate behaviour was a clause in the Children Act 1908 pertaining to the use of domestic fireguards. This transpired because of the outcry of coroners who conducted inquests into the deaths of children fatally burned in their homes, supposedly a safe refuge, a space constructed as a maternal responsibility. Coroners increasingly believed such accidents were a result of either maternal carelessness or negligence, especially those involving unguarded fires and absent mothers. Yet, limited by inadequate laws and unwilling juries, the coroner could do little but admonish the mother. However, growing Government concern over the abilities of working-class mothers and the health of the nation finally brought the issue of absent fireguards and burnt children to Parliamentary debate, culminating in a provision which appeared to have been aimed more at prevention than punishment.

Coronial law and practice inevitably impact upon the human rights of those affected by deaths. It is important that such rights be incorporated in how death investigations, up to and including coronial inquests, take place. This article explores the significant impact of the jurisprudence emanating from the European Court of Human Rights, as well as the application of such law by the courts of the United Kingdom and potentially in other countries. It argues that viewing the work of coroners through the lens of human rights is a constructive approach and that, although in the coronial legislation of Australia and New Zealand, many human rights, especially those of family members, and civil liberties are explicitly protected, there remain real advantages in reflecting upon compliance with human rights by death investigation procedures and decision-making.

Proper certification of death has legal, social, and epidemiological significance. There is unfortunately little in the existing medical literature relevant to such an important issue in Singapore. With the implementation of the Coroners Act 2010, there has been recent surge in interest in this matter, highlighting a need for additional instruction on the accurate completion of death certificates. This review explains how a death certificate should be filled out, with particular focus on the difference between the terms cause, mechanism, mode, and manner of death. The article is aimed at doctors in Singapore, and highlights legal and practical issues.

In keeping with recent critiques of literature on the body and the life course, the argument of this paper is that social identities can, to a certain extent, be constructed post-mortem and in the absence of a living body. The authors make this case with reference to a sociological autopsy study of a hundred suicide case files in a coroner's office in a medium-sized British city. The research draws on ethnographic approaches to the study of documents. There is discussion of some of the diverse artefacts in the coroners' files: medical reports, witness statements and suicide notes. The identity work revealed in these sources is as much about the living as the dead and is especially bound up in the process of avoiding blame.

The Salt-Overly-Sensitive (SOS) pathway controls the net uptake of sodium by roots and the xylematic transfer to shoots in vascular plants. SOS3/CBL4 is a core component of the SOS pathway that senses calcium signaling of salinity stress to activate and recruit the protein kinase SOS2/CIPK24 to the plasma membrane to trigger sodium efflux by the Na/H exchanger SOS1/NHX7. However, despite the well-established function of SOS3 at the plasma membrane, SOS3 displays a nucleo-cytoplasmic distribution whose physiological meaning is not understood. Here, we show that the N-terminal part of SOS3 encodes structural information for dual acylation with myristic and palmitic fatty acids, each of which commands a different location and function of SOS3. N-myristoylation at glycine-2 is essential for plasma membrane association and recruiting SOS2 to activate SOS1, whereas S-acylation at cysteine-3 redirects SOS3 toward the nucleus. Moreover, a poly-lysine track in positions 7-11 that is unique to SOS3 among other Arabidopsis CBLs appears to be essential for the correct positioning of the SOS2-SOS3 complex at the plasma membrane for the activation of SOS1. The nuclear-localized SOS3 protein had limited bearing on the salt tolerance of Arabidopsis. These results are evidence of a novel S-acylation dependent nuclear trafficking mechanism that contrasts with alternative subcellular targeting of other CBLs by S-acylation.

This article combines several different literatures (legal, medical and theoretical) in order to explore privacy law cases which involve accident survivors. I adopt an inductive methodology which emphasises the accident survivors' experiences. Their accounts demonstrate their position of special vulnerability. However, accident survivors currently receive inadequate protection because the New Zealand privacy tort does not recognise their special vulnerable status. The accident survivors' privacy claim in Andrews v TVNZ, for example, failed because the Court held that the publication was not highly offensive. The legal status quo is problematic because accident survivors whose privacy has been breached expect the law to provide protection at a time when they are vulnerable and unable to protect themselves. The privacy intrusions experienced by accident survivors cause adverse health outcomes. Alternative perspectives from theoretical and empirical medicine reveal the extent of the problem and help to suggest necessary reforms. This literature justifies recognising accident survivors as a special class of plaintiffs. New Zealand's privacy tort could be reformed by presuming that they have a reasonable expectation of privacy and that images of accidents are distressing and humiliating.

"Few scholars have investigated infanticide in modern Britain. Still less work has explored the connection between feminist analyses of this issue during the 1870s—a time when child homicide was perceived as endemic—and its relationship to other, more well-known campaigns by the women’s movement that also focused on the double standard of sexual morality as embodied by law. This article re-evaluates the response to judicial treatment of infanticide issued by the feminist-led Committee for Amending the Law in Points Wherein it is Injurious toWomen (CALPIW) and the Vigilance Association for the Defence of Personal Rights (VADPR). It argues that until a VADPR-sponsored civil damages case was defeated at the Court of Appeal in 1881, the feminist critique held the possibility of radically reshaping women’s medico-legal treatment in England and Wales. Its ultimate failure, moreover, explains the surprising absence of infanticide as a specific campaign issue for the British women’s movement from the 1880s until shortly before the First World War."

The Coroners and Justice Act (2009) represents the latest in a long series of legislative and policy measures aimed at reforming the coroner system. Unfortunately, the Act represents a continued failure to recognize that the legal orientation of the coroner system threatens its capability to contribute to adequate cause-specific disease surveillance and, in doing so, to fulfil its proper role in a public health system.

Following a sudden or unexpected death, coroners are generally tasked with announcing the death to the next-of-kin (NOK). It is arguably one of the most difficult duties a coroner engages in, especially considering how little death-telling training they receive. Correspondingly, it is likely the worst news the NOK can hear. The DN process has been perceived by outsiders and researchers as a one-time, unilateral death-telling event. I will argue that it is, instead, an interactional process with multiple actors and mechanisms. It does not begin or end with the death-telling event but is only part of the process for the coroner and the NOK. How can we improve the process of DN for those who necessarily participate in it? By conducting research in order to discover how the interactional process can be ameliorated to force profound changes that will challenge existing DN practices. This paper will examine the DN process from a Symbolic Interactionism (SI) perspective between coroners and NOK using a Grounded Theory (GT) methodological framework. Symbolic Interactionism (SI) informs an analysis of actions and meanings in those actions, while GT provides the tools to make theoretical sense out of those actions and meanings.

Following a sudden or unexpected death, coroners are generally tasked with announcing the death to the next-of-kin (NOK). It is arguably one of the most difficult duties a coroner engages in, especially considering how little death-telling training they receive. Correspondingly, it is likely the worst news the NOK can hear. The DN process has been perceived by outsiders and researchers as a one-time, unilateral death-telling event. I will argue that it is, instead, a series of interactional processes with multiple actors and mechanisms. It does not begin or end with the death-telling event but is only part of the process for the coroner and the NOK. How can we improve the process of DN for those who necessarily participate in it? By conducting research in order to discover how the interactional process can be ameliorated to force profound changes that will challenge existing DN practices. This paper will examine the DN process from a Symbolic Interactionism (SI) perspective between coroners and NOK using a Grounded Theory (GT) methodological framework. Symbolic Interactionism (SI) informs an analysis of actions and meanings in those actions, while GT provides the tools to make theoretical sense out of those actions and meanings.

The autumn of 1918 marked the onset of the Spanish Influenza, one of the worst disease pandemics in recorded history. It is estimated that one-third of the global population was afflicted, with an estimated 50 million deaths worldwide – over half a million of those being American citizens. This disease was highly virulent due to its comorbidity with pneumonia and tuberculosis, with a tendency to selectively target males within the young and middle adult cohorts. Previous research examined the relationship between cause-of-death and patterns of postmortem disposition during the 1918 influenza outbreak in Milwaukee. Results indicated a discrepancy in postmortem treatment based on location of death. A distinction between County Cemetery and Potter’s Field burial location was revealed. However, no known spatial boundary exists for these areas within the greater county grounds complex. The present study employs documentary data from Milwaukee County, Wisconsin to investigate the causative power of medical specialization (i.e. physician v. coroner) on designated burial location. Results indicate that the level of medical expertise does play a role in burial location. There is a high degree of variation in physician burial designation compared to the coroner level, which exclusively places individuals within a Potter’s Field or anatomical purposes. Further investigation could not discern an obvious pattern based on age-at-death, sex, ancestry or the date, cause or location of death. Therefore, an undisclosed, possibly financial, factor may be responsible for the locational discrepancy. Designated burial location plays a role in postmortem identity within this context and requires additional research.

Research notes the broad complicity of white public officials in historical racial violence and repression. These discussions emphasize the role of criminal justice actors in perpetrating and enabling this repression. Extending this assessment, the authors examine coroners’ facilitation of white racial dominance through administrative performances constructing white innocence. Using cases from post-Emancipation South Carolina, the authors document race-related patterns of exculpatory effort, through the omission and curation of evidence amid the post-Reconstruction rise of white supremacist redemption. The authors theorize that these exculpatory efforts helped sustain an ideology of white innocence and institutional legitimacy by constructing a white “law-abiding” public. The authors argue that such coroner misconduct not only degrades the rule of law but has broader implications, including its corruption of the corpus of mortality and crime data. Finally, the authors suggest that t...

Understanding the causes of deaths and how they can be prevented is critical for improving healthcare outcomes. At a population level, over-reporting or under-reporting of deaths can have a profound impact on policy decisions, which in turn affect global economies and the day-to-day lives of citizens. At the individual level, understanding how and why deaths occur may prevent similar deaths or serious harms from occurring in the future. One in 20 people are exposed to preventable harms in medical settings globally, and 12% of preventable harms result in disability or death.1

The idea of the nineteenth-century urban working-class home as a “thoroughfare” has recently begun to be turned on its head through a reinterpretation of contemporary accounts. Yet, this re-imagining of boundaries is still heavily reliant on middle-class accounts of working-class homes. My work addresses this issue by establishing the thresholds of the nineteenth-century urban working-class home through the words of the inhabitants themselves. Specifically, this paper (and my wider research on the working-class home) draws on coroners’ inquests in order to gain access to these homes and the testimonies of daily practices from the inhabitants therein, in order to show that their thresholds—while not necessarily physically strong—were clearly delineated by inhabitants and there were well defined practices among the working-class community when it came to entering each other’s homes. I will argue that these boundaries were far from fluid or non-existent, as frequently described by social commentators of the time. In conclusion, this paper, by drawing on the testimonies of actual inhabitants, further refutes the idea of the home as a “thoroughfare” and suggests that perhaps the nineteenth-century urban working-class home is better defined as “An Englishman’s Castle.”