The Royal Liverpool Children's Inquiry  
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Recommendations
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Chapter 9. The Coroner
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Recommendations for Coroners
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  • The Coroners' Society shall instruct Coroners that:
    • in the proper exercise of their judicial discretion, the decision to order a post mortem examination is not to be delegated to Coroner's Officers and Deputy Coroners must be available at all times;
    • organs are not to be retained unless relevant to establishing the cause of death and only when specified by the pathologist in writing.
  • The Home Office and the Coroners' Society shall ensure all necessary medical education for Coroners.
  • The Home Office and the Coroners' Society shall ensure all necessary training of Coroner's Officers and ancillary staff.
  • Coroners shall be introduced, their function and procedures explained and the next of kin invited to express any specific concerns and requests.
  • If a decision is made to authorise a post mortem examination Coroners shall ensure that the next of kin are advised of:
    • the reasons for authorising the post mortem examination;
    • their right to ask the Coroner that the examination be carried out by a pathologist independent of the hospital in which the deceased died;
    • the place and time of the examination and the identity of the pathologist;
    • the nature of the examination, including the need to open the body and to remove and weigh organs;
    • the need for samples and possible retention of organ;
    • their option to delay the funeral, while the pathologist fixes and examines any organs, to enable the return of the organs to the body for burial or cremation;
    • their option for a funeral without the return of the organs, in which case they shall be invited to consent to respectful disposal by the Coroner;
    • their option to make their own arrangements for respectful disposal of the organs.
  • If a decision is made not to authorise a post mortem examination, Coroners shall notify the next of kin of that decision and give sufficient reasons for the decision.
  • Coroners shall ensure the expeditious examination and recording of samples and organs.
  • Coroners shall establish efficient systems for securing final post mortem reports following histological examination.
  • Coroners shall ensure that all existing retained organs, tissue, blocks, slides, photographs and X-rays are specified within any preliminary and final post mortem reports.

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Last updated 30th January 2001

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