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Unnatural Death 2017 - Dr Mark Burgin

26/07/17. Dr Mark Burgin BM BCh (oxon) MRCGP considers how a low-cost generalist screening report can assist the coronial process.

Coroners become involved with deaths where the cause is unknown, violent, where the person was deprived of liberty or the death (not cause) is unnatural.

The coroner depends upon the relatives of the deceased to provide evidence where the death was unnatural due to improper or negligent treatment (clinical negligence).

Once opened, an inquest addresses 4 questions about the death - who, when, where and how – but the inquest will not further consider the clinical negligence. (1)

Where a death was, e.g. on a terminal care pathway, the Coroner will consider Article 2 of the European Human Right Act and whether a larger inquest is required. (3) (2)

Investigating the death

The Coroner investigates a death by asking for statements and a pathologist performs a post mortem examination to confirm the death was from natural causes.

Where the death has been caused wholly or partly by improper or negligent treatmentthe death will be unnatural even if the pathologist has said that it was natural causes.

Understanding the difference between a death from natural causes and an unnatural death is difficult. e.g. pneumonia where a doctor failed or delayed antibiotic treatment is unnatural.

The relatives can instruct an expert to write a low-cost generalist screening report to show the coroner that there is reasonable suspicion that the deceased has died an unnatural death.

Chain of Causation

There must be a chain of causationand the Coroner will only inquire into acts and omissions that are directly responsible for the death but will thoroughly examine all steps in that chain. (4)

The relatives may want the coroner to consider the broad circumstances and may have specific questions on whether an individual doctor’s action contributed to the death.

The relatives can tell the Coroner at an inquest anything that they feel is important but the Coroner can only look deeper if an action that led to the death was not too remote.

The screening report is not limited in this way and can assist the family by considering whether any individual professional might have contributed to the death.

Coroner’s conclusions

Coroner’s conclusions can disappoint relatives who expect the type of verdict given in other courts but understanding that conclusions are written in code can help.

A narrative conclusion may use words such as; contributed to, because, inadequate, inappropriate, insufficient, lacking, unsuitable, unsatisfactory and failure.

Neglect goes further than clinical negligence as it is a gross failure to provide basic medical attention e.g. when doctor on balance fails to make simple (‘basic’) checks that leads to the death.

The level of proof required for conclusions varies from unlawful killing (beyond reasonable doubt), accident, alcohol or misadventure (on balance) or open (insufficient evidence). (5)

The conclusion misadventure means a deliberate human act which unexpectedly and unintentionally goes wrong e.g. sporting accident but can be used where a doctor has made a mistake.


The strength of the Coroner system is that by not attempting to assign blame it can maintain independence and authority but depends on relatives to raise concerns.

The Coroner’s role is to bring the facts of the case to the public and with powers and resources that are not available to the normal person.

Coroners typically conclude their findings in less than a year and can make a report how to avoid similar deaths in future and to improve medical care.

The Coroner’s inquest may close a chapter or raise further questions but always gives the family useful information as to whether the issues are worth pursuing.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website

  1. R v HM Coroner for Western District of East Sussex, Ex p Homberg (1994)

  2. R v HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson [1995] QB 1.

  3. R (Middleton) v HM Coroner for West Somerset [2004] 2 AC 182)

  4. Coroners and Justice Act 2009

  5. Chief Coroner 2016 guidance number 17 Conclusions: Short-Form and Narrative

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