Inquests more likely for younger people and deaths from medical care complications

Coroners are more likely to hold inquests for deaths involving younger people or people who died of fatal complications from medical care, according to a study from University of Melbourne experts and published in CMAJ (Canadian Medical Association Journal.)

Coroners must usually be notified of a death if it was violent or unexpected, if the identity of the deceased is not known, or if the deceased was in the custody or care of the state when he or she died.

Australian researchers compared characteristics of deaths investigated through inquests with characteristics of the much larger number of investigations that take place behind closed doors. They looked at data on 20 379 deaths in five Australian states over seven and a half years; 1252 (6.1%) proceeded to inquest, and about half of those inquests were held at the discretion of the coroner.

The researchers found that inquests were much more likely for childhood deaths and much less likely for deaths among the elderly. Deaths arising from complications of medical care often prompted inquests, whereas suicides rarely did.

"There are several reasons why coroners have preferences for inquests in certain cases and not others," said lead author, Mr.Simon Walter from the Melbourne School of Population Health. "Some deaths, like those of children, are shocking to the community and there is often an expectation that a public inquiry be held. On the other hand, for other kinds of deaths, such as suicides, coroners may feel that they have little to say about how to prevent similar events in the future."

"Inquests, and the publicity surrounding them, shape public knowledge and understanding of death," said Professor David Studdert, co-author of the study, and leader of the research group at the University of Melbourne. "What this study shows is that the entire picture could be somewhat distorted because of choices made behind the scenes about which types of deaths to highlight."
"As governments around the world look to coroners to function as proactive agents of public health, not merely as passive investigators of death, there is a growing need to demystify coroners’ functions," conclude the authors.