This Special Issue, Frontiers in Coronial Justice, reflects on the future of death investigation studies in the coronial context. Where the uptake of the death studies movement in the social sciences more broadly has expanded the interdisciplinary study of death, comparatively little attention has focused on the work of coroners or their death investigation practices. Important, but albeit ad hoc, contributions from the disciplines of medicine, law, public health and criminology, highlight both the possibilities for coronial scholarship and how coronial studies continue to percolate at disciplinary margins. And yet, there is growing social attention to death generally, from death cafés to death salons, and the ‘positive death movement’ more broadly. Society is clustering around conversations seeking social change in facing death, including preparatory discussions around end of life wishes and options. Yet, by their very nature, unexpected, sudden or violent deaths – those that fall under the jurisdiction of the coroner – constitute a distinct category of death; one that is, in many ways, incapable of being prepared for. Nevertheless, such deaths present instances of considerable medical, legal and social industry, with attendant issues around autopsy and inquests, for example. This industry is also changing, as coronial law and policy reform across international jurisdictions has refined, clarified and sought to evolve the coronial role. Together, these developments evidence why coronial law and practice deserve sustained attention. Correspondingly, a theme that unites the papers in this special issue is a greater appreciation of the principles and practices of coronial death investigation. It is intended that, by showcasing work that cuts across law, socio-legal studies, criminology and history, this Special Issue will contribute to delivering new frontiers in coronial research.
At a snapshot, the genres of scholarly attention to the coronial jurisdiction are wide and varied. Coroners’ work has intermittently piqued the attention of socio-legal scholars (e.g. Wells, Reference Wells1991, Reference Wells, Lee and Morgan1996; Sampson, Reference Sampson2003; Pemberton, Reference Pemberton2008; Corrin and Douglas, Reference Corrin and Douglas2008), and legal scholars have canvassed specific issues, such as human rights, in the context of coronial work and litigation (Hunyor, Reference Hunyor2008, Reference Hunyor2009; O'Brien, Reference O'brien2009; Ismail, Reference Ismail2010; Hyam, Reference Hyam2010; Chevalier-Watts, Reference Chevalier-Watts2010; McIntosh, Reference Mcintosh2012; Freckelton and McGregor, Reference Freckelton and Mcgregor2014), including literature that touches upon deaths in certain contexts, such as Northern Ireland (e.g. Bell and Keenan, Reference Bell and Keenan2005). Save few exceptions, criminological scholarship is found largely wanting on any wholesale attention to theorising death investigation. As a research focus, coronial work has been addressed through methodological questions, such as the value of using coronial data (e.g. Pelfry and White Covington, Reference Pelfrey and White Covington2007), or where coronial processes and documents (coronial findings, inquest proceedings and transcripts) form the basis for case-study research (e.g. Cunneen, Reference Cunneen2006; Prenzler, Reference Prenzler2010; Porter, Reference Porter2013). Until recently, case-based research has comprised the most significant body of criminological consideration of death investigation practices and systems, and has centred on controversial deaths, with a predominant focus on deaths in custody and policing-related deaths, but extending to deaths in disasters and other scenarios (e.g. Warwick Inquest Group, 1985; Scraton and Chadwick, Reference Scraton and Chadwick1986, Reference Scraton and Chadwick1987; Hogan, Brown and Hogg, Reference Hogan, Brown and Hogg1988; Hogan, Reference Hogan1991; Beckett, Reference Beckett1999; Scraton, Reference Scraton1999).
Nonetheless, this criminological work has delivered a concentrated and critical body of contributions to inquest study, typified by the signal work of Phil Scraton (e.g. Scraton and Chadwick, Reference Scraton and Chadwick1986, Reference Scraton and Chadwick1987; Scraton, Jemphrey and Coleman, Reference Scraton, Jemphrey and Coleman1995; Scraton, Reference Scraton1999, Reference Scraton2002, Reference Scraton2004, Reference Scraton2006, Reference Scraton2013), who has queried inquests into controversial deaths since the 1980s. This research has scrutinised not only practices such as policing, but also official responses to deaths in certain contexts. In a damning indictment, Scraton's research has highlighted how official discourses on death, including coronial inquests, are shot through with ‘powerful political-economic interests’ shaping the material conditions of life and death (Scraton, Reference Scraton2002, p. 110). The delivery of justice in the form of coroners’ inquests has been critiqued for being ‘sustained by ideologies which are expressions of structural inequalities’ around race, class, patriarchy and childhood, and which become ‘powerful determining contexts’ in explanations of death (p. 110). Correspondingly, through case-based research, the form and procedures of inquests have been analysed to reveal a litany of deficiencies that ultimately compromise the inquest's value as a truth-seeking exercise, leaving researchers underwhelmed, the truth degraded, and the bereaved denied justice (Scraton, Reference Scraton1999, p. 273; Reference Scraton2002; Warwick Inquest Group, 1985).
Despite these exceptions and promising theoretical beginnings, criminologists and socio-legal scholars have still tended to neglect the coronial jurisdiction as a site of justice and injustice, or afford it steady theorising across its jurisdictional idiosyncrasies. Research into coronial practice, turning on specific issues, has gained a foothold in disciplines such as medicine (e.g. Buchanan and Mason, Reference Buchanan and Mason1995; Ranson, Reference Ranson and Oxenham2008, Reference Ranson2010; Lynch and Woodford, Reference Lynch and Woodford2014; Middleton and Buist, Reference Middleton and Buist2014; Middleton, Reference Middleton2015; Moore, Stokes and Gray, Reference Moore, Stokes and Gray2016), public health (e.g. Bugeja and Ranson, Reference Bugeja and Ranson2003; Biddle, Reference Biddle2003; Hill and Cook, Reference Hill and Cook2011; Carroll, Hawton, Kapur, Bennewith and Gunnell, Reference Carroll, Hawton, Kapur, Bennewith and Gunnell2011; Neuilly, Reference Neuilly2013; Sutherland, Kemp, Bugeja, Sewell, Pirkis and Studdert, Reference Sutherland, Kemp, Bugeja, Sewell, Pirkis and Studdert2014), law (e.g. McKeough, Reference Mckeough1983; Selby, Reference Selby1998; Freckelton Reference Freckelton, Freckelton and Mendelson2002, Reference Freckelton2006, Reference Freckelton2007, Reference Freckelton2008a, Reference Freckelton2008b, Reference Freckelton2009a, Reference Freckelton2009b, Reference Freckelton2010; Vines, Reference Vines2000, Reference Vines2007; Vines and McFarlane, Reference Vines and Mcfarlane2000; Freckelton and Ranson, Reference Freckelton and Ranson2006a, Reference Freckelton, Ranson, Freckelton and Peterson2006b; O'Marra Reference O'marra2006a, Reference O'marra2006b; King, Reference King2008; Gibson, Reference Gibson2008; Brazil, Reference Brazil2011; Prictor, Reference Prictor2012; Shircore, Reference Shircore2013; Moore, Reference Moore2014; Mok, Reference Mok2014; Aberdeen, Reference Aberdeen2016), sociology (e.g. Prior, Reference Prior1985, Reference Prior1989; Howarth, Reference Howarth and Mitchell1997; Hallam, Hockey and Howarth, Reference Hallam, Hockey, Howarth, Hallam, Hockey and Howarth1999; Gregory, Reference Gregory2014), and social work and psychology (e.g. James and Jones, Reference James and Jones1988; Drayton, Reference Drayton2013; Matthews, Fitzpatrick, Quinlan, Ngo and Bohle, Reference Matthews, Fitzpatrick, Quinlan, Ngo and Bohle2016; Dartnall and Goodman-Delahunty, Reference Dartnall and Goodman-Delahunty2016), with their expertise in grief, bereavement and death studies – disciplines that nevertheless examine key issues, such as the subordination of grief to justice concerns (e.g. Riches and Dawson, Reference Riches and Dawson1998). Other relevant contributions appreciate coronial history, including legal and cultural history (e.g. Hunnisett, Reference Hunnisett1961; Clark and Crawford, Reference Clark and Crawford1994; Burney, Reference Burney2000; Fisher Reference Fisher2007, Reference Fisher2011; Hurren, Reference Hurren2010; Sharpe and Dickinson, Reference Sharpe and Dickinson2011; Houston, Reference Houston2014; Butler, Reference Butler2014; MacDonald, Reference Macdonald2015), or recognise how the historical legacies of colonialism shape contemporary deaths (e.g. Razack Reference Razack2011a, Reference Razack2011b, Reference Razack2014, Reference Razack2015).
Given that coronial law mandates a response to a broad genre of deaths, it exposes a wide-ranging set of issues worthy of sustained examination. In response, criminologists and socio-legal scholars have reignited attention to the coronial jurisdiction, tackling a myriad of issues. Some literature is topic-specific, capturing Indigenous deaths and deaths in custody (e.g. Finnane and Richards, Reference Finnane and Richards2004; Cunneen, Reference Cunneen2006; Goldson, Reference Goldson2006; Scott Bray, Reference Scott Bray2008; Watterson, Brown and McKenzie, Reference Watterson, Brown and Mckenzie2008; Ransley and Marchetti, Reference Ransley and Marchetti2008; Razack, Reference Razack2015), policing (e.g. Martin and Scott Bray, Reference Martin and Scott Bray2013; Scott Bray, Reference Scott Bray2013; Baker, Reference Baker2016) and immigration custodial deaths (e.g. Powell, Weber and Pickering, Reference Powell, Weber and Pickering2015). Yet the field is now equally concerned with medical and legal epistemologies (e.g. Kramar, Reference Kramar2006; Carpenter and Tait, Reference Carpenter and Tait2010; Scott Bray, Reference Scott Bray2012; Leslie, Reference Leslie2013; Scraton, Reference Scraton2013; Barnes, Kirkegaard and Carpenter, Reference Barnes, Kirkegaard and Carpenter2014; Tait, Carpenter, Quadrelli and Naylor, Reference Tait, Carpenter, Quadrelli, Naylor, Berents and Scott2015), autopsies and cultural concerns (e.g. Carpenter and Tait, Reference Carpenter and Tait2009, Carpenter, Tait, Adkins, Barnes, Naylor and Begum, Reference Carpenter, Tait, Adkins, Barnes, Naylor and Begum2011, Carpenter, Tait, Quadrelli and Drayton, Reference Carpenter, Tait, Quadrelli and Drayton2015), coronial fact-finding (e.g. Scott Bray, Reference Scott Bray2010; Tait, Carpenter, De Leo and Tatz, Reference Tait, Carpenter, De Leo and Tatz2015), inquests in a new media age (e.g. Scott Bray, Reference Scott Bray2013), negotiating emotions, grief and trauma, and promoting wellbeing (Carpenter, Tait, Quadrelli and Thompson, Reference Carpenter, Tait, Quadrelli and Thompson2015; Trabsky and Baron, Reference Trabsky and Baron2016; Tait, Carpenter, Quadrelli and Barnes, Reference Tait, Carpenter, Quadrelli and Barnes2016), and the contours of coronial history (Leslie, Reference Leslie2008; Kirton-Darling, Reference Kirton-Darling2014; Trabsky, Reference Trabsky2015). Accordingly, it is against this background that each paper in this Special Issue contributes to moving coronial scholarship forward. They interrogate assumptions and expectations of the jurisdiction, manifest through an examination of coronial principles and practices, including open justice, collegiality, professionalisation and the contemporary challenges to, and expansion of, the coronial role.
Taking key coronial developments in the United Kingdom (UK) and Australia in recent years as their starting point, Rebecca Scott Bray and Greg Martin consider the coronial jurisdiction as one undergoing immense legal and policy reform, to illustrate why coronial law and practice deserve further scholarly consideration. They begin by tracing the contentious landscape of UK coronial law reform that has resonated internationally, including some of the core reform achievements in Australia, which have enshrined values around death prevention and familial recognition. Thereafter, they examine key controversies that threatened to disrupt UK reform, and which had the net effect of refocusing attention on the importance of the jurisdiction.
Scott Bray and Martin argue that, even in the light of substantial reform, and, in some ways because of it, many coroners are adjusting to revitalised coronial frameworks, which are throwing up both established and contemporary coronial challenges. The challenges include those relating to the public nature of this ancient office, human rights considerations, and, the bugbear of modern coronial aspirations, effective death prevention. And these challenges exist in the face of often highly emotionally charged circumstances. Ostensibly, then, coronial investigations are not reducible to mere fact-finding; they perform a much broader meaning-making task around death, and their justice work is complicated. Accordingly, Scott Bray and Martin argue that, in an era of significant reform, the nature of coronial death investigation is worthy of further attention.
In his paper, Sam McIntosh argues that the rationales for openness in inquests into use-of-force deaths at the hands of the state are very different to those rationales underpinning traditional conceptions of open justice in criminal and civil justice settings. However, while the families of deceased persons and the general public have legitimate interests in learning about the circumstances of use-of-force deaths at the hands of the state, the principles of openness and public accountability ought not to be taken for granted in such circumstances, since there needs to be a normative basis for these claims. McIntosh proposes that recognition theory provides the moral foundation for the prioritisation of openness in these cases of use-of-force deaths at the hands of the state. Moreover, recognition theory strengthens the value of openness because of its intrinsic link to non-redistributive and non-compensatory forms of justice.
McIntosh shows, for instance, how it is usual for the cause of a loved one's death to be explained to families by a physician, or by the police, or sometimes through an ordinary inquest. When the state fails to respond adequately to use-of-force death, misrecognition occurs and harm may accrue. To deny the right to know how a loved one died, when death occurs at the hands of the state, McIntosh argues, is to misrecognise the generally accepted right families of deceased persons have, where the right to the truth is a fundamental metaphysical need of all human beings. A sense of injustice will often result when families are denied the right to know the truth as to how a loved one died, or suffer long delays in obtaining it through a reliable, public and official narrative. Examples McIntosh uses to illustrate these points about truth, reliability and delay include the inquests into the Hillsborough tragedy of 1989, and the 2010 Saville Inquiry into the Bloody Sunday massacre of 1972, which has been criticised for its length and cost.
McIntosh concludes that the application of recognition theory raises questions as to whether the interests of families of deceased persons are adequately recognised. Given the potential harms associated with misrecognition, McIntosh suggests there may be a rebalancing of priorities that considers the consequences of misrecognition, such as arguments for providing public funding for families at inquests into use-of-force deaths, or renewed efforts to tackle the delays that are typical in these kinds of inquests. A normative understanding of openness here might also lead to more radical reform, which allows civil society organisations like the Howard League to intervene in certain inquests to advocate on behalf of certain groups that identify with deceased persons.
Similar to McIntosh, David Baker examines cases of death after police contact (e.g. road traffic fatalities, fatal shootings, deaths in police custody), where his interest is in how Article 2 of the European Convention on Human Rights (ECHR) has affected coronial processes and practices in England and Wales. Baker's argument proceeds in three parts. First, he argues, in cases of death after police contact, obligations imposed by Article 2 require that a more thorough and rigorous inquest be undertaken – an ‘Article 2 inquest’ – than was previously required prior to the enactment of the Human Rights Act 1998 (UK), which incorporates the ECHR. Second, juries sitting in Article 2 inquests have tended to record a new type of verdict, known as a ‘narrative verdict’, which identifies actions and omissions in cases of death after police contact, and increasingly highlights issues associated with the failings of multi-agency work, communication, training and risk assessment. Third, in cases of death after police contact, coroners are now mandated to produce reports if they believe lessons can be learned to prevent future deaths. The purpose of reporting is not only to provide post-inquest recommendations to prevent future fatalities, but also to disseminate information to relevant organisations identified during an inquest so as to promote public safety and promulgate better practice.
Baker argues that, although the coronial system in England and Wales has been affected greatly by Article 2 obligations, pre-existing structures and issues inherent in the coronial system have also affected the way those obligations have been implemented in practice. For example, the fact that the coronial system is regional in nature, has ambiguous roles and functions, and that coroners are noted for using discretion in the processes and practices they employ, means that the changes imposed by Article 2 have been rather piecemeal and driven mainly by precedent. It is Baker's argument therefore that while Article 2 obligations have driven significant reform in the way cases of death after police contact have been investigated in England and Wales, that has nevertheless occurred within the institutional constraints of the extant coronial system.
One of the structural issues characteristic of the coronial system in England and Wales, identified by Baker, is a lack of consistency in training and appointment, which is an issue that has some bearing on Myles Leslie's paper about collegiality as a central value of medically trained coroners who find it hard to see, and easy to dismiss, lethal practice as delivered by physician colleagues they investigate. Drawing on data gathered in the course of an ethnographic study (i.e. analysis of documents, interviews and direct observations), Leslie's focus is on in-care death investigations, that is, where medically qualified coroners, working at the Office of the Chief Coroner in Ontario, Canada, find themselves investigating the quality of care delivered by professional colleagues.
Leslie shows how medical professional norms and values can have a role to play in the official identification and reporting of deaths that occur under medical care. Significantly, Leslie argues, collegiality is also an instrument of trust that simultaneously provides investigators with tremendous access to information, yet severely limits the flow of that information into the public domain. Leslie argues that collegial deference and respect for the autonomy and expertise of fellow physicians tends to mean that coroners expurgate death certificates, which, in turn, obscures issues of (in)competence, and reduces the accuracy and reliability of certificates. By deferring to colleagues, coroners enact a core value of the medical profession, and in following the norm of collegiality they ensure investigations are kept as local as possible, and that matters of (in)competence are about private rather than public safety.
Medically trained coroners have certain advantages over lay coroners who arrive at in-care deaths carrying only the legal authority of their office. For instance, medically qualified coroners have both the hard technical and soft cultural skills that enable them to read both the content and between the lines of medical notes. Their combined status also puts them in an excellent position to enact collegiality to build trust with other health-care professionals in an investigation, as well as to identify and elicit information about in-care deaths. However, the enactment of collegial values to maintain trust and to keep information flowing also has significant limitations, including the routine expurgation of official, publicly accessible documents produced by medical coroners, the two main effects of which are: (i) to lower the official count of medical errors and issues of competence; and (ii) the sequestering of public safety decision-making into collegial forums. Consequently, Leslie shows how the content of death certificates is shaped by collegial norms, such that the incidence of medical error is underreported. In these circumstances, he proposes that a key intervention may be to focus on altering the perception that keeping things local and professional is the best response when confronting issues of harm and competence, which, he says, would appear to hinge on redefining medical error and competence as public safety issues rather than private collegial issues.
The coronial profession is also something that concerns Marc Trabsky in his paper, which looks at the development of the coronial manual as a technique of occupying office in the nineteenth and twentieth centuries. The manual, and its inventory of circulars, forms and precedents, defined the scope of the authority of the coronial jurisdiction, and provided instructions to guide coroners in court procedures, and in the performance of their duties and conduct towards the dead. It was also preoccupied with questions of technical knowledge, administrative procedure and bureaucratic governance. Accordingly, Trabsky shows how the language of prudence that characterised juridical treaties prior to the eighteenth century was gradually supplemented in the professional manual by technocratic discourse. The manual thus occupies an important role in the formation of the modern office of the coroner, and the professionalisation of that office. Moreover, Trabsky suggests, the history of the emergence of the coronial manual correlates with a story of empire, the bureaucratic expansion of colonial institutions, and the intensification of centralised governance.
Hence, while the eighteenth-century guidebooks always included forms and precedents for exercising colonial duties and obligations, the modern manual amplified the technocratic role coroners assumed in administrating justice in the colony, as evidenced by the embodiment in the manual of the language of technology, professionalism and institutionalisation. The handbook of the early twentieth century emphasised the liabilities and privileges of the role of coroner, and through the dissemination of the manual there developed greater coronial accountability, which also meant that coroners became integrated into the hierarchical career structure of the modern judiciary. However, the professionalisation of the coronial role did not signal coroners’ abdication of an ethics of responsibility. On the contrary, Trabsky shows how, precisely through the professionalised technology of the manual, the office of coroner held onto an ethics of responsibility.
For instance, modern coronial guidebooks, intended as comparative textbooks to guide a diverse readership (including students, doctors, barristers and coroners), not only set out the legal framework and devices underpinning standardised coronial practice, but also sought to provide practical advice on how coroners should behave in their public roles. Demonstrating clear crossovers with the arguments of Baker and Leslie, Trabsky shows how some of the most contentious aspects of the coronial manual pertained to rules about the discretion of coroners to hold inquests, where, much to the chagrin of the medical profession, for example, it was proposed that inquests into deaths in hospitals and asylums should fall under the scope of the coronial jurisdiction. Indeed, it was believed that coroners were duty-bound to investigate fatalities in those institutions so that the public could be assured that people undergoing medical treatment received proper care and attention. For Trabsky, the decision to hold an inquest here is not merely a matter of authority, but is about an ethics of responsibility, in that there was an obligation – rather than discretion – to hold an inquest, which was regarded as inherent to coroners’ conduct in office. In short, the coronial manual set out a range of jurisdictional techniques to guide coroners in forming lawful relations with the dead, but it also required that coronial bureaucrats perform their duties in a manner that retained the question of ethical conduct.
In the final paper of this Special Issue, Gordon Tait and Belinda Carpenter address issues surrounding suicide in a study using data from observations at inquests and semi-structured interviews conducted with coroners in England and Australia. In particular, they consider the factors that contribute to the underestimation of suicide rates in coronial systems, which, they argue, are three-fold. First, this systemic underestimation reflects the legacy of suicide as a criminal offence, such that although it is no longer a crime in most Western countries, suicide's long history as a criminal offence continues to have a significant contemporary effect on the way it is perceived, conceptualised and adjudged, especially in those countries where suicide is determined largely by coroners.
Second, because of the enduring stigma attached to suicide, coroners often find they are pressured by families of deceased persons to make findings other than that of suicide. This is particularly evident in England, where there are public coronial inquests for all suspected suicides, which means that English coroners are required to deal with grieving families when making their deliberations. Third, the functions of the coroner are no longer confined to traditional roles, such as death investigation and prevention, but increasingly go beyond the simple finding of facts to include a therapeutic role that might consider, for instance, how a finding of suicide might impact upon those left behind, and how to provide closure to grieving families, all of which affects the likelihood that coroners will determine a death as suicide.
Tait and Carpenter's results bear out these points, and in particular they highlight some of the differences between coronial determinations of suicide in England and Australia. For example, in England, where the standard of proof remains beyond reasonable doubt, deaths are less likely to be classified as suicide than they are in Australia, where the lower standard of proof, on the balance of probabilities, applies. In England, too, the use of narrative verdicts – also discussed by Baker – compounds the issue, since narrative verdicts describe the circumstances of death without categorising it. Also, in England, coroners tend to be more cognisant of the continuing social stigma associated with suicide and the possible impact that it might have on bereaved families. This means that they tend to perceive their roles as extending beyond administrative functions to include a concern for the emotional wellbeing of bereaved families. This is particularly so in England, but less so in Australia, where coroners appear to have little contact with bereaved families, and express limited responsibility for their post-death wellbeing.
Hence, we return to the arguments of McIntosh, who, it will be recalled, proposes that, in cases of use-of-force deaths at the hands of the state, recognition theory might provide the normative basis for the claims of families of deceased persons to know the truth about how their loved ones died. Even though Tait and Carpenter focus on suicide, their assessment of how English coroners perceive their role as encompassing a concern for the wellbeing of those left behind highlights the fact that coroners can perform an important governance function, insofar as achieving truth and justice for the dead and their families may have positive effects on the emotional and psychological health of the wider community.
