First report of the Departmental Committee appointed to inquire into the law relating to coroners and coroners' inquests, and into the practice in coroners' courts.

  • Great Britain. Committee on Coroners.
Date:
1909
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Licence: Public Domain Mark

Credit: First report of the Departmental Committee appointed to inquire into the law relating to coroners and coroners' inquests, and into the practice in coroners' courts. Source: Wellcome Collection.

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    19 February 1909.) [ Continued. 1544. (Chairman.) I believe you are Anesthetist to University College Hospital ?—I am, and I am also Consulting Anesthetist to the National Hospital for Paralysis and Epilepsy, Queen’s Square, and Senior Anesthetist to the Royal Dental Hospital. 1545. And you are a past President of the Society of Anesthetists P—Yes. 1546. And for many years of your professional life you have devoted yourself to the administration of anesthetics ?—I have. 1547. What is your opinion as to deaths under anesthetics coming under the heading of unnatural deaths ?—That is rather a difficult question for me to answer. I can only say that lawyers with much more authority than I have are doubtful upon the point. 1548. Some coroners, I believe, hold that it is their duty, in every case of a death under anesthetics that is reported, to hold an inquest, while other coroners hold that they have a discretion P—Quite so. I take it that no death is natural except when you die in your bed from old age; a man who even dies from measles dies an unnatural death. 1549. But still you have more human intervention in the case of a death under anesthetics P—In some cases, yes. 1550. (Sir Horatio Shephard.) How do you distin- guish between that and an operation ?—Deaths after surgical treatment are probably “unnatural” deaths, as are also those of patients under any form of medical treatment. 1551. (Chairman.) Do you know what is done in Scotland ?—I know this much, that they have a private inquiry by the Procurator Fiscal. 1552. Does that work well, so far as you know ?—I believe so. 1553. Is there any special means by which he gets expert advice and help ?—I believe that he can call in an assessor—whether he does so in all cases I am not sure, but I am under the impression that he always has an assessor. 1554. When an inquiry takes place into a death under anesthetics, I think you say that there are two distinct questions involved P—Yes, I have put it in that way. Tess. Would you say what they are?—My first heading is, whether the death was actually due to the anesthetic. 1556. Due to it with or without other causes P— Yes. Then a further question is: was the anesthetic given for a lawful purpose and by a person qualified to administer it ? 1557. In your opinion are the existing coroners’ courts a satisfactory tribunal for dealing with those two questions >—If I may say so with submission to those who are present, I should say, asarule no. They may be in capable hands, but you cannot legislate for every- body, and in some cases the inquiry is a farce. 1558. What would you suggest as a better inquiry into the cause of these deaths P—I think that there ought to be someone, either an assessor or an expert present, to assist—either an officer like the Procurator Fiscal or the coroner. 1559. Do you think that a jury is of any use or not in these cases ?—They are quite useless. The advantage of having the Procurator Fiscal is that he would probably have a wider experience in all cases brought before him, and he would get the hang of the thing better than a man who has comparatively few. I do not, of course, mean to say for a moment that many coroners do not do their work extremely well, but they do it without regard to the jury ; they tell the jury what verdict to come to. 1560. We know that there are some 360 coroners, and we also know that some of them receive the magnificent salary of 41. a year?—What can you expect ? 1561. The jury, of course, naturally have no know- ledge of the medical questions and medical terms, and the proceedings in a delicate inquiry of this kind must be absolute Greek to them ?—Absolute Greek. 1562. So that the whole matter turns on what the coroner says to them ?—Entirely. 1563. Therefore, the coroner by himself would be a more satisfactory tribunal ?—Much more satisfactory, but it would depend upon the coroner s knowledge. 1564. Especially, in your opinion, if he was assisted by a medical assessor P—Yes, with adequate knowledge of the subject. 1565. An expert assessor P—Yes 1566. Would there not be this difficulty about an expert assessor? You have got about 360 coroners, and you would require a considerable body of men available for going about the country if you are to have an expert inquiry in each case of death under anzsthetics >—Of course, without the figures before one, one would not know how much time would be involved in it.’ It is a question, of course, whether all cases would have to be inquired into. The duty of the coroner I believe is to ascertain the cause of death. If this involves crime the jury return a verdict in that sense. In most cases of deaths under an anesthetic the issue is clear, and the question of crime is absent. An informal inquiry made by the coroner with expert help such as most hospitals could supply, or made by some person expert in such cases, and reporting to the coroner, would rapidly establish the nature of the case, and avoid the waste of time and public money incident to the present system, and would abolish the garbled newspaper reporting, which is undoubtedly a danger to the public. Such a scheme would save the coroner’s time as well as that of other people. If the evidence was unsatisfactory the formal inquest could be held. On one occasion a death occurred, and as the patient had had an anesthetic an inquest was held. The patient had succumbed to a severe operation, and no | question of poisoning by the anesthetic was present. This fact had been communicated to the coroner before the inquiry. However, the inquest was held, and everybody connected with the case, except the surgeon, who was really the chief person concerned (although not in any sense open to blame) was subpenaed! That case was put to the jury as a death from the anesthetic, but the coroner was reminded of the medical evidence, and then advised a verdict more consistent with the facts of the case. I have heard of several similar cases, and these indicate to my mind that coroners do not as a rule possess sufficient technical knowledge to make them the best judges in such inquiries. I hold also that these public inquiries into deaths under anesthetics are unnecessary and involve vexatious loss of time to hospital authorities, and a waste of public 1567. You mean that if the coroner by a preliminary inquiry decided that it was not necessary to hold an inquest, you would not then require the assistance of a medical assessor ?—That is so. 1568. Have you any opinion upon this point about which Dr. Hewitt has been telling us—whether un- qualified persons ought to be allowed to administer anesthetics P—What do you mean by “ unqualified ”’ ? 1569. First of all, take the pure layman (I exclude the dentist for the moment), the bonesetter, the herba- list, the amateur doctor,;and the quack?—TIt is extremely dangerous. They ought not to be allowed to do it. 1570. The risk to the patient is great, you think ? —Great 1571. Is it your opinion that, as a general rule, when it is possible, the person who administers the anesthetic and the person who performs the operation should be different persons P—Certainly, I feel strongly upon this point. 1572. That is to say, that while the attention of the ansthetist is required to be fixed on the effect of the anzsthetic on the patient, the surgeon has to attend to his own special work ?>—He should do so. 1573-4. I may ask you, with regard to dentists, do you agree with what Dr. Hewitt said on that point, that only medically qualified dentists should be regarded as qualified men in the sense that they should be allowed to administer nitrous oxide gas, not ether or chloroform ?