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Coroners' Reports

cap n chris

Well-known member
Many years ago (about 20) I made an enquiry about the contents of a Coroner's Report into a caving fatality as part of my CIC dissertation and got absolutely nowhere with it because apparently (I can look up the original correspondence/letters if needs be) anyone unconnected with the individuals involved are not recognised as parties to the findings/conclusions. Thinking this kinda thwarted the whole point of a CR, namely that lessons could be learned and a wider audience might benefit from learning from the event(s), it irked. A lot of time has passed since then and perhaps the world has moved on significantly so my general query is this: where can anyone read Coroners' Reports into caving fatalities? Is it possible? My understanding (historically) is that you/we can't and no-one is any the wiser after the event. Am I wrong?
 
It is slightly weird.... An inquest is (generally) open to the public and can be reported on by the press (subject to some constraints, mostly around 'decency'. But the final report is quite restricted in availability(for 75 years) (interested parties only). I'm not quite sure how interested parties are defined. Coroners can do other things like make recommendations.
Reports to Prevent Future Deaths are publicly available.
 
In common with most Court proceedings, if you have an interest, you can attend and make notes and that's it. It's forbidden to make audio or video recordings. Otherwise we are reliant on reportage.
 
I was a juror in a Coroner's Court many years ago. We were told the purpose of the Court was to determine Who had died, Where they died and How they died. There were 5 incidents looked at and for the clear cut examples where no decisions were required, the Coroner directed the Jury on what their findings would be and wrote that down. This surprised us a bit! Anyway, one case wasn't clear cut and we needed to retire and come up with our findings. Another involving the death of an individual on the London Underground (I was living in London at the time) had family members present and there were arguments among them as well! Anyway, my point is that there didn't seem to be a priority on releasing or discussing any lessons learned at all.
 
In the case of a caving fatality, it would seem reasonable that the national representative body for caving should meet the criteria for "interested party", in which case, if the BCA were to gain sight of the report, perhaps they could prepare a "lessons learnt" note for wider distribution?

Certainly, in the case of a cave diving fatality a few years ago, the CDG issued a comprehensive report allowing lessons to be learnt. However, in this case, if I recall correctly, the CDG report was not primarily based on the coroner's report, and went into considerably more detail with regards to the equipment and procedural failures that contributed to the fatality.
 
When you say releasing - they are moving them to a storage area where you can go and look at then, so really need to know what you want beforehand...
 
Anyone interested in what coroners do might like this documentary series. Although its Channel 5 it is quite matter of fact.

 
I was a juror in a Coroner's Court many years ago. We were told the purpose of the Court was to determine Who had died, Where they died and How they died. There were 5 incidents looked at and for the clear cut examples where no decisions were required, the Coroner directed the Jury on what their findings would be and wrote that down. This surprised us a bit! Anyway, one case wasn't clear cut and we needed to retire and come up with our findings. Another involving the death of an individual on the London Underground (I was living in London at the time) had family members present and there were arguments among them as well! Anyway, my point is that there didn't seem to be a priority on releasing or discussing any lessons learned at all.
I guess it's probably not very useful for _every_ coroner's report to include a set of public recommendations. There were 36,900 coroners inquests in 2023.
 
I was a juror in a Coroner's Court many years ago. We were told the purpose of the Court was to determine Who had died, Where they died and How they died. There were 5 incidents looked at and for the clear cut examples where no decisions were required, the Coroner directed the Jury on what their findings would be and wrote that down. This surprised us a bit! Anyway, one case wasn't clear cut and we needed to retire and come up with our findings. Another involving the death of an individual on the London Underground (I was living in London at the time) had family members present and there were arguments among them as well! Anyway, my point is that there didn't seem to be a priority on releasing or discussing any lessons learned at all.
It is very uncommon for Inquests to have juries...presumably these cases would not normally have had a jury?
 
I can't say - all I know is that I received notification that I was to appear on the jury (and of course, did so). It was many years ago and things may have changed. As I said, there were several deaths to consider with expert witnesses, etc when required These deaths ranged from someone found dead in their flat by neighbours (where the Coroner recorded a finding without the Jury's input), to a death of a building site worker who was in a deep trench which collapsed as they were installing shuttering to prevent this happening, despite it being against "health and safety" rues and regulations, where the Jury had to submit their finding.
 
The inquest into the deaths of D. Gough and J. Fitton who drowned in OFDll Dec 1979 was held with a jury who asked quite detailed questions about the cave, the callout system in place, the rescue and then made recommendations. The inquest was very thorough and both rescuers and members of the stricken party were questioned. There is a very detailed report about the inquest written by Frank Baguley in the Cambrian Caving Council journal the Red Dragon (I should imagine in 1980/81). One of the recommendations made was for a full communication system installed in the Streamway to be monitored whenever cavers were in the Streamway. Some on the jury were current or ex-miners. At a later date we contacted the coroner with a alternative which was permanent markers showing where the Streamway could be exited in a emergency.
 
Quite a few years back I attempted to get hold of coroners reports into a few deaths in Cheshire during the 1920s and early 1930s (aircraft accidents) with a hope of pinning down where some incidents had actually occurred. While the reports are meant to be available after 75 years it turned out that none were available as they simply hadn't been kept, just a ledger recording the fact that an inquest happened. Had the same with Police reports in Derbyshire, in that case (and I got the same from Cheshire Police) I was told the local government reorganisation in 1974 led to all manner of records from Counties being disposed of by the new councils which were largely staffed by the employees of the city which became the county town.

As for lessons learned, the only way I can see anything meaningful coming out in the near term would be if an event led to an HSE investigation, and that could be quite a number of years down the line.
Last February had reporting of the outcome of the inquest (though it's still being persued through the courts by the looks of it) into the death of a Scout on the Great Orme which occurred 5 1/2 years before.
And we're still waiting to hear what if any lessons there are from the deaths of Dave Fowler and 2 clients on Aonach Eagach in August 2023, the inquest is set for preliminary hearings accord to the media for 10th Feb.
 
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