Over the eight centuries since the office was established in England, the role of coroner has evolved from tax collection to an independent judicial office that investigates sudden, violent or unnatural deaths.
In 1988 the British changed the coroner's act so that no criminal charges could result as a consequence of evidence produced at an inquest. However, the notable case of Dr. Harold Shipman (who was convicted of murdering 15 patients) led to three public inquiries that forced a review of this law.
But in the Bahamas there has been no review, no amendments, and no regulations or rules made under our coroner's act since it was passed in 1909.
And how well does that century-old law enable our coroner to meet the changing needs of a rapidly developing society, and provide service to the public in general, and the bereaved in particular?
Well, the first issue is that there is no coroner's court as such. Each magistrate is, by virtue of his office, a coroner, but there is no official coroner equipped with an office, budget and staff.
Under Bahamian law, the coroner is a magistrate appointed on an ad hoc basis to hear inquests. Although there was a time when all such cases were allocated to a single magistrate, that arrangement was discontinued a few years ago.
There was an advantage to that arrangement in that a specialist coroner did not have to deal with the pressure of other cases, which were bound to be seen as more urgent because they concerned the living. The demand for an inquest lacks that vitality, in every sense of that word.
However, under both systems a backlog of unheard cases accumulated. And long delays represent a failing to meet the needs of those bereaved families. Given the escalating rate of reported unnatural deaths, the backlog will likely increase.
It may be that this small jurisdiction needs more than one coroner, so that an alternate can hear matters from which the first coroner might recuse himself. With more than 900 lawyers and a similar number of doctors, we should have sufficient qualified personnel to constitute multiple coroner's courts to meet the current level of need.
The years of delay experienced by Bahamians in getting inquests held by the coroner's court adds insult to injury. It prolongs grieving, aggravates the sense of grievance for the deceased's family, and impacts the reputation of the judicial system, which at this point needs refurbishing.
Local psychiatrists have written widely and well on anger management issues as a cause of violence in our society. The perceived lack of effective recourse or accountability through appropriate channels may also be a contributing factor in stimulating public anger.
And the fact remains that in 100 years, our coroner's court has failed to evolve to achieve modern standards for accountability.
Take one case which illustrates both problems. A 42-year-old patient died unexpectedly in hospital in 2002. It took five years for that case to be brought before the coroner's court, and another year for the inquest to be heard.
That inquest involved more than 20 witnesses, and occupied about 24 court days, over 15 months. The evidence emerging from the case is voluminous. Apart from clinical "neglect", according to one expert witness, hospital records showed a complete "systems failure".
The evidence in that case points to serious public safety issues, which should be addressed by two statutory boards created for that purpose: the Hospitals Board, and the Medical Council. These bodies have the duty to investigate and evaluate private hospitals and medical professionals as an adjunct of their powers to license those hospitals and doctors.
However, Bahamian law does not give a coroner the power to refer matters to anywhere but the supreme court for criminal charges, once there is an appropriate verdict.
Even if our law did give the coroner authority to refer a matter to a statutory authority for remedial action, this assumes that we have, for instance, a Hospital Board that is able and willing to act. It also assumes that the Medical Council is not prevented by a judge's order from carrying out an evaluation of the professionals it licenses. If these assumptions are wrong, the information coming out of an inquest, at public expense, would not be used to the public benefit.
The inquest process can also reveal deficiencies in prisons, the police force, and other organizations responsible for the circumstances of a death. This information could put the agencies responsible in a better position to respond more promptly, to address deficiencies, and to prevent other lives being avoidably lost.
The coroner's court is - or should be - the citizen's watchdog when it comes to investigating abuse of power. The citizen has a right not to be unlawfully deprived of his life by the state. A verdict of manslaughter against a police officer, or any other person, needs to proceed in the supreme court, and not lie buried in the attorney-general's office.
The coroner should be a watchdog for society - to establish the real cause of death. We need an informed citizenry and strong civic bodies to push for an effective follow-up to a coroner's verdict. And to develop an informed citizenry, we need the investigative journalism of a free press.
But in the Bahamas, some suspicious deaths never make it to coroner's court. We are building up an inordinate backlog of those cases which are referred. Verdicts of manslaughter can languish silently in the AG's office, regulatory bodies charged with protecting the public are weak and /or hamstrung, the rule of law lapses, and the press needs to push for answers and reforms.
What kind of reforms? Ideally, we should have an official coroner and a coroner's office, as in England. However, as a starting point, to make the court more efficient and prevent the build-up of a backlog, we could make the following reforms without much cost.
1. The coroner should have power to sit alone, without a jury, in certain cases not involving agents of the state (such as police, wardens, immigration and defense force officers).
2. There should be a minimum and maximum number of jurors so that the absence of a single juror does not lead to an inevitable adjournment.
3. The remuneration of jurors should be increased.
4. There should be published rules and regulations for the coroner's court.
The first two changes are critical to the more efficient disposal of inquests and require only small changes to the law. All these changes could be speedily put in place, and go a long way to having an effective and properly functioning coroner's court.
In other jurisdictions, the role and the importance of the coroner's courts are expanding. Here it is diminishing. Why?
A coroner's court should be able to respond to the community's needs in a timely fashion. This requires review of the legislation, and also review of the funding, support facilities and staff available to the coroner.
"Governments do not rise and fall on proposed amendments to the coroner's act", according to one pundit. But the circumstances of a death may reveal issues of wider importance to the community, which have to be rectified.
So, either we continue to watch the decline of this ancient and vital judicial office, or we position our coroner's court to be the watchdog for citizens that it is intended to be.
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