Coroner’s Investigations and Assisted Dying: A Missing Safeguard

When the Assisted Dying Bill is reviewed in the House of Lords this autumn a key question will be whether to amend the provision excluding assisted deaths from automatic coroner’s investigation. 

The concern is that coroner’s inquests would cause unnecessary delay and distress for bereaved families. As Kim Leadbeater put it: “These are not unexpected deaths; sadly, they were inevitable.” However, family members will not always be informed in advance of an assisted death, and without formal scrutiny, some deaths could appear unexplained.  

Proponents of the Bill consider that assisted deaths would be adequately scrutinised in advance, principally through patient declarations, assessments by doctors, and oversight from a multidisciplinary panel. Additionally, as Ms Leadbeater has pointed out, “anyone can report a death—including an assisted death—to the coroner, or indeed to the police, if they have any concerns that it was not carried out in accordance with the Act, and if any offences have been committed, they will be investigated.”

This last assertion unintentionally gets to the heart of the problem: without a meaningful investigation, there is no way to determine whether offences have been committed or the requirements in the Act have been met. This is a catch-22: unevidenced concerns reported to the coroner or police are unlikely to be investigated. Yet without a meaningful investigation, no evidence will emerge to support those concerns.

It is likely that most assisted deaths would not involve criminal wrongdoing and would meet the requirements of the Act. However, a significant concern remains about how cases that do not meet these standards would be identified and addressed. The state must ensure it complies with its duty under Article 2 of the ECHR to conduct an effective investigation. Declarations by independent doctors and panel review before death, or by a medical examiner afterwards, are not comparable to a publicly conducted judicial investigation.

Concerns also arise when the failings originate with the medical professionals concerned in the assisted dying process. There are real risks of abuse, as evidenced by the widely reported misuse of Do Not Resuscitate Orders, which were at times applied by doctors without consent, under pressure, or even applied to entire groups such as those in care homes.

The former Chief Coroner, Thomas Teague KC, argues that coroner’s inquests would act as a powerful deterrent against abuse and malpractice. He also flags that without an inquest, there will be no post-mortem and therefore no definitive means of determining whether the disease met the legal criteria or the circumstances of death complied with the law. For instance, there would be no reliable way to determine whether the approved substance led to a quick and painless death or a distressing and, perhaps, unlawful one.

This article was first written for and published by The Times on 9 July 2025. To read the full article, please click here (£).