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recurance

Geoff Gray

20 Jun 2019 · Coroner HH Peter Rock QC · Surrey

The coroner's concerns

  1. 1. firearms deaths not subject to forensic post-mortem

    “I instructed as an independent expert in forensic pathology. He told me that the practice in Northern Ireland is that every firearms death, whatever the circumstances, will be subject to a forensic post-mortem.”
  2. 2. lack of specific guidance on post-mortem examinations for firearms deaths

    “Both and , the forensic pathologist who conducted the post-mortem told me that that there is no specific guidance to either pathologists, and as I understand it to coroners, that urges them to give particular consideration to the nature of the post- mortem examination in cases of death by firearms, even when that death is of a child”
  3. 3. undetected homicides due to suicide assumptions

    “It is of concern that where assumptions of suicide lead to cursory post- mortem investigations this creates a risk that homicides will go undetected. The higher the possibility that homicides will be distinguished from self-inflicted deaths, the greater the deterrence to those who might have reason to try to make a murder look like a suicide”
  4. 4. inadequate post-mortem examinations in firearms deaths

    “The use of a forensic post-mortem, or at very least something more than a basic 'routine' examination in all cases of sudden death by gunshot may, by enhancing the quality of investigations and ensuring that assumptions of suicide are properly tested, reduce that risk.”

Responses

2019-0216-Response-by-Chief-Coroner.pdf ↗· Chief Coroner of England and Wales

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Geoff Gray · Recurance