A study into decision making at the initial scene of unexpected deaths

Dean Jones

Research output: Book/ReportCommissioned report


The subject of this report is the result of a study following the Forensic Science Regulator’s (FSR’s) 2012 audit of Home Office Registered Forensic Pathologist’s (HORFP’s) post mortem reports (not yet published). The report concerns cases where HORFP have been asked to continue a post mortem examination (PM) initially commenced by a non-forensic pathologist. Analysis of data received from returned questionnaires submitted by police, coroners and pathologists in 33 such cases, has highlighted issues in respect of decision making at unexplained death scenes by those responsible for investigating deaths in the community. This study was initiated by the Home Office Forensic Pathology Unit (HOFPU) on referral from the FSR , and with the agreement of the Chief Coroner and the National Police Lead for forensic pathology as well as the Pathology Delivery Board (PDB).

Of the 33 cases provided to the study: one was omitted due to the fact that it was a road traffic death; 10 transpired to be homicides and a further 5 were suspicious deaths requiring further investigation. In 15 of the cases, from information available at the scene, it was considered that the death should have been treated as suspicious from the outset.

The study has highlighted what appears to be variations in quality of initial scene assessments. It is suspected that ‘cognitive bias’, rather than a full assessment, may influence decision making. This was noted especially in cases where the deceased had been using drugs, alcohol, or were elderly. This study found no evidence to indicate that financial constraints on the part of the police were a factor in the failure to use a HORFP.

Although the cases examined are examples of where the ‘system worked’ and homicides (which may otherwise have gone undiscovered) were identified as such, it is concerning that evidence uncovered in this limited study has identified cases where apparent and obvious indicators of suspicion were overlooked by those making decisions at the scene of unexplained deaths. It therefore seems reasonable to suspect that homicide cases may have been missed in the past, and could continue to be missed or forensic evidence lost. Action is required to address the shortfalls in the adequacy of the assessment of death cases and the associated decision making process concerning the use of HORFP’s.
Original languageEnglish
PublisherHome Office
Commissioning bodyHome Office
Number of pages24
Publication statusPublished - 15 Dec 2015
Externally publishedYes


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