Wednesday, 22 June 2011

The dysfunctional system of coroners' verdicts

Campaigners for cycling and road danger reduction have often drawn attention to the problematic character of many verdicts handed down by the English coroners' courts, which have often seemed far too ready to dismiss as "accidental" deaths on the roads where there are many factors of contributory negligence including bad , dangerous and illegal behaviour by road users, and sometimes defects of road design and engineering which can also be pointed to as factors. The limited range of verdicts that coroners have available to them and the limited nature of their role means, that although their court is often the forum for the closure of official investigation and indeed official involvement in the death of a human being, the verdicts that they come up with seem far too often to in no way reflect the circumstances of the case and the avoidable contributory factors that make these deaths only very questionably "accidental", and as such contribute to an official culture of "sweeping under the carpet", where few lessons are ever learned and applied in such a way as to make these so-called "accidents" less frequent in the future.

Well my purpose in this post is to point out that this is an endemic feature in the English system of coroner's courts and verdicts, not one that is confined to road deaths. The same points can be made about deaths that have nothing to do with traffic. Road deaths are not a special case in the broken coroners' system. Here is a case reported in the Evening Standard today:
Anthony Soh, 18, a student at Imperial College, had been at an "all you can drink" promotion at the university bar before telling friends that he planned to jump into the lake in Hyde Park to celebrate the end of his exams.
The first-year mechanical engineering student was last seen outside the student bar in south Kensington on March 22. He told friends he was returning to his halls on the other side of Hyde Park.
A search was launched after he failed to attend lectures the next day. His body was found in the Serpentine two weeks later by a woman riding a pedalo.
In an online tribute, his older brother Jeff wrote: "Anthony was amazingly bright and ambitious... his energy was contagious."
At an inquest into Mr Soh's death yesterday, one of his friends told how the group had played a game where forfeits meant finishing a drink in one go. Mr Soh had to down a pint in 30 seconds twice. The Westminster coroner recorded a verdict of accidental death.
It seems to me that in this case the "accidental death" verdict, though in some sense a expressing a truth,  in no way does justice to the circumstances surrounding this young man's very tragic death. Here was a very young student, born in the UK but from a Chinese family, probably something of a fish out of water, still only in his first year at a British university, probably the first year he had spent away from home, probably unused to drinking large quantities of alcohol, still on the premises of the university, getting into a situation through the misuse of alcohol, almost certainly through peer pressure, probably involving older students, that lead directly to his death.

It sounds like blame can be directed in several directions here. In the first place at the managers of the bar, which was part of the university, and therefore, through them, at the whole university administration, for offering this crazy, negligently-unwise and dangerous "all you can drink" promotion just after the exams. In the second place, the students who Mr Soh was with, who organised and encouraged the stupid drinking forfeits game. The students at Imperial College are amongst the academic cream of Britain, some of our most intelligent youngsters. They should be more responsible than this. They should have taken better care of Mr Soh. And thirdly the friends who heard Mr Soh declare he was going to jump into the Serpentine and left him alone to walk across the park and do this, when it should have been apparent to them that he was in a state where he should not have been left alone. All these people had some kind of common human duty of care to Mr Soh which they failed to discharge. They were all  negligent, even if not criminally so, and somehow the verdict the coroner brings in should be able to reflect this.

Now, the reason I am pained by this case, and am mentioning it here, is that I studied at Imperial College for four years. I know the bar in question and I know the halls of residence that Mr Soh would have been walking to and the route he would have taken. I know that one of the most noticeable social features of Imperial College – I have been to other similar institutions and can make comparisons, and they are not all the same – one of the most noticeable social features of Imperial is the culture of alcohol abuse, of excessive drinking, that has long been part of the fabric life of that college and which neither the college authorities nor the student union do anything to try to stamp out. Indeed, quite the reverse, they profit from it. It seems to be connected with the laddish culture of a college that is devoted to science and engineering (the medicine is mostly on a different site, not at South Kensington, where this happened), subjects that, traditionally, attracted mostly men, so it was always (though it is changing) very much a male environment, socially dominated by sports (particularly rugby) and drinking. I can remember this culture of the drinking games from when I was there. I remember the people regularly going out of the bar blotto late at night and walking across the park and doing japes on the roads and going to swim in the Serpentine. This is a long-standing, entrenched culture. It was obvious to me at the time that people would die from it. One of my friends, one of the most enthusiastic participants in the laddishness, did die, though not there, but later, in a diving accident in Greece, which I also suspect, but cannot be certain, was related to alcohol.

The coroner in the case of Mr Soh should have pointed a finger of blame at Imperial College itself. A college of course cannot be held responsible for the misdemeanours of its students, but they can be held responsible for creating or tolerating an environment where the abuse of alcohol is very common and accepted and where the circumstances that lead to deaths like this become quite likely. If such a finger of blame had been pointed, if some kind of verdict could have been brought in that qualified the "accidentalness" with recognition of the official negligence that created the circumstances, then it would have become more likely that something would change in the future at Imperial. I don't expect the administrators of the college to be punished over such a case, but I would like them to be forced to think hard about their responsibilities to the inexperienced, immature young people in their care, and about what policies they can adopt to decrease the chances of deaths like this one. Then, as they say, the tragic death of "amazingly bright" 18-year old Anthony Soh will not have been in vain.

Here is some more about Anthony Soh, written by his brother:
Anthony was amazingly bright and ambitious; he always looked to excel, and was passionate about mechanical engineering. His mind was full of creativity and he was always experimenting in all aspects of his life from tic tacs to magnets, in martial arts and in engineering. He was always one step ahead of the game when it came to mechanical engineering, before KERS in formula 1 had come out, he had already thought of the idea of storing wasted energy in a car from coasting (when your foot is off the accelerator) in the form of electricity to be used (aged 15). He also had a passion for magnets and had experimented with devices to shoot out metallic objects using magnetic energy by the age of 14, which came to be known as a 'rail gun' a few years later. His prediction that electric cars/motorbikes would dominate future travel at the age of 16 is also looking to come true... In my eyes, he was a true genius and we had always had a pact to start our business as the three of us...


  1. While nothing to do with the sad case of Mr Soh, some Coroners make incredibly ill-judged and I believe amazingly foolish and irrelevant comments.

    In the case of this cyclist, killed as a result of being hit by three cars, in a 70 mph speed limit.

    'He later died of serious head injuries.

    The coroner’s court heard how Mr Honour was not wearing a helmet at the time, prompting Berkshire coroner Peter Bedford to issue a stark warning about the importance of cyclist safety.

    He said that wearing a helmet could possibly have saved Mr Honour’s life.'

    This remark led me to wonder what expertise the Coroner might have regarding cycle helmets and their efficacy in preventing head injuries at such speeds? My conclusion: I suspect the Coroners expertise in such matters is about the same as might reasonably be expected of the protection afforded by a piece of plastic at such collision speeds. i.e. most probably not very much.

    I think I heard of this case. courtesy of Freewheeler.

  2. No, amoeba, it wasn't me, it was Stabiliser here with a follow-up here.

    My objections to the institution of Coroner are that the job is for life, it conventionally goes to a member of the establishment who can generally be relied upon not to rock the boat, there is no accountability, it is almost impossible to get rid of a Coroner, and there is no transparency. How many Coroners have motoring convictions, and what are those convictions for? The subject is unmentionable and therefore never mentioned.