Coroners and death certification law reform: the Coroners and Justice Act 2009 and its aftermath

Introduction

Part 1 of the Coroners and Justice Act 2009 ¹ reformed the law on coroners and death certification in England and Wales. It represented a response to longstanding and widely acknowledged defects in these two essential public safeguards. It contained two major reforms – a new structure for the coroner service which would be headed by a Chief Coroner, and new arrangements for death certification to be led by local medical examiners.

The legislation was passed by the Labour Government in its last legislative session.

Implementation was planned for April 2012 with a new coroner appeals system coming a year later. However, following the 2010 election the new Government announced on 14 October 2010 that it considers the main coroner reforms to be unaffordable. ² It will not create the new Chief Coroner post or bring in the new appeals system. It plans to repeal the relevant provisions of the 2009 Act – the repeal powers are in the Public Bodies Bill now before Parliament. It seems however that the Government is to implement the new death certification arrangements.

What follows is an analysis of the Act and the thinking behind it, and of the Government's recent decisions on implementation.

The path to reform

The last Government's thinking on coroner and death certification reform changed over the years. In 2003 it published two review reports commissioned after the conviction in 2000 of Harold Shipman for murdering patients – the Home Office Fundamental Review of Coroner Services and Death Certification ³ and the Shipman Inquiry. ⁴ In 2004 the Home Office, under David Blunkett, outlined radical proposals for a new unified coroner and death certification agency. ⁵ This agency was to regulate all deaths by scrutinizing treating doctors' death certificates and more fully investigating some deaths as needed. It would be staffed by legally qualified coroners for the investigative work and doctors to supervise the scrutiny of death certificates. It would work out of local offices but be centrally financed and managed. It would replace local authorities in the appointment and support of coroners, and oversee a new unified death certification system applying equally to cremations and burials.

Coroners would be full-time: the number of coroner areas would be cut by around half, and their average size doubled. There would be a Chief Coroner and a national head of the agency's medical staff. A statutory charter would set out the service standards that bereaved families should expect. All existing coroner appointments would lapse when the new arrangements came in, and appointment to the new structure would be by open competition.

Between 2004 and 2006 responsibility for the coroner service passed from the Home Office to the Department for Constitutional Affairs (now the Ministry of Justice) and there was a re-think. The statutory charter and the new role of Chief Coroner remained in the Government's plans, but there would be no linked reform of death certification or centrally financed agency and coroners would continue to be appointed and supported by local authorities. The objective of fewer larger coroner districts under full-time legally qualified leadership was retained. It was still envisaged that on introduction of the new structure all existing coroner appointments would lapse and the new posts would be filled by competitive appointment. The main provisions were set out in a draft Coroners Bill, published in 2006. ⁶

This prompted a sharply critical report from the Parliamentary Select Committee on Constitutional Affairs, under Alan Beith's chairmanship. ⁷ They concentrated their fire on the Government's ‘retreat’ from the new unified central agency included in the Blunkett proposals, and on the absence of any linked reform of death certification.

The Committee's report led in due course to a further re-think and the gradual unveiling of the reform package in the 2009 Act, which covers both coroner services and death certification.

The 2009 Act reforms

The main changes covered in the 2009 Act were:

Medical examiners, a new type of public health official working for National Health Service Primary Care Trusts (Local Health Boards in Wales), would supervise death certification. They would be headed by a National Medical Examiner appointed by the Secretary for Health;

Reform objectives

Introducing the reforms in the House of Lords ⁸ the last Government's spokesman said they had two objectives (Volume 710, Column 1204)

‘to restore public confidence in the protection afforded by the death certification process’, and

The 2009 Act structures

The last Government did not say much about why it abandoned the Blunkett concept of a new integrated coroner and death certification agency, but the reasons are not difficult to guess. The centralization of responsibility for financing an inquisitorial system with large deficiencies and inequalities in standards of accommodation and staffing, and few reliable boundaries to the scale of its future work, would excite hostility in any Whitehall Finance Director. The serious management problems in its early years of the Children and Family Court Advisory and Support Service, the multidisciplinary juvenile justice agency established in 2001 to bring together civil probation, social work guardians ad litem and some legal functions, must have been a discouraging precedent. And no-one could say that central government responsibility for a public service necessarily guarantees enough money and equal standards of provision across the country – witness the accusations that after 60 years the NHS is still a ‘postcode lottery’.

It is noteworthy that in designing the new structures the 2009 Act not only departed from the integrated agency for death certification and investigation proposed in the Blunkett model, but in some respects goes in the opposite direction.

The Act provided two separate and parallel structures, each with its own carefully defined and exclusive jurisdiction and separate national leadership. Medical examiners would have exclusive jurisdiction to deal with the large majority of deaths from natural causes. The coroner's jurisdiction would be limited to investigating violent or unnatural deaths and deaths of people in state detention. Coroners would also have powers to assess deaths of unknown cause. But if they conclude that the death was not violent or unnatural and the deceased was not in state detention they would pass the case to (or back to) the medical examiner unless they reached that conclusion after ordering a postmortem or holding an inquest.

The purpose was to enable the new medical examiner resource to deal on its own with nearly all natural disease deaths, and preserve the coroner for deaths requiring the powers that she/he would have exclusively – to order un-consented postmortems, conduct inquests, and require the attendance of witnesses and the production of evidence and material.

Some arithmetic

The last Government said, ⁸ (Vol. 711, Col. 572) that it hoped that the present 235,000 deaths a year (of the total England and Wales deaths of 500,000) referred to coroners would fall to ‘130,000 to 150,000’, which would enable coroners to deal more effectively with the cases where their skills and powers are necessary. If this were to occur, there would be 85,000 to 105,000 deaths now referred which would not be referred in the future. A large majority of these deaths would be certified by medical examiners without any reference to coroners; the remainder might be referred but would be returned to medical examiners after being judged to be from natural causes.

A large reduction in the referral rate is a good aim. At present, in England and Wales nearly 47% of all deaths are referred, more than a quarter of which are found to be from natural causes. ⁹ This is a very high referral rate by international standards. If the last Government's aim were to be achieved, the referral rate would fall to around 25%. This, though still relatively high, would be closer to the rate of referral for specialist investigation observable in other countries. For example, the US National Association of Medical Examiners has accreditation criteria for member services which include a rate of referral of at least 20% of all deaths. ¹⁰

There might also be a reduction in the compulsory postmortem rate, which at around 21% of all deaths remains very high by international standards, being three times the rate in Canada, and about twice the rate in Australia, the USA, New Zealand and Scotland ³ (pp. 11, 19). This, too, would be welcome. The Home Office Fundamental Review ³ (p. 216) estimated in 2003 that about half the money spent on the coroner service went on postmortem and mortuary costs. A recent report from Pounder and others of a Tayside project describes the scope for a reduction in the England and Wales autopsy rate with significant savings. ¹¹

Medical examiner role and independence

The prospect that up to 75% of all deaths might be dealt with by the medical examiner service on its own, without any reference to or involvement of the coroner, raised acutely the issue of its independence. From a public safety perspective, the most serious defect in the whole area of death regulation lies not within the coroner system but in the lack of any effective supervision over the death certification process; and particularly in the absence of any reliable means of ensuring that deaths which should be reported to the coroner are reported.

This was the main structural weakness that enabled Shipman to continue with his murders for so long. It has been seen in other cases as well, notably the inadequate handling of Clostridium Difficile outbreaks in the Maidstone & Tunbridge Wells NHS Trust between 2004 and 2006. The Healthcare Commission estimated that around 90 deaths in this Trust were due to this outbreak. ¹² It seems that none of these deaths were referred to the coroner and that in most cases the causes of death were not properly certified.

Under the new arrangements in the Act, treating doctors would have a statutory obligation to refer deaths to the coroner in suitable cases, as registrars already do. And there would be a new provision explicitly enabling family members or others with an interest, including health-care staff, to refer anxieties to the coroner as well. These are helpful innovations, but they would not have disposed of the issue of the medical examiner's independence. The concern arose because some 60% of all deaths occur in NHS hospitals, and the NHS provides final care for nearly everyone who dies from disease. In all but obviously reportable cases the medical examiner would be the final arbiter of which deaths are reported to the coroner, and his or her payment and appointment by an NHS body was bound to be seen as an issue, even if the body were to be the Primary Care Trust rather than the Hospital Trust. This lack of independence might have damaged public confidence in a concept which in principle has the potential to remedy the main public safety weakness in death regulation.

The Act, in Section 19, required Primary Care Trusts to monitor medical examiners as to whether they meet expected standards of performance. It would also inhibit Trusts from having ‘any role in relation to the way in which medical examiners exercise their professional judgement as medical practitioners’; and there would be regulations preventing medical examiners from acting in cases where they might have conflicts of interest.

The Section 19 provisions were not sufficient to deflect a good deal of anxiety and criticism in Parliament on the issue of medical examiner independence. Transferring medical examiner employment from the NHS to the coroner service or the local authorities which support it, giving coroners a say in their appointment, or making them subject to guidance from the chief medical adviser to the Chief Coroner were among the suggestions made.

The last Government gave little or no ground on the issue. However, the new Government will be obliged to redesign the medical examiner arrangements because, as announced in their White Paper on National Health Service reform, ¹³ they intend to abolish the Primary Health Trusts to which the medical examiners would have been attached. The indications are that they will aim to attach them to local authorities as part of an enlarged public health role for local government. That would largely dispose of the independence problem. It would also have some logic since local authorities already support both the coroner and the registration services. Great care will however be needed to ensure suitable appointments to these posts and to support the new system in its critical early years.

Unnatural and unknown cause deaths: evidentiary standards and indications for postmortems

Wherever medical examiners are located, careful cooperation between them and the coronial side of death regulation will be essential. The deaths most likely to need an agreed approach are those which occur in hospital in complex medical situations and prompt questions on whether treatment or decisions not to treat may have contributed to a death and whether, therefore, it should be considered unnatural.

There is also an issue on the interpretation of the phrase ‘the cause of death is unknown’ in Section 1 of the Act, which determines the jurisdiction of the coroner and the types of death which should be reported to him or her. If the phrase is interpreted to cover, for example, a case where someone known to have advanced cardiovascular disease dies and the treating doctor is confident that the disease has caused the death but uncertain whether the final event is a heart attack or a stroke the coroner referral rate and the postmortem rate are both likely to remain higher than is justified and the last Government's strategy assumed.

It is for the public health authorities at national level to define and as necessary justify the levels of accuracy the public interest requires in the scrutiny of natural disease deaths. The Shipman Inquiry, ⁴ (p. 512) made a recommendation to the effect that the coroner's power to order a compulsory postmortem should not routinely be used to determine whether someone has died from one naturally fatal disease rather than another. The Fundamental Review ³ (p. 167) recommended that in such cases an autopsy should not be performed over the family's objections.

There has been no response to these recommendations. However, the last Government reversed the stance it took in both 2004 and 2006 that the matters on which families would have appeal rights should include decisions to order, or not to order, a postmortem. Its decision, enshrined in the Act, is that such appeals could only be made against a decision not to order a postmortem. Families objecting to a postmortem would have no appeal right. The more flexible and potentially less invasive postmortem powers described above may reduce the risk of the conflicts that have arisen in the past between coroners and Jewish and Muslim communities over postmortems. Nevertheless the question when, or whether, they should be ordered in deaths which are natural but of uncertain immediate cause is important to the overall postmortem rate and to the costs of the coroner service as well as to the wishes of families.

This issue remains to be clarified. Linked to it are issues about the evidentiary standards to which certifying doctors, medical examiners and coroners should work. It has so far been intended that treating doctors should, as now, certify causes of death ‘to the best of my knowledge and belief’. It is presumably intended that the evidentiary standard governing most inquest determinations will remain the ‘balance of probabilities’. Still to be defined are the levels of probability to which medical examiners should work, and in particular what degrees of uncertainty over the exact medical cause of death should govern decisions whether or not to refer a death to the coroner.

Scope of the inquest

The 2009 Act incorporates, in Section 5, what is currently in regulations about the ‘matters to be ascertained’ in the coroner's investigation. This is the historically tight definition – who the deceased was; how, when and where the deceased came by his or her death; and the registration particulars. It is modified in two ways. There is an addendum, reflecting the House of Lords judgement in the Middleton case, ¹⁴ to the effect that in cases falling within Article 2 of the ECHR convention the ground rules are to be interpreted as ‘including the purpose of ascertaining in what circumstances the deceased came by his or her death’.

There is another addition saying that the section is subject to a provision in a schedule which gives the coroner power to make reports designed to prevent future deaths – a re-statement of what has long been in Rule 43 of the Coroners' Rules, ¹⁵ but strengthened to place an obligation on the coroner to make such a report in suitable cases and on the recipient – a public authority in most cases – to give the coroner a written response.

The courts have so far clearly ruled deaths in detention or at the hands of the state to be within Article 2, but it is less clear that violent or unnatural deaths occurring in circumstances where the state's responsibilities are protective and regulatory – e.g. in public transport and sports or entertainment venues – are within Article 2 and hence could be certain of the wider ‘and in what circumstances’ inquest.

When taxed on the point in Parliament the last Government said that widening the provisions in the Bill dealing with the generality of inquests would be unnecessary. Pointing in particular to the new and strengthened preventive report power, the Lords Minister said: ‘The coroner has discretion to set the scope of an inquest and may decide to investigate the broad circumstances that caused or contributed to any death, even if Article 2 is not formally engaged’, ⁸ (Vol. 711, Col. 614). It is to be hoped that this assurance is right, and that future inquests into public transport catastrophes, for example, will not be inhibited in scope by the Act.

There are two other issues to raise on the scope of the inquest. The first is to note that in deciding to rely on the ancient formulation quoted above and then tack on the Article 2 reference the last Government rejected the alternative of setting out clearly what inquests should or could cover. The Master of the Rolls in a recent Appeal Court judgement ¹⁶ commented on this as follows while the Act was still before Parliament:

‘There are now two types of inquest. They are the traditional inquest and what we will call the Article 2 inquest. The essential difference between them is that the permissible verdict or verdicts in a traditional inquest is significantly narrower than in an Article 2 inquest. In addition it is said that the scope of the investigation is or is likely to be narrower at a traditional inquest … We are bound to say that it is in our view surprising that the differences between them are not absolutely clear … We note in passing that the differences between the two types of inquest are likely to continue to be important because Clause 5 of the Coroners Bill in its present form retains the same distinction without defining the difference. We think that this is a great pity and that it would be desirable for the new statute to set out the differences between an Article 2 inquest and any other inquest. It is surely desirable that parties and practitioners should simply be able to refer to the statute to appreciate the differences (if they are to persist) without the necessity to delve into the jurisprudence.’

It does seem a lost opportunity, when coroner reform legislation is so infrequent, to rely on this time-honoured but perhaps unclear or restrictive formulation; and in addition, to transfer that formulation from subordinate legislation which a Government can fairly easily change to the face of the primary legislation, which it can change only through the cumbersome process of further primary legislation.

The other issue concerns inhibitions on coroners' inquest determinations, designed to keep them clear of questions on criminal and civil liability. Section 10 of the Act picks up what is now in the Coroner's Rules, and puts it onto the face of the primary statute:

‘A determination … may not be framed in such a way as to appear to determine any question of (a) criminal liability on the part of a named person, or (b) civil liability.’

This may be compared with the way the matter is handled in Section 2 of the Inquiries Act 2005 ¹⁷ :

1) ‘An inquiry panel is not to rule on, and has no power to determine, any person's civil or criminal liability;

2) But an inquiry panel is not to be inhibited in the discharge of its functions by any likelihood of liability being inferred from the facts it determines or the recommendations that it makes.’

The same issue is dealt with in diametrically opposite ways in the two pieces of legislation, with the coroner provision being clearly the more inhibited. There has been no explanation of this difference, perhaps because Parliament did not notice it or ask for one.

Inquests and public inquiries

With the 2009 Act and the Inquiries Act 2005, the last Government legislated twice in a few years to create new structures for the two main processes for publicly investigating deaths and other events of serious concern to the public.

The 2009 Act would keep the traditionally narrow bounds of the generality of inquests (while acknowledging recent Article 2 jurisprudence). But, within those apparently somewhat elastic confines, the capacity of the coroner's inquest to deal satisfactorily with complex and contentious deaths would be improved. High Court, Appeal Court or Circuit Court judges, serving or recently retired, might be appointed by the head of the coronial jurisdiction to head inquests (without, as now, needing to be appointed Assistant Deputy Coroners by the local coroner at the instigation of central government). The choice of such cases and of judges to run them would be made by the Chief Coroner in consultation with the Lord Chief Justice, and not by the Government. Within inquest law coroners would retain some discretion to determine the exact scope of their inquests, as well as the power to decide when there is to be an inquest. The Government would have no role in deciding whether there is to be an inquest, what its exact scope would be, who should take it, and what its procedures should be. Nor would the Government have any role in the financing of individual inquests.

In contrast, in the inquiry field, the 2005 Act preserves to Government its traditional powers to decide when and whether such inquiries should be held, what their terms of reference should be, and who should conduct them – whether a judge (and if so which one) or some other person known to and approved by Ministers. It controversially added new explicit powers to alter the terms of reference during the inquiry's course, and thus to ensure that matters which the responsible Government Minister does not wish the inquiry to cover are excluded from its scope. It also took powers to withhold remuneration and expenses payments from the inquiry for matters considered by the Minister to be outside the inquiry's terms of reference; and the Act enjoins inquiries to have regard for their own costs and those falling on witnesses.

In effect the last government cautiously strengthened the inquest and –whether or not intentionally – weakened the status of the ad hoc public inquiry. This came out clearly when after much debate the last Government withdrew from the 2009 Act provisions for secret and jury-less inquests in cases where it judged very highly sensitive security information to be at stake. In spite of several attempts it could not gain support to what many in Parliament thought likely to diminish the independence and standing of the coroner's inquest. When it agreed to withdraw these provisions from the Bill and rely instead on setting up inquiries under the 2005 Act in the very small number of cases expected to arise, members of the Lords immediately pressed for amendments to the Inquiry Act to provide, in such cases, that they would always be conducted by a High Court Judge, that she/he should determine the scope of inquiry as though it were an inquest, and that the Government should deny itself the powers to set the boundary of the inquiry, or alter them during its course, or declare any particular line of inquiry to be beyond its scope. The last Government agreed to this in substance, and the relevant provisions are in paragraphs three and four of Schedule 1 in the 2009 Act.

This Parliamentary preference for the coroner's inquest over the ad hoc Government-appointed inquiry runs counter to the tendency, observable over many years, for politicians and the public to demand public inquiries instead of or in addition to inquests into deeply controversial deaths or catastrophes involving multiple deaths. We may see fewer such demands, and fewer such inquiries. This would be progress. Since the legislation was designed to reform a coroner system dedicated exclusively to the judicial investigation of deaths, it would have been perverse to leave it under-equipped for the largest and most testing challenges. It would be satisfying if, in future, the inquest came to be accepted as a normal and sufficient legal and judicial process for investigating deaths however controversial the circumstances.

Role and public standing of the coroner's inquest: issues of openness and privacy

Implicit throughout the Parliamentary debate was, on the legislators' part, a strong respect for and commitment to the inquest as a public safeguard. Its independence from any official interests and its public character are clearly much prized. Inquests into military deaths in Iraq and Afghanistan were cited with approval in debate, which may also have been coloured by continued suspicion of the use made by Government of intelligence material in justifying the Iraq invasion. The inquests into the deaths of Princess Diana and Jean-Charles de Menezes, both conducted by senior judges, may also have had a positive influence on the general perception of the inquest as a means of clarifying the circumstances of very controversial deaths.

The Home Office Fundamental Review, ³ (pp. 77–82) and to a greater degree the Shipman Inquiry, ⁴ (pp. 218–20) both recommended significant reductions in the scale of public inquesting. Similar recommendations had been made in earlier reviews – Brodrick in 1971, Wright in 1936 and Chalmers in 1910 ³ (Annex D). Coronial reforms elsewhere in the Commonwealth over the last quarter century have usually included reductions in the inquest rate to very much lower levels than are found in England and Wales ³ (Annex E).

The case for reduction is that inquests can be traumatically intrusive for bereaved families, can publicize medical and other personal details normally regarded as private, cause delays, increase costs and often have predictable outcomes. Whatever the merits the last Government did not accept this case, and the 2009 Act enshrines the public inquest as one of the two central procedures for coronial investigation (the other being the postmortem). It is envisaged that inquests will continue to occur in around 6% of all deaths, the proportion having risen from 4% in 2003 – a significant rise. Had the Government proposed replacement of the inquest with private or administrative investigations on any significant scale it would probably have encountered overwhelming opposition. The lesson to draw from debate on the Act is that openness trumps both privacy and any idea of a more selective and economical use of public judicial death investigation.

Other issues

In response to Parliamentary pressure, the last Government agreed that means-tested legal aid for inquests may be provided by the Community Legal Services to families of service personnel dying on active service and of those who die in state custody or during police operations. Funding in other cases would remain available only with special dispensation from the Ministry of Justice.

The last Government's position was always that the inquest is not an adversarial process and so generates much less need for professional representation and thus legal aid than criminal proceedings. However, the various public authorities whose interests may be at stake in inquests – e.g. the Prison Service, the Ministry of Defence in military inquests, police and health authorities – are often represented by solicitors and counsel paid for from their service budgets, so do not seem to accept Government's view. If the Government cannot convince professionally managed public services to trust the inquest process without specialist legal representation it is not to be expected that families, completely inexperienced in such matters and perhaps traumatized as well, will do so. Ministry of Justice Ministers indicated in debate that they would be trying to persuade colleagues in the other public service departments to reduce reliance on counsel in inquests. ¹⁸ It will be interesting to see if the public services alter their practice.

Neither the Act nor any Government statement envisages altering or removing the power of police authorities to provide coroners' officers. It is a serious defect in the last Government's reform programme that this is not addressed. Coroners who have to rely on police authorities for their officers are likely to have little influence on the number or choice of the individuals who are provided, and probably limited influence or control over their management. It is anomalous that they should be reliant on staff from a public authority other than the local authority which appoints them and is charged with supporting them.

The new Government's decisions

The Government justifies its decision not to implement structural reform in the coroner service by the need to reduce the deficit. The reform would have cost £10 million in the first year and £6 million a year thereafter. The Ministry of Justice's overall budget, £8.9 billion in 2010–2011, is projected in the recent spending review to fall by 2014–2015 to £7.3 billion. ¹⁸

As argued above death certification is the least safe aspect of the regulation of deaths in England and Wales because there is no means of ensuring that deaths which should be reported for further investigation are reported. The decision to continue the death certification reforms is therefore welcome. It might at first sight seem inconsistent with the decision to abort the main coroner reform. However, the recurrent costs of the new medical examiner service, which would fall on the Department of Health budget, are to be met from fees to bereaved families so there would be no significant net cost to public finance. The Government might also perceive the new medical examiner posts as offering the prospect of reduced referrals to coroners and hence of reducing coroners' costs. There would be still more scope for cost reduction from a reduction in the autopsy rate, since autopsy and mortuary costs loom large in the service's overall spending. It is significant that the Government's statement, in listing the enhanced central guidance and monitoring it envisages in lieu of the Chief Coroner reform, should specifically mention guidance on postmortems. The central government grant to local authorities is to be heavily reduced over the next few years and local government's programmes will be facing severe cost pressures, so the opportunity to make savings in the coroner service must seem attractive. Ministers may also have been concerned to avoid further death certification scandals on their watch.

It might be expected, too, that the Government will try to salvage and to regularize the use of judges in the conduct of contentious and complex inquests, since this reduces the pressure to establish public inquiries. To judge from its comments after publication of Lord Saville's Bloody Sunday inquiry, the present Government is even more averse to public inquiries than the last one had become. ¹⁹

From a public spending perspective the Government's decisions may seem rational , though a reduction in the coroners' autopsy rate to levels found in other jurisdictions would probably yield enough savings to resource the reforms in full. From the wider social and family interest in a modernized and effective coroner service the decision to abort the main coroner reform seems likely to be very adverse. The Ministry of Justice's own internal resources are to be halved over the next few years. Without the professional leadership and independent authority that a Chief Coroner, Chief Medical Adviser and their small supporting teams would have provided, the Ministry's civil servants will find the reform issues now left largely to them extremely difficult to progress and implement effectively. In consequence it may be at least another generation before there will be a properly effective response to the widespread complaints of inconsistency and unpredictability that have dogged our fragmented coroner service for many decades.

Proactive and thorough reforms of coroner services in the last 25 years throughout Canada and Australia and in New Zealand, and some Northern Ireland reform in 2006, contrast favourably with a long history in England and Wales of ‘too little, too late’. The Chalmers report in 1910 led to limited reform in 1926. The Wright report of 1936 led to still more limited change in the 1950s. Little of any significance was done after the Brodrick report of 1971. That the present coroner reform project, so long advocated and already weakened by the last Government's vacillations and compromises, should in its most important remaining components have fallen at the last fence will seem to most people deplorable; and nonetheless so for its consistency with a long tradition of political neglect and low priority with respect to this important public service.