Important recommendations for change to the Coroners Service

22 June 2021

A report by the Justice Committee published on 27 May 2021 makes sweeping recommendations for improvement and reform of the Coroner Service which, if implemented, could result in in more positive outcomes of healthcare Inquests and possibly even the prevention of deaths caused by systematic failures identified at inquest.

The Justice Committee is appointed by the House of Commons to examine the expenditure, administration and policy of the Ministry of Justice and its associated public bodies as well as the expenditure of the Attorney General’s Office, the Treasury Solicitor’s Department, the Crown Prosecution Service and the Serious Fraud Office.

The Report recognised that the Coroner Service has improved substantially since the Coroners and Justice Act 2009 was implemented in 2013, with the first two Chief Coroners doing a great deal to improve the quality of the service through their leadership and training. The new third Chief Coroner, His Honour Judge Thomas Teague QC, was praised for keeping the service going through the very difficult circumstances of the Covid-19 pandemic and encouraged to continue the good work of his predecessors.

Needs of bereaved people not yet sufficiently at the heart of the coronial service

However, The Justice Committee also concluded that the needs of bereaved people are not yet sufficiently at the heart of the coronial service, citing evidence that there are still pockets of behaviour by Coroners where bereaved people are not treated with the respect and consideration that they and their deceased loved ones deserve. The report also highlighted an unacceptable variation in the standard of service between Coroner areas, due in part to the fact that local authorities responsible for funding the Coroner Service have different assessments of local priorities and the importance of the Coroner Service. Successive governments were criticised for failing to establish a National Coroner Service for England and Wales in order to provide a consistent service to an acceptable standard.

Lack of signposting to specialist support

A further criticism was that not enough was being done to direct people to specialist support services, many of which are voluntary and receive no central government funding and are unavailable in around half of Coroners’ Courts. Longstanding and significant shortfalls in pathology services available to Coroners, which results in delay and distress for bereaved people, were also noted. As things stand, central government or the NHS have no direct responsibility for the supply of pathology services and the report warns that, without urgent and effective action by the Ministry of Justice, pathology services for the Coroner Service may disappear.

Making prevention of future death reports more effective

The committee also raised concerns about Regulation 28 reports, more commonly called ‘prevention of future death reports.’ Coroners already have the power to make a report to prevent future deaths under regulation 28 Coroners (Inquests) Regulations 2013. The aim of such a report is to improve public health and safety. The committee noted that Coroners vary in how they approach this aspect of their role (some issue many fewer prevention of future death reports than others) with no follow-up to see if those reports have had the desired impact. The committee proposes a new body to oversee risks to public safety discovered by Coroners at inquest and enforce actions to reduce those risks, acting in concert with other regulatory bodies such as the Health and Safety Executive and the Care Quality Commission.

Future articles

In future articles we will look at specific recommendations made by the committee concerning a duty of candour requirement for the inquest process, what they had to say on ‘the inequality of arms’ (where families denied legal aid struggle to pay the costs of legal representation at inquest out of their own pocket or go unrepresented while the state has its legal representation paid for out of government funds) and how these suggested improvements may affect inquests for stillbirths – something that six years of hard and persistent lobbying by Shoosmiths client Michelle Hemmington’s Campaign for Safer Births has pushed for.



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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