Select Committee on Constitutional Affairs Eighth Report


4  The coronial system: local service, national framework

Existing structure

73. There is no national Coroners Service. Both appointments of staff to and funding for the coronial system occur at the local level. According to Michael Burgess, HM Coroner for Surrey, there are currently 112 coroners working in around 120 local jurisdictions. They are mostly barristers or solicitors of not less than 5 years standing, although 11 are registered medical practitioners, some of whom are also qualified lawyers. Each coroner is an independent judicial officer within his own district, appointed and resourced by the Local Authority. 27 coroners hold "whole-time" appointments, with the rest working as part-time coroners, free to carry on their medical or legal practice. The whole-time coroners deal with approximately 50% of all cases referred to coroners.[84]

74. Coroners are supported by coroners' officers who are their investigative support staff. There are approximately 420 coroners' officers who are employed and resourced by the police authorities in some jurisdictions but by local authorities in others.[85] All other personnel and resources, including the coroner's salary, mortuary and post-mortem examination fees and accommodation, if any, are provided by the local authority. In some jurisdictions, particularly in rural areas, the police officer who is first to deal with a suspicious death will also carry out the duties of a coroner's officer.

75. Michael Burgess, HM Coroner for Surrey & Coroner of The Queen's Household, categorised the resources of the coroner as:

a)  legal resources, being the statutory framework governing coroners and their function;

b)  human resources, being the coroners, their deputies, officers and other staff; and

c)  other financial and administrative resources, including accommodation.

It was his view that all were lacking in the current system: statutory provision is unclear; coroners and their staff are inadequately trained; and resources, particularly accommodation, are in short supply and are badly organised.

LEGAL RESOURCES

76. The legal framework for the functions of a coroner is by no means clear. Michael Burgess gave evidence that:

it is necessary to understand what the coroner's function is and currently in statute that is not clear. All we have got is that we are to hold inquests and those inquests are expected to find certain things as proved or not as the case may be.[86]

77. The legal framework for death investigation will be examined in more detail in Section 6 below. Here, we will focus on evidence that general coronial practice and standards of service across the country are variable. There are many reasons for this - including inconsistencies in training and funding, addressed below - but it is also argued that the localised nature of the coronial system, with no one in overall charge, has led to great inconsistency of practice.[87]

78. Nevertheless, a localised system brings with it both advantages and disadvantages. It is usually considered an advantage that each coroner inherits local traditions. They are sovereign in their own district, responsible only to the law through judicial review and not to any regional or national hierarchy, nor to any national or local 'organiser'. A newly appointed coroner will see how things were done in the past, with the assistance of the officers and staff, and will generally continue to manage the jurisdiction in the same way, unless there is a good reason for change. The coroner has complete freedom to change practice within the jurisdiction and may do so where, for example, this is considered necessary to meet changed local conditions. Part of the price of a national system would be a certain loss of responsiveness to local circumstances.

79. The disadvantages to localised practice include a non-standardised approach to similar problems of procedure and practice. What may be characterised as a sensible response to local conditions in some circumstances may appear capricious and arbitrary in others. Lack of standardisation means that the expectations of the bereaved and others, such as legal representatives, are difficult to manage. Some may have a good experience with the coronial system having encountered a sympathetic coroner with carefully considered and compassionately administered practices. We have certainly received evidence to this effect and witnessed for ourselves a carefully handled inquest.[88] However, we have also received evidence of horror stories, with accounts of unsympathetic and inflexible practice.

80. These characteristics were also noted by the Shipman Inquiry. The 3rd Report recommended radical change on the basis that:

the system is not working as well as it should. The evidence received by the Inquiry suggests that there is much dissatisfaction with the present arrangements. It is said that the existing system is fragmented, is not sufficiently professional, is applied to very variable standards in different parts of the country and does not meet the needs of the public, especially the bereaved.[89]

HUMAN RESOURCES

81. Michael Burgess underlined the importance of coroners, their deputies and officers being:

sufficient and well meaning as well as being properly trained and well disposed. I think we are fortunate in this country in that broadly speaking we have got a good cadre of coroners, even though on occasions they will fail, but we all fail at times.[90]

82. There have been concerns about the criteria by which coroners are appointed by their local authorities and whether individuals sitting on local authority appointment panels have any detailed concept of what the work of a coroner entails. It is well within living memory that some local authorities traditionally appointed successor coroners from the same legal practice as their predecessors.[91] As a result, there have been calls for coroners to be appointed by a national judicial appointments board in order that the criteria for appointments may be standardised.[92]

83. Coroners' officers are appointed by their employers, who may be the Local Authority or the Police Authority, depending on the jurisdiction. We have received much evidence which demonstrates the vital rôle that coroners' officers play, particularly as the main point of contact between the coronial system and the bereaved. It is, therefore, a matter of serious concern that rarely are sufficient resources made available to appoint enough staff to cope with the heavy workloads. Again, there are wide regional variations in the provision made for coroners' officers.[93]

84. There is no national strategy for training. Neither coroners nor their officers are required to undergo any training, either upon appointment or at any time thereafter. Some training is made available: for coroners with assistance on a 'good-will basis' from the Judicial Studies Board; and, for coroners' officers, by the Coroners' Officers Association in collaboration with various providers. However, the training available is arranged on an ad hoc basis with no compulsion to attend. Indeed, both coroners and their officers often have to attend training courses in their own time because there is no cover available for them during working hours.

85. Michael Burgess also highlighted the pressure of heavy workloads on many coroners and their staff. He stressed that coroners, their deputies and officers must:

… have sufficient time to carry out their function. Many coroners I know spend long hours, well beyond the European time constraints that we are all supposed to work to, in order to get through their caseload and give attention to their cases.[94]

FINANCIAL AND ADMINISTRATIVE RESOURCES

86. Resourcing of the coronial system comes mostly from local authorities, with the police authorities resourcing coroners' officers in many areas. This fragmentation of resources means that no overall figures for spending on the coronial system are issued by Government. The Luce Review estimated that, in 2000-2001, public spending on the coroner service was £71 million, of which around half went on mortuary, autopsy and other testing costs. Registration cost a further £6 million. Cremation fees paid by families totalled £30 million.[95]

87. Whilst the costs of the system may be estimated at around £71 million, these figures cannot take into account the "hidden subsidies" fed into the current system. These include resources, support services and accommodation provided by the private offices of those part-time coroners who are still in private practice, mostly as solicitors; and other resources, such as accommodation and administrative support for coroners' officers, provided by local police forces.[96]

88. Whatever, the overall cost of the coronial system, the major problem we have identified from evidence we have received relates to the uneven distribution of resources across different jurisdictions, partly due to the lack of consistency in the resources granted to coroners by their local authorities. This inevitably has an impact on consistency of practice and standards of service offered by coroners across England and Wales. Michael Burgess states that:

The great weakness that flows from that is that there will not be consistency of practice and the resources available to individual coroners will be very varied … The resource issue is something that constantly comes to the fore.[97]

89. Michael Burgess has also highlighted the particular difficulty faced by many coroners in finding court space for hearing inquests.

Certainly, so far as courts are concerned, we are very poorly off. We do not form part of the main court structure of the country and therefore when it comes to requiring and seeking court accommodation, we often are unable to use courts, we are very much at the back of the queue. Indeed I heard very recently of coroners who have had to adjourn inquests part-heard with juries for months because their allotted time had expired and the case had not finished and that cannot be good.[98]

90. In summary, the coronial system lacks national direction, with wide variations in regional practice. Whilst local and police authorities provide varying degrees of financial and administrative support for the coronial system, there are also hidden subsidies, the magnitude of which is almost impossible to calculate. The system is beleaguered, with insufficient training for coroners and their staff, inadequate funding, a lack of facilities and uneven distribution of resources, leading to inconsistent levels of service across England and Wales.

Government proposals

LOCAL SERVICE, NATIONAL FRAMEWORK

91. The Luce Review recommended that a new national, unified coroner and death certification service should be created. This service would be funded centrally and would have around 60 local offices manned by a full-time coroner and a medically qualified Statutory Medical Assessor. The Luce Review recommended that these local areas should mirror police authority boundaries, but that there should be a "flexible and sympathetic approach to rural areas with long travel distances".[99] In addition, the Luce Review recommended that coroners should be appointed after open advertisement through the Judicial Appointments Commission and that coroners officers would be employed directly by the new national Coroners Service. Training and development would be an early priority and individuals would be encouraged to develop specialist areas of expertise.[100]

92. However, under the reforms proposed in the draft Bill, the coronial system remains essentially local. Local authorities will remain responsible for appointing coroners with the consent of the Lord Chancellor[101] but the Government promises that "procedures for appointments will be more robust and…in line with national guidance".[102] It remains the case that only the Lord Chancellor, with the agreement of the Lord Chief Justice, may remove a coroner from office.[103] Coroners will continue to be resourced by local authorities and coroners' officers will remain employees of police or local authorities, according to local practice.

93. The LGA has registered serious concerns about accountability and governance with respect to coroners:

there is a widespread view that coroners are not accountable and do not always provide a consistent or effective service. The LGA believes that as long as the ultimate power to 'hire and fire' remains with the Lord Chancellor then the coroner will not be truly accountable, as councils will continue to pay the bills but have no control over performance and policy.

The LGA believes that an independent legal function, accountable to the head of the judiciary yet funded through local taxation, sitting alongside a local authority's democratic role is an outdated anomaly in a political environment where council leaders, supported by ODPM ministers, are calling for local people to be given more control of public services through devolution of power to communities.[104]

94. SOLACE, the Society of Local Authority Chief Executives and Senior Managers, has supported the LGA's assertions, adding that:

There is no real partnership between local authorities and coroners. Neither do local authorities have genuine management responsibilities for coroners. …

Local authorities are equally frustrated about having to fund a service that is costly and which they have little control over in terms of the quality of service provided to the community.[105]

95. The LGA has given evidence that councils are already redesigning their other services around the user and that the coronial system should be brought in line with these efforts:

Parts of the coroners service are delivered not by local government, but locally by the police, health service or the private sector. Achieving a step change in re-designing coroners services around the user means joining up all service providers with local government, as the current and likely future manager and funder of coroners services, in the driving seat.[106]

96. The government proposes a "national framework" for coroners as an alternative to a national service. Specifically, the draft Bill provides for:

  • New boundaries to be set by the Lord Chancellor, defining what will be known as coroner areas (Schedule 1, Part 1, paragraph 3). There will be around 60 new coroner areas.
  • Appointment of a full-time Senior Coroner to each coroner area, supported where necessary by one or more full-time Area Coroners and part-time Assistant Coroners. These appointments will be made by local authorities with the consent of the Lord Chancellor (Schedule 1, Part 1, paragraphs 1 & 2). Local authorities will continue to be the main source of funding for the coronial system.
  • Appointment of a Chief Coroner (Clause 56), accountable to the Lord Chancellor. The Chief Coroner will have many responsibilities - discussed further below - including responsibility for the preparation of rules and guidance and for collating the annual reports made to him by Senior Coroners. It is intended that the Chief Coroner will provide national leadership for local coroner services.
  • The Chief Coroner will be advised by a new Coronial Advisory Council (Clause 63).

97. The Government argues that these reforms will provide both local and national accountability. The Minister stated:

I think this is a good set of proposals. I know that sometimes people think that taking something which is not working locally and making it national can improve it. Sometimes it can. Sometimes what we want to do is have national standards but a local partnership … There is a really moot point, a machinery of government point, about what is the right balance between national and local. I think in this Bill we are building on the local strengths but we are having national standards. That is the right way to do it … The question is can we build onto a local system national standards and get the right result and I hope that we have the balance right here.[107]

98. However, whilst the office of the Chief Coroner is broadly welcomed, many argue that the Government's failure to reform the way the coronial system is resourced will do nothing to address local inconsistencies in resourcing and service. Dame Janet Smith expressed her disappointment that a national coroner service has been rejected:

I detect a desire not to set up a central structure. There is going to be a chief coroner and he is going to have a chief medical adviser and there is going to be an advisory council but there is not going to be, as I understand it, an executive organisation. I would have liked to see one because, as I mentioned earlier, I would like to see coroners officers employed by the Coroners Service to give them a career structure and to ensure that they get the right sort of training instead of the fragmentation that they have at the moment.[108]

99. Michael Burgess suggested that the value of central leadership by a Chief Coroner might be undermined unless the distribution of resources was rationalised on a national basis:

I think we all support the concept of a Chief Coroner. He will be publicly recognised as a respected figurehead for the national service, but that presupposes that this is going to be a national service. It should result in some sort of consistency, but unless there is the consistency of resources the consistency may not be as all-encompassing as one might hope.[109]

100. Victor Round added:

[The Coroners' Society has] doubts whether [the Chief Coroner is] going to be any better at winning an even supply of resources than we have been. There really is a postcode lottery about resources.[110]

We did rather hope to see a national system. We had almost got to the stage of assuming it would happen, and so we are a bit shaken to find that we still have the old battles to fight. [111]

Mr Round added that inquests are getting longer, particularly in cases such as prison deaths which must comply with the requirements for investigations under Article 2 of the European Convention on Human Rights. This has:

put tremendous pressure on to court accommodation, on staff, and on back-logs; some of us are reeling under them now, and really quite frightened about the future. We did think this new national service would solve this problem, and it has done nothing for it at all.[112]

101. The Government's proposals lack detail and fail to tackle adequately the resource and structural problems currently facing the existing, outmoded coronial system. The limitations of the local structure of the current system, giving rise to uneven distribution of resources, will remain. It is difficult to see how a Chief Coroner can function effectively as a force for standardisation without being part of a national service. A national service would almost certainly involve significant extra cost, but the failure to introduce one will mean that the current inequalities of resource will continue.

A PROFESSIONALISED SERVICE

102. Coroners appointed under the Coroners Act 1988, most of whom are part-time, will cease to hold office once the draft Bill comes into force and the Lord Chancellor will have power to make regulations to provide compensation for loss of office (Clause 71). The Government has stated that "It is intended that transitional arrangements will be made to ensure the system continues to function until the arrangements under the Bill take full effect."[113] It is possible that the expertise of existing coroners may be lost if they perceive that there is no financial benefit in applying for a full-time coroner post and giving up their, potentially more lucrative, professional commitments.[114] Whilst there may be no shortage of potential applicants, many of them are likely to have no previous experience of coronial law.

103. Moreover, we have received evidence that neither existing coroners nor their officers and staff "can be regarded as having any continuing job security at all", following redefinition of the jurisdictional boundaries. Coroners' officers may be forced to reapply for their jobs without guarantee of success if their employment is moved from police authorities to local authorities as a result of negotiations in progress. Similarly, clerical staff currently working in solicitors' offices have no guarantee of employment within the new service. Mr Ian G McCreath MBE, HM Coroner for North Northumberland, has stated that:

There must be major concern that many, who carry out an extremely valuable service to the bereaved at present, will seek to leave the Coronial service between now and April 2009 if opportunities for more secure employment elsewhere arise.[115]

It is vital to ensure that changes to the jurisdictional boundaries of the coronial system and to the staff involved in administering it do not inadvertently result in valuable skills and experience being lost.

104. Once the new jurisdictional boundaries are drawn up, there are potential problems in large rural jurisdictions. For example, under the proposed system, Cumbria and Northumberland, with a combined population of fewer than 500,000 taken together, can be expected to form one coroner area, which is an enormous geographical area for one person to cover.

105. On 6 February 2006, the Minister stated in Parliament that:

There is no reason why coroners should not travel to the families. We will ensure that Her Majesty's Court Service buildings, county courts and magistrates courts are available for the coroners to exercise their jurisdiction locally, so that they can work around the families and circumstances, rather than expect the families to work around them or their private practice as solicitors.[116]

106. Coroners have expressed alarm at the notion that they may be expected to travel around their jurisdictions, particularly those which cover very large geographical areas. Victor Round made two important points in evidence:

The first is that the coroner is then sitting on a car seat instead of sitting on an inquest, and the second is that all those courts we used to travel out to have been shut. It is like cottage hospitals. It is the same situation. It may be a good thing but it does not provide us with anywhere to go. So 65 coroners, 41 jurisdictions, is really the death knell of any kind of local service.[117]

107. When this was put to the Minister, she appeared to change her mind. On the subject of coroners travelling, she said:

Coroners will have to make the decision about where they sit and whether or not they choose to ask people to come to them or they decide that they are going to go to people. That is one of the things that they will be in a position to decide. That is the best way to do it. We are not telling them where they have to hold their inquests. If they are going around in their car to go to a local place, to hold an inquest in a particular local village, that is a matter for them to decide. If they feel that it should be done locally rather than asking people to come to them, they will no doubt have good reasons for that and for therefore being in a car in order to get there.[118]

108. We then asked about the availability of accommodation in which travelling coroners might hold inquests. The Minister replied that she was satisfied that there would be sufficient accommodation available, adding that Clause 33 of the draft Bill makes provision for ordering that accommodation be made available.[119] This is certainly true, although it is far from clear on the face of the draft Bill that the local authority could be obliged to provide more than one location in a given jurisdiction in which a coroner may hold inquests.

109. In widely scattered areas, it will be necessary to make use of part-time Assistant Coroners and to have means of access to the coroner's service which do not depend on visiting a coroner's office which is at a great distance or inaccessible by public transport.

110. The Government needs to clarify how their proposed system is intended to function in scattered and remote areas. If it is the Government's intention that local authorities responsible for large jurisdictions should provide a coroner with more than one place in which to hold inquests, we recommend that this should be made apparent on the face of the Bill when it is published.

RESOURCES

111. The DCA has highlighted the possibility of economies of scale under the new regime, but admits that:

The reform of the coroner service will have some effect on public expenditure. Local authorities will retain responsibility for funding their local coroner but, in line with Government policy, the Department for Constitutional Affairs is committed to funding any net additional costs that fall on local government which arise from changes made by the reforms. The best current estimate is that the initial start up costs for the reformed service will be £14.5 million, with additional running costs in the region of £5 million per annum. [120]

112. The Minister has confirmed that a large proportion of the funds estimated by the DCA will be dedicated to the office of the Chief Coroner, the Coronial Advisory Council, training for coroners and their staff and additional medical support for coroners.[121] The Minister stated that the additional annual running costs would break down as follows: [122]
Chief Coroner and Deputy Chief Coroner £1,000,000
Coroner for Treasure£370,000
Appeals£1,100,000
Inspection of the coroner service£250,000
Chief Medical Adviser and team£430,000
Coronial Advisory Council£120,000
Medical assistance for local coroners£1,300,000
Ongoing training£120,000

113. This makes a total of £4,690,000. Councillor Bryony Rudkin of the Local Government Association has questioned the DCA's financial estimates for additional funding for the coronial system, stating that the LGA was convinced neither of their accuracy nor that local authorities and police forces together would receive the whole of the sums projected. [123] It is apparent from the figures provided to us by the Minister that the majority of the projected budget is, indeed, destined for central projects, such as the office of the Chief Coroner, and will not be used to assist local and police authorities.

114. These estimates relate to the reforms only and do not address the problems inherent in the current system. The proposals do not offer funding to solve current problems, nor is there any indication of what new support, if any, is envisaged.

115. When we put it to the Minister that it was unreasonable to expect standardisation of service levels in the context of continuing inequalities of resources across coroner areas, the Minister replied:

I think that the things that will ensure that there are national standards and consistency of service is the leadership of a Chief Coroner, and I think that it is important not to underestimate the importance of having a national leadership figure for the coroners, who all operate in a very independent but also isolated way. … And I think that coroners will have that national leadership of a Chief Coroner and a Deputy Chief Coroner with a Chief Medical Adviser and a National Coronial Council and a Charter for the Bereaved and the opportunity to issue guidance, which I think will make a huge difference.[124]

The Minister added that the proposed system of reporting from coroners to the Chief Coroner will expose those areas which are inadequately resourced. She did not, however, specify whether funds would be made available to address any deficits discovered. With or without a system of reporting, it seems clear that, if the Government were interested in addressing inequalities of funding, it could obtain the necessary information now, directly from coroners, without having to wait for this legislation to be passed.

116. If the main body of Coroners are to operate full-time, they will need to be adequately supported and this may lead to additional costs. Many hidden subsidies will cease to operate, not least those provided by solicitors' offices. Aidan Cotter, HM Coroner for Birmingham and Solihull and the President of the Coroners' Society, has publicly supported this concern:

law firms which have part-time coroners within their practices have also subsidised the service to a significant amount and the government is going to have to appreciate that if they do away with part-timers, they are going to have to provide a lot more resources.[125]

117. Local authorities are particularly concerned about what they see as the escalating costs of coroners' services and the current shortfall in funding of the coronial system. Councillor Bryony Rudkin of the Local Government Association gave evidence that:

because, I think, local authorities have felt that reform was coming for such a long period of time, some authorities, police authorities and local authorities together, have perhaps not invested the money that they should have done because they have been waiting for something else to happen. Therefore there have been deficits. I have seen evidence of deficits in my own region.[126]

118. Local Authorities consider that the Government's proposals "clearly represent new financial burdens for councils".[127] For example:

  • Clause 33 of the draft Bill requires local authorities to provide and maintain proper accommodation to enable coroners to conduct investigations and hold inquests. This is a departure from the current position and will represent significant additional costs to many local authorities which do not, at present, provide dedicated accommodation for coroners.
  • Clauses 44 to 46 make provision for coroners to take evidence by way of "live link" in certain circumstances, meaning a live television link or similar to the coroner's court so that the witness need not be present in person. Our specialist advisers tell us that coroners do not currently have this technology. It must, therefore, be made available by the local authorities if coroners are to make use of these provisions. Clearly there are significant cost implications here.
  • Additional costs may also be incurred under the new arrangements for moving bodies to appropriate post-mortem facilities (Clauses 26 and 27) and as a result of the new appeals procedure (Clauses 60 and 61).

119. In relation to the funding of support for coroners, ACPO has made it clear its view that it is no longer appropriate for police forces to continue to provide coroners' officers from their ranks and resources:

Their main points are that the coroner service has moved away from its historic role as an important selector of criminal deaths and its case-work is now predominately in the non-criminal area; and that police priorities and resources should be concentrated on their law and order responsibilities.[128]

Both ACPO and the Local Government Association have stated that police forces and local authorities do not have the resources to increase funding for coroners' officers.[129] The Coroners Officers Association believes that extra funding is now "urgent".[130]

120. We are extremely concerned about the Government's approach to resourcing the reformed coronial system. When asked about this, the Minister stated that:

My own view … is that they are sensible proposals which improve a system which, in many respects, is doing a very good job but, in some respects, is not. It is long overdue for improvement. I think they are sensibly building on the current system.[131]

121. The problem with this argument is that it assumes that the current system provides foundations sufficiently solid to build upon. It does not. The evidence we have heard paints a picture of a service managing to hold itself together through the determination of individual coroners and their staff and the local cooperation arrangements which have developed over the years. The service has, for decades, been chronically under-resourced and urgent repairs are needed to the existing structure before the Government can hope to achieve reforms which are intended to build on that structure. This requires money. When we put it to the Minister that the Treasury had refused funding for coroner reform and the Government's proposals were, therefore, tailored to fit what it could afford out of the existing DCA budget, the Minister responded:

The implication of what you are saying is that if I was given a tonne of money by the Treasury I would somehow do things completely differently. I can say to you completely honestly that I would not. I think this is a good set of proposals.[132]

122. The Minister receives very little support for this view in the considerable quantity of evidence we have received. When asked for additional financial information about the specifics of funding for coroner reform, the Minster sent us the following:

In terms of the first issue, affordability; currently the DCA has allocated 2006/7 funds and will shortly be considering 2007/8 allocation for which the overall Departmental funding limits are known. The relative priority of all programmes will be considered as part of this. Funding for 2008/9 and beyond, however, is dependant upon the CSR 07 settlement which has not yet been agreed, and therefore it is not possible to form firm views at this stage on how this will be allocated.

The Department will inevitably face challenges on prioritisation for both 07/08 and the SR07 period. However, we are committed to reforming the Coroners service as quickly as possible, taking account of the financial parameters in which we have to operate.[133]

123. This gives no indication that the Government is in a position to achieve substantial reform of the coronial system, backed with sufficient resources. The DCA does not know how much it can dedicate to coroner reform in terms of funding and, in any event, coroner reform will be competing with other programmes for the funds that are available. We conclude that no new funding has been provided to the DCA by the Treasury for coroner reform and, consequently, the DCA is attempting to achieve these reforms on a shoestring.

124. The existing system is under-resourced and requires a significant injection of funding. The Government, however, has failed to make the necessary financial commitment and has not properly costed the reforms it has proposed. In addition, it seems likely that the Government has taken no account of the financial deficits in the existing system, nor of the hidden subsidies provided to the system by part-time coroners and others which will mostly be lost once coroners take on full-time employment.

125. The Government should address the problems of under-resourcing in the existing coronial system in order to create solid foundations on which reforms can be built. This will require a careful assessment of the aggregate costs of the existing system, to include hidden subsidies, together with an assessment of deficits in particular areas.

126. The Government should establish a mechanism for auditing the expenditure of local authorities on the coronial system and ensuring that coroners are given equivalent resources.

127. We further recommend that the Government should reform the structure of the coronial system by creating a national service with centralised and adequate funding so that all coroners are able to work to the same high standards.


84   Ev 68, para 4 Back

85   Ev 61, para 13 Back

86   Q1 Back

87   Qq1, 87, 103, 247; Ev 61, para 15 Back

88   Committee visit to the Medico-Legal Centre in Sheffield, 12 April 2006 Back

89   3rd Report of the Shipman Inquiry, Forward p v Back

90   Q1 Back

91   Q9 Back

92   Qq8, 58; Ev 62, para 19 Back

93   Qq130, 149, 153 Back

94   Q1 Back

95   Ev 61, para 15 Back

96   Home Office Position Paper, p 7, para 16 Back

97   Q1 Back

98   Q1 Back

99   Ev 61, para 16 Back

100   Luce Review, Chapter 16 Back

101   Draft Coroners Bill Schedule 1, Part 1, para 1 Back

102   Department for Constitutional Affairs, Coroners Service Reform: Briefing Note, p 6 Back

103   Draft Coroners Bill Schedule 1, Part 4, para16 Back

104   Ev 87, paras 13 and 14 Back

105   Ev 119, paras 8 and 10 Back

106   Ev 88, para 5 Back

107   Q281 Back

108   Q59 Back

109   Q22 Back

110   Q103 Back

111   Q104 Back

112   Q107 Back

113   Explanatory notes to the Draft Coroners Bill, p 69 Back

114   Ev 153 Back

115   Ev 146 Back

116   HC Deb, 6 February 2006, Col 614 Back

117   Q107 Back

118   Q278 Back

119   Q279 Back

120   Explanatory Notes to the draft Coroners Bill, p 118 Back

121   Q248 Back

122   Q252 Back

123   Q136 Back

124   Q247 Back

125   "Light after Death", Law Gazette, 23 March 2006 Back

126   Q136 Back

127   Ev 87, para 17 Back

128   Luce Review, Chapter 15, para 40 Back

129   Q153 Back

130   Ev 77, para 15 Back

131   Q280 Back

132   Q281 Back

133   Ev 112 Back


 
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