Memorandum submitted by Coroners Society of England and Wales (CTB 4)

1. The Coroner's Court is an inferior Court of Record. It is equivalent to the Magistrates Court if we were to try to fit it into the familiar civil and criminal structures. It has therefore evolved as a local court of summary justice; thereafter any other similarity ends.

2. The Coroner's Court delivers a local judicial service. There are 110 coroner's districts and therefore 110 separate and distinct services. Each coroner is appointed by the local authority which has the responsibility under s27 Coroners Act 1988[i] to fund the service and also to provide the infrastructure for the service. Local authorities satisfy this duty in varying degrees. Deputy and Assistant Deputy Coroners are appointed by the Coroner with the approval of the local authority. Coroners are locally appointed judicial officers who serve the local community.

3. Coroners' officers and Coroners' administrative staff are provided and employed by various combinations of the local authority and/or the police authority. The more detailed and complex the investigation the more reliance there will be on expert forensic investigation by the police, even if there is little or no prospect of the circumstances amounting to a crime. Coroners' officers may have had a background within forensic investigation, however for those that have not there is little by way of training opportunities for this to be addressed.

4. The Coroner has a statutory duty[ii] to investigate and find fact concerning "violent and unnatural deaths, deaths of unknown cause and deaths in prison". This is an inquisitorial, not adversarial, jurisdiction, and so unlike other courts, where the proceedings can be compromised by agreement and consent, the coroner does not sit on the sideline, to judge the evidence as it is revealed, but has to take the lead in the investigation.

5. Coroners usually sit alone where they are judges of the law, the procedure to be followed and the facts. In certain cases, set out in s 8 (3) Coroners Act 1988[iii], coroners must sit with a jury of between 7 and 11, drawn from the electoral roll. In effect the coroner must sit with a jury when the death occurred in prison, police contact, a reportable occurrence (such as an industrial accident) or the death occurred in circumstances the continuance of which is prejudicial to the health and safety of the public. An inquest with a jury takes longer and costs more than an inquest into similar facts held before a coroner alone. Further a coroner sitting alone can give reasons for the findings of fact whereas a jury is not permitted to explain its deliberations. It must be understood that an inquest before a coroner alone is just as thorough and valid as any inquest held in full or in part before a coroner and a jury.

6. There has been legislation in the recent past which has fundamentally changed the nature of the coroner's work. It is perhaps fair to admit that no coroner forecast the impact that the Human Rights Act 1998 would have on the Coroner's jurisdiction. However, neither did anyone else. The Coroner's jurisdiction is recognised as the usual way the State discharges its procedural obligation (sometimes referred to as an ("adjectival" duty) under art. 2 "The Right to Life" to initiate an investigation into any death which "occurred in circumstances in which it appeared that one or other of the substantive obligations had been, or may have been, violated and it appeared that agents of the State were, or may have been, in some way implicated." There was no Treasury funding for this and the financial responsibility for carrying through this duty has been absorbed by local authorities. As a result of this legislation, many investigations are now more complex, inquests are longer and they cost more. The alternative would be public inquiries but they would not come free to central government!

7. Following the legislation, case law has developed the role of the coroner in matters where the State have care of individuals and quite rightly the public have been enabled to complain. Public authorities and arms-length government bodies would appear to have no difficulty in affording representation. Families and individuals who are also properly interested persons appear to have difficulty in receiving public funding and then I understand it is at a very basic level. There has however been no additional resource to local authorities to facilitate these more complex enquiries.

8. One more example of legislation potentially affecting the Coroner's jurisdiction is the recently implemented Corporate Manslaughter and Homicide Act 2007. As you will be aware this Act facilitates the prosecution of corporate bodies responsible for a death. In England, Wales and Northern Ireland all these cases will come to the Coroner. In some there will be a prima facie criminal case made out to the standards applied by the CPS to initiate a prosecution. (These cases will all be heard by High Court Judges as opposed to Crown Court Judges.) In the vast majority of cases that threshold will not be reached. These cases will remain with the Coroner for determination - it takes little imagination to realise that there will be issues raised by properly interested persons, including families, which will require a very detailed investigation of the systems operated by the corporate body. There will also be submissions that unlawful killing on the basis of corporate manslaughter should be considered as a conclusion. The Coroners' Society has advised that more work, and more complex work at that, will be caused by this legislation but as yet there is no additional funding agreed for local authorities.

9. There has also been the significant impact from the deaths of service personnel overseas particularly in Iraq and Afghanistan. The coroner's services were never funded or resourced to deal with these eventualities. These cases have also highlighted problems with finding fact as to by what means the cause of death arose as a result of evidential problems. (see 25b below)

10. In spite of reviews of the Coroners' services during the 20th Century and the first 8 years of the present century, the current law is in effect the 1887 Victorian legislation. This is reflected in the consolidating Coroners Act 1988.

11. Against this background it is perhaps unsurprising that while there are some coroners' services that are appropriately resourced, there are also those without adequate accommodation, support and investigative staff or even a court. Notwithstanding this, a survey of service users[iv] conducted by the DCA (reporting in September 2006) advised that there was a satisfaction rating of 77%. This is a benchmark of the dedication of coroners, their officers and support staff. Further I understand from officials in the MOJ that compared to other public service providers there would appear to be relatively few complaints about coroners.

12. The latest Government plans for coroner reform in the 21st Century have followed the same pattern of the plans in the 20th Century. There were comprehensive considerations of the Coroners' services and the death certification service in the Fundamental Review of the Coroners Service by Mr Tom Luce and the Inquiry into the activity of Harold Shipman by Dame Janet Smith.

13. The Home Office then produced HoHome Office broadly embraced the recommendations and issued a position paper, which in the view of the Coroners' Society would have addressed the issues that had been identified so as to put funding and structures in place to develop a first class national death investigation and certification service. There was then a reorganisation of government department portfolios and policy responsibility for Coroners moved to the DCA and subsequently the Ministry of Justice.

14. The latest published draft Coroners Bill was not included in the Queen's Speech last autumn. The draft bill, even with the amendments published on the 27 March 2008 (following consultation), is for all intents and purposes a nomenclature change, it enshrines the local delivery and funding of the service and it introduces the concept of the Chief Coroner - a post in the disastrous position with responsibilities but no authority. There would appear to be no additional funding to local authorities or police authorities, presumably on the basis that they are already expected to fund the coroners' services and their infrastructure.

15. The Chief Coroner and his/her office is the only national structure introduced and funded. How the Chief Coroner will function without any budgetary control over local authorities is unclear. The Society have repeatedly asked what power or influence the Chief Coroner would have over local Coroners' services - which the Secretary of State for Justice, previously the Lord Chancellor or before then the Home Secretary did not have. If the draft Coroner Bill is included in the next Queen's speech the public will quite rightly expect a reformed service. If there is no change to the so called "postcode lottery" then the Chief Coroner seems likely to be made a scapegoat.

16. The Society recognises that, given the lack of treasury investment, the real reform will be non-legislative, the most important part of which will be persuading local authorities to invest in the coronial service infrastructure. Not far behind this would come the development of the role of the Coroner's Officer as a recognised career, with a national training qualification and ongoing professional development.

17. It came as a surprise to the Society that Coroners were mentioned in the Counter-Terrorism Bill. For more than a decade the Society has raised with government officials the need for primary legislation amendments to enable coroners to fulfil our duty without having to bend/break the law. Repeatedly officials have advised that parliamentary time was not available for such amendments.

18. Matters that have been raised by the Coroners' Society include:

a. To enable post mortems examination to be carried by the appropriate expert in proper facilities beyond the boundaries of a jurisdiction or neighbouring jurisdiction. S 22 Coroners Act 1988[v] only permits a body to be moved within a jurisdiction or an adjoining jurisdiction for post-mortem examination. There is a shortage of local expertise and resources, particularly in specialist histopathology areas of neuropathology, paediatric pathology and forensic pathology, such that coroners are morally obliged to step outside the law to meet the needs of service users.

b. To permit the transfer of a body to a more appropriate jurisdiction to hold an inquest even though the body has been released for funeral. S 14(1) Coroners Act 1988[vi] enables transfers of cases but only if "the body is lying in the district". This causes serious problems in the case of cross jurisdiction multi-fatality incidents. When two or more coroners may have to hear inquests arising out of the same circumstances and incident. It seems sensible to be able to transfer a case at any stage before the coroner concludes the inquest.

c. The law relating to adjourning inquests when the coroner has been informed that a person has been charged before a Magistrates Court with a criminal offence amounting to unlawful killing is contained in s 16 Coroners Act 1988[vii]. The criminal procedure changed some years ago whereby those charged with an indictable only offence of this nature now appear at a Crown Court without there being committal proceedings at the Magistrates. Thus a person is now not charged before a Magistrates court and if a coroner was to follow the law the inquest could not be adjourned when there were concurrent criminal proceedings arising out of the same incident.

d. In some jurisdictions a final inquest hearing cannot easily be listed because the coroner has no court, or at least no court that is suitable for a jury, the number of witnesses, properly interested persons, media interest etc. This problem is compounded by s 5 (2) Coroners Act 1988[viii] whereby a coroner can only sit within his/her own district. The Society would like coroners to be able to hold inquests anywhere in England and Wales.

19. It is interesting that the matters raised above (18) would all affect the ability of a "Special Coroner" to inquire effectively into the facts arising from those matters that prompted the relevant sections in the Counter -Terrorism Bill. If the Coroner sections were to be included, it would be convenient to include these minor but important basic amendments to the Coroners Act 1988.

20. The Society is not against "ticketing" for coroners to hear certain types of cases involving various specialities. This would lead to a more efficient use of training and coronial time. A limited ticketing system is possible but would require detailed consideration of the arrangements for transferring cases and service funding. Cases could be transferred by agreement but there could be many willing transferors and insufficient transferees. It is likely to be the more complex matters that would be subject to such a mechanism.

21. The Society represents all coronial judicial office holders. It is inappropriate for the judiciary to comment of the policy of the Executive. The comment I make is about the practical implementation of the policy.

22. The Coroner is involved in an investigation from the moment the death is reported. The coroner does not (unlike a judge in the Crown Court) come in to try the issues which the prosecution and the defence have outlined. Like a judge in the Family Courts, the coroner directs and guides the inquiry but more so, in that the Coroner cannot rely on the properly interested person (we do not have parties) to identify all the issues that require investigating. Even where there is no family the Coroner must still carry this burden. It is therefore difficult to come into an investigation part way through. I have had cases transferred to me after another coroner has been involved and it is often necessary in effect to reinvestigate to ensure sufficiency of inquiry.

23. It may be helpful to emphasise that the Coroner is involved when the death is reported, throughout the investigation and for any hearing. Investigations rely upon information gathered for the coroner, along with information gathered in parallel investigations. The majority of information comes from the police but it can also come from the Health and Safety Executive, the Independent Police Complaints Commission, the Prison and Probation Ombudsman, the Military Police, HM Rail Inspectorate etc. An example of this type of information would be evidence of a rebuttal nature gathered by the HSE when investigating a safe system of work. To disclose this information in an inquest could jeopardise an effective future prosecution but it is important for the coroner to know the information as it ensures that the thrust of the evidence as to by what means the cause of death arose is fully explored. Another example would be a fatal road collision where the police discover large quantities of illicit drugs in the vehicle. The circumstances of the collision may be unconnected with the find and so, although the coroner would be informed of the drugs, that information may well be excluded from the inquest so as not to compromise a separate criminal investigation. Other examples are intelligence reports on mobile phone, computer and website access interrogation. Just because documentation is part of the investigation, it does not mean the material will be used in the inquest or disclosed to properly interested persons.

24. Coroners are already involved in Public Interest Immunity[ix] applications and for those matters which involve National Security there is no need for the information to go beyond the Coroner if juries were to be removed. I have already indicated that an inquest with a jury is not superior to one held before a coroner alone.

25. Dealing specifically with s 64 Counter Terrorism Bill, clause 2 (1) would appear very wide such that the Secretary of State could issue a certificate for almost any case.

a. There is already provision at rule 17 Coroners Rules 1984 that: "Every inquest shall be held in public; provided that the coroner may direct that the public may be excluded from an inquest if he considers that it would be in the interests of national security to do so." I had not considered excluding properly interested persons as "the public." I suppose that because the nature of the Coroner's jurisdiction is to allay rumour and suspicion and to find facts of public importance arising from the death, such an interpretation would be far off my radar. The idea of finding fact only to keep the circumstances secret is certainly novel. Coroners have over the years been subtitled "the people's judges" and it would be unfortunate if these proposals compromised even the perception of coronial judicial independence.

b. Mention of the interests of a relationship between the United Kingdom and another Country does raise some concern as to the reason for its inclusion. I was in contact last year with the Ministry of Defence whereby I made it clear that Coroners expected to receive all information about an unexpected or unnatural death and that everyone must cooperate fully with the coroner's inquest. This included Government departments. I was particularly keen on securing the attendance of witnesses to the deaths of service personnel overseas when the witnesses could be a foreign national. I was not prepared to accept a bland declaration from a (UK) Government department that overseas nationals would not attend and I expected that all reasonable effort would be made to request assistance from allies. This issue caused coroners, particularly those sitting in Oxfordshire, significant practical difficulties in obtaining evidence for some of the "military inquests". I do not understand the need for this sub-paragraph as the relationship with another country in itself could be in the interests of UK national security. If it is not so what? What Secretary of State would ever balance the relationship with another country (which was not also in the interests of our National Security) before the needs of any member of the UK public or more especially a bereaved UK (service) family and the legal requirements of a UK Court?

c. Other public interest would appear to be a very vague and wide phrase. Inquests only determine facts which are in the public interest. Therefore this could apply to every inquest. If the matter is not in relation to National Security there could be accusations that a coach and horses has been driven through the separation of powers whereby the executive do not interfere with the judiciary. I make this as a neutral observation as I suspect that any exercise of this power would start rumour and suspicion and damage any legal process.

26. S.65 relates to specially appointed coroners. It would be preferable for every coroner to be enabled to deal with every case. If coroners need security clearance every coroner should be so cleared - I do not know if there is a presumption that every High Court Judge is security cleared or whether they are all so cleared. If they are, there should be no difficulty in applying the same process to every coroner. I have a real concern about the Secretary of State who issues a certificate also appointing the special coroner to the case. I would also be concerned if another member of the same executive appointed a special coroner. You cannot pick your own tribunal and it would cause less damage to our legal system if the coroner with jurisdiction could keep the case because s/he had been security cleared -- or at second best that coroner appointed a special coroner from a panel.

27. S 66 and s 67 RIPA 2000 - I can see no problem with Coroners being added to those permitted to receive this disclosure. Not so that the information can be made public but so that it can add context to the rest of the evidence. Further if the alternative is that the coroner proceeds without knowledge of potentially relevant evidence which is held by authorities, justice cannot be done as the finding of fact may be very wrong.

28. It is now necessary for me to refer back to paragraph 6 in which I mention the Human Rights Act. The procedural obligation to investigate the "Right to Life" is very much part of the Coroner's core business. For the investigation to be effective it must be[x]

a. independent

b. effective

c. reasonably prompt

d. sufficiently open to public scrutiny

e. involve the next of kin

29. I would only ask whether an appointed special advocate who cannot discuss the certificated material with the family fulfils this procedural obligation.

30. For avoidance of any doubt I can confirm that coroners will, of course, fully respect the will of Parliament.

April 2008


[i] (The Coroners do not in practice lay accounts before the Council but either treat expenditure as if a department of the local authority or work with an imprest account)

s27.-(1) Every coroner shall within four months after paying or making any fees, allowances or disbursements in accordance with the provisions of this Act, cause a full and true account of all fees, allowances and disbursements so paid or made by him under this Act to be laid before the relevant council.

(2) Every account under this section shall be accompanied by such vouchers as under the circumstances may to the relevant council seem reasonable; and the relevant council may, if they think fit, examine the coroner on oath as to any such account.

(3) On being satisfied of the correctness of any such account, the relevant council shall order their treasurer to pay to the coroner the sum due; and the treasurer shall without any abatement or deduction pay that sum-

(a) in the case of a metropolitan district or London borough council, out of the general rate fund;

(b) in the case of a non-metropolitan county council, out of the county fund; and

(c) in the case of the Common Council, out of the general rate,

and shall be allowed that sum on passing his accounts.

(4) In the case of a coroner for a coroner's district consisting of two or more metropolitan districts or London boroughs, the expenses of the councils of those districts or boroughs in respect of the coroner's service shall be apportioned between those councils in such manner as they may agree or, in default of agreement, as may be determined by the Secretary of State. [CA]

[ii] s8.-(1) Where a coroner is informed that the body of a person ("the deceased" ) is lying within his district and there is reasonable cause to suspect that the deceased-

(a) has died a violent or an unnatural death;

(b) has died a sudden death of which the cause is unknown; or

(c) has died in prison or in such a place or in such circumstances as to require an inquest under any other Act,

then, whether the cause of death arose within his district or not, the coroner shall as soon as practicable hold an inquest into the death of the deceased either with or, subject to subsection (3) below, without a jury.[CA]

[iii] s8 (2) In the case of an inquest with a jury-

(a) the coroner shall summon by warrant not less than seven nor more than eleven persons to appear before him at a specified time and place, there to inquire as jurors into the death of the deceased; and

(b) when not less than seven jurors are assembled, they shall be sworn by or before the coroner diligently to inquire into the death of the deceased and to give a true verdict according to the evidence.

(3) If it appears to a coroner, either before he proceeds to hold an inquest or in the course of an inquest begun without a jury, that there is reason to suspect-

(a) that the death occurred in prison or in such a place or in such circumstances as to require an inquest under any other Act;

(b) that the death occurred while the deceased was in police custody, or resulted from an injury caused by a police officer in the purported execution of his duty;

(c) that the death was caused by an accident, poisoning or disease notice of which is required to be given under any Act to a government department, to any inspector or other officer of a government department or to an inspector appointed under section 19 of the [1974 c. 37.] Health and Safety at Work etc. Act 1974; or

(d) that the death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public,

he shall proceed to summon a jury in the manner required by subsection (2) above. [CA]

[iv] DCA commissioned IPSOS MORI Survey DCA Research 6/06 "Users Experiences of Coroners' Courts" The Minister at the DCA wrote, "The survey was conducted by Ipsos MORI in June and July and we now have the results. Overall, 77% of those surveyed were either satisfied or very satisfied with the service they experienced. There were particularly high levels of satisfaction with the way the bereaved were treated by coroners and their staff, and the clarity of information they received. This is very encouraging and compares well with the experiences of users of other public services such as the NHS (78% satisfaction), Courts (74% satisfaction) and the police (66% satisfaction).

The survey also helps identify ways in which improvements can be made, for example, providing even better information about individual cases and rights, particularly in relation to post-mortems and aftercare services. The results give an important snapshot of where the service is now and is also a benchmark to measure changes against, especially in the context of the reform proposals..."

[v] s22.-(1) Subject to subsection (2) below, where by the direction or at the request of a coroner, a post-mortem examination of a body is to be made, the coroner may order the removal of the body to any place which may be provided for the purpose either within his district or within an adjoining district of another coroner. [CA]

[vi] s14.-(1) If it appears to a coroner that, in the case of a body lying within his district, an inquest ought to be held into the death but it is expedient that the inquest should be held by some other coroner, he may request that coroner to assume jurisdiction to hold the inquest; and if that coroner agrees he, and not the coroner within whose district the body is lying, shall have jurisdiction to hold the inquest. [CA]

[vii] s16.-(1) If on an inquest into a death the coroner before the conclusion of the inquest-

(a) is informed by the clerk of a magistrates' court under section 17(1) below that some person has been charged before a magistrates' court with-

(i) the murder, manslaughter or infanticide of the deceased;

(ii) an offence under section 1 of the [1972 c. 20.] Road Traffic Act 1972 (reckless driving) committed by causing the death of the deceased; or

(iii) an offence under section 2(1) of the [1961 c. 60.] Suicide Act 1961 consisting of aiding, abetting, counselling or procuring the suicide of the deceased; or

(b) is informed by the Director of Public Prosecutions that some person has been charged before examining justices with an offence (whether or not involving the death of a person other than the deceased) alleged to have been committed in circumstances connected with the death of the deceased, not being an offence within paragraph (a) above, and is requested by the Director to adjourn the inquest,

then, subject to subsection (2) below, the coroner shall, in the absence of reason to the contrary, adjourn the inquest until after the conclusion of the relevant criminal proceedings and, if a jury has been summoned, may, if he thinks fit, discharge them.[CA}

[viii] s5.-(1) Subject to subsection (3) and sections 7 and 13 to 15 below, an inquest into a death shall be held only by the coroner within whose district the body lies.

(2) Subject to subsection (3) and section 13 below, a coroner shall hold inquests only within his district.[CA]

[ix] R v Chief Constable of West Midlands, ex p Wiley [1994] 3 WLR 433 'Public interest immunity is a ground for refusing to disclose a document which is relevant and material to the determination of issues involved in civil or criminal proceedings. A claim to public interest immunity can only be justified if the public interest in preserving the confidentiality of the document outweighs the public interest in securing justice'.


[x] Jordan v The United Kingdom (2003) 37 EHRR 2 Para 106 to 109 see also R (Amin) v Secretary of State for the Home Department [2003] UKHL 51 - in which the it was accepted that Jordan set out the minimum standards which must be met, whatever form the investigation takes.