Contents
Purpose of the Coroner Service
Coroners’ investigations and inquests
2 The Coroners and Justice Act
Changes made by the first two Chief Coroners
Guidance and training for coroners and their staff
Appraisal process for coroners
Parts of the Coroners and Justice Act 2009 were not implemented
Government review of the Coroners and Justice Act
3 Putting bereaved people at the heart of the Coroner Service
The importance of the Coroner’s approach to bereaved people
Reducing delays so a funeral can be held
Support for bereaved people from other organisations
Coroners’ Courts Support Service
Disclosing evidence to bereaved people
Institutional defensiveness and a lack of candour
Legal aid for representation at inquests
Steps to assist bereaved people other than legal representation
Challenging coroners’ decisions
Amending Section 13 of the Coroners and Justice Act
Responsibility for supply of pathology services to the Coroner Service
Post mortem examinations using scanning
Regional centres of excellence for pathology services
Lack of progress in addressing the shortage of pathologists
5 Local funding, national leadership
Calls for a National Coroner Service
Arguments against creating a National Coroner Service
Expense and disruption of a reorganisation
Arguments in favour of a National Coroner Service
Inconsistent resources and practices effect bereaved people
The case for a Coroner Service Inspectorate
Importance of Coroner Service’s role in reducing fatal risks
Decisions about inquest scope can determine whether issues of concern are discovered
Lawyers to assist coroners at complex inquests
Variations in numbers of reports issued by coroners
Action plans and narrative conclusions
Search and analysis of published reports and responses
8 The Coroner Service’s response to covid-19
An increasing backlog of cases
Ministry of Justice action to reduce outstanding inquests
Conclusions and recommendations
List of Reports from the Committee during the current Parliament
Published: 27 May 2021 Site information Accessibility statement