The Coroner Service Contents



1 Introduction


Purpose of the Coroner Service

Statutory functions

Coroners’ investigations and inquests



Coroner Service skills

2 The Coroners and Justice Act


The role of the Chief Coroner

Changes made by the first two Chief Coroners

Guidance and training for coroners and their staff

Appointment of coroners

Appraisal process for coroners

Merging areas

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 status of bereaved people

The importance of the Coroner’s approach to bereaved people

User-friendly procedures

Reducing delays so a funeral can be held

Written information

Support for bereaved people from other organisations

Coroners’ Courts Support Service

Rights for bereaved people

Disclosing evidence to bereaved people

Some inquests are adversarial

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


4 Role of pathology

Responsibility for supply of pathology services to the Coroner Service

Shortage of pathologists

Post mortem examinations using scanning

Savings from using scanning

Regional centres of excellence for pathology services

Lack of progress in addressing the shortage of pathologists

5 Local funding, national leadership

Local relationships

Calls for a National Coroner Service

Arguments against creating a National Coroner Service

Local decision making

Expense and disruption of a reorganisation

Risk of ‘levelling down’

Arguments in favour of a National Coroner Service

Inconsistent resources and practices effect bereaved people

The case for a Coroner Service Inspectorate

6 Public disasters

Legal aid

Judge-led inquests

Specialist coroners

Pen portraits

7 Prevention of future deaths

Importance of Coroner Service’s role in reducing fatal risks

Decisions about inquest scope can determine whether issues of concern are discovered

Independent expert witnesses

Lawyers to assist coroners at complex inquests

Variations in numbers of reports issued by coroners

Insufficient following up

Action plans and narrative conclusions

Search and analysis of published reports and responses

Possible follow-up mechanisms

8 The Coroner Service’s response to covid-19

Remote coroners’ hearings

An increasing backlog of cases


Ministry of Justice action to reduce outstanding inquests

Conclusions and recommendations

Formal minutes


Published written evidence

List of Reports from the Committee during the current Parliament

Published: 27 May 2021 Site information    Accessibility statement