The Coroner Service has improved substantially since the Coroners and Justice Act 2009 was implemented in 2013 but bereaved people are not yet sufficiently at its heart.
The first two Chief Coroners have done a great deal to improve the quality of the Service through leadership, guidance, and training. Much has been done to improve the Coroner Service’s response to incidents with mass fatalities, and again we have the Chief Coroners to thank for this. The new third Chief Coroner, His Honour Judge Thomas Teague QC, has our full support as we encourage him to continue their good work. We also thank all those who have kept the Coroner Service going through the very difficult circumstances of the covid-19 pandemic.
We heard from a wide range of sources, not least bereaved people and organisations that help them, that there is a still an unacceptable variation in the standard of service between Coroner areas. It is widely accepted that this is due in part to the fact that local authorities are responsible for funding the Coroner Service and they have different assessments of their local priorities and the importance of the Coroner Service within that. We also received evidence that indicates 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.
Successive governments have failed bereaved people by failing to establish a National Coroner Service for England and Wales. A National Coroner Service is the only way bereaved people can be provided with consistent services at an acceptable standard.
Most people are unaware of the Coroner Service until they first encounter it, often at an extraordinarily difficult time following an unexpected death of a loved one. We found that not enough was being done to provide written information and to direct people often enough and soon enough to specialist support services in the voluntary sector. There is an admirable charity that offers support to bereaved people attending inquests, but it receives no central government funding so is unavailable in around half of Coroners’ Courts.
There is a longstanding and significant shortfall in pathology services available to coroners, which leads to delay and distress for bereaved people. Neither any central government department nor the NHS accepts responsibility for the supply of pathology services to the Coroner Service, and the problem has been left unaddressed for many years. Without urgent and effective action by the Ministry of Justice, pathology services for the Coroner Service may disappear.
The Coroner Service has an important role in reporting fatal risks so that action can be taken to prevent future deaths. Coroners vary in how they approach this aspect of their role with some issuing many fewer reports than others. Most concerningly, there is no follow-up to see if coroners’ reports have had the desired impact. We call for a new body that will oversee risks to public safety discovered by coroners and inquest juries and monitor and enforce action to reduce these risks, acting in concert with other regulatory bodies such as the Health and Safety Executive and the Quality Care Commission.
Finally, it is unfair that public funding is available for bereaved people to be legally represented at inquests only in exceptional cases and subject to a means test. This is the case even at inquests that involve many public bodies each of which are legally represented at public expense. Non-means tested legal aid should be automatically available at the most complex inquests such as those following public disasters. In all inquests where public bodies are legally represented bereaved people should be entitled to publicly funded legal representation.