1.The subject of this Inquiry is the Coroner Service of England and Wales. The Ministry of Justice is responsible for Coroner Service policy and local authorities for funding 85 local coroner services. Coroners are judicial officers. Senior Coroners in each area are responsible with the relevant local authorities for the local coroner service and are aided by part-time Assistant Coroners. Larger areas may also have one or more full-time Area Coroners. All coroners are appointed by the local authority (with the consent of the Chief Coroner and the Lord Chancellor). Historically, coroners’ officers (who investigate deaths on behalf of coroners) have been seconded from local police forces. Other administrative support including accommodation is provided by the local authority.
2.The Coroners and Justice Act 2009 (CJA 2009), which came into effect in July 2013, reformed the Coroner Service, including, most significantly, creating the post of Chief Coroner for England and Wales.
3.The role of the Service is not well known. Alex Chalk MP, Parliamentary Under Secretary at the Ministry of Justice, told us:
It is to ensure that deaths, where they are violent, unnatural or unknown, are appropriately scrutinised both out of respect for the individual themselves and those who are bereaved, but also so that we, as a society, can have wider public confidence that the facts of those deaths and, in particular, the answers to the four statutory questions [ … ]—who, how, when and where—are well established.
4.The coroner’s role is to find facts rather than attribute blame and the CJA 2009 sets out that coroners’ and juries’ conclusions must “not be framed in such a way as to appear to determine any question of criminal liability on the part of a named person, or civil liability”. This legal limitation on inquest conclusions does not prevent coroners from highlighting where things have gone wrong and should be put right. Indeed, a coroner must make a report where the investigation or inquest he or she has conducted reveals something which raises concern that there is a risk of future deaths. The coroner must make such a report to the person who may have the power to take action that could eliminate or reduce that risk. The coroner may recommend that action should be taken, but not what that action should be. Before the CJA 2009, coroners had the power to make such reports but were not under a duty to do so.
5.Deputy Chief Coroner Derek Winter told us about his experience of what bereaved people expect from the Coroner Service:
In my experience, most families when they come to the coroner’s court tell me that they just don’t want this to happen to somebody else. That is what it is about.
Victoria Lebrec, Head of Policy, Campaigns and Communications at RoadPeace (which is a national charity for road crash victims in the UK) summed up what we heard from many sources:
families just want to know that their loved one has not died completely in vain and that something is being learned from it.
6.The CJA 2009 sets out that coroners must investigate deaths that have been reported to them if they think that:
7.The coroner (or jury, where there is one) must answer five questions:
8.Where Article 2 of the European Convention on Human Rights (right to life) applies (for example, in cases where the person died an unnatural death in state detention) the scope of the coroner’s investigation must be widened to include an investigation of the broad circumstances of the death, including events leading up to the death in question.
9.The then Chief Coroner, His Honour Judge Mark Lucraft QC told us about the legal limits on the role of coroners:
The purpose of the inquest, even when the Article 2 … is engaged, is not to provide an answer to any sort of ‘why’ question, in the sense of any deeper societal explanation for a death. Nor can the inquest attribute personal blame in the sense the criminal courts do. In some situations, this means there may be a dissonance between what a participant might want an inquest to deliver, and what is legally possible.
10.In most deaths there is no need for a coroner’s investigation. Instead, the doctor who provided care during the last illness of the deceased person completes a certificate of the medical cause of death. This, in turn, is presented to the local registrar who issues an authority for the disposal of the body. However, some deaths require further investigation and must be reported to the coroner who decides whether to carry out further inquiries. Judge Mark Lucraft QC told us:
It is a very small fraction of all the deaths that the coroner is looking at. Their work will be, largely, dealing with very sad situations. The families that they are dealing with are going through grief. They have recently been bereaved. It is an unexplained death.
11.Most deaths reported to coroners are resolved without an inquest. Judge Lucraft told us:
many of the deaths that are investigated by a coroner do not lead to a court hearing with an inquest. It is that part of a coroner’s job that, I suspect, goes largely unseen by many members of the public.
Deputy Chief Coroner, Derek Winter, expanded:
One of the greatest effects of the [CJA 2009] was to allow us to discontinue an investigation when we found out, usually after post-mortem examination, that the death was natural. Those cases, otherwise, went through to what seemed to be an unnecessary inquest.
12.In 2019, approximately 531,000 deaths were recorded of which 211,000 were reported to coroners. Some 82% (172,000) of deaths referred to coroners were resolved by investigation without an inquest.
13.Around 30,000 deaths proceeded to full inquests. Of those, 527 inquests with juries opened in 2019, and 478 of them related to deaths in state detention. Accident/misadventure was the most common conclusion at inquests in 2019.
14.Professor Nicola Padfield (Professor of Criminal and Penal Justice, Cambridge University) described the range of skills needed by coroners and their staff, and the absence of a standard ‘job description’:
Coroners need extraordinary skills: energy and curiosity, determination, integrity, neutrality, empathetic communication skills, excellent understanding of law and medicine, team leadership and case management skills …
There is also a need to understand the training, skills, role, and performance of coroners’ officers. What happens before an inquest by way of preparation is clearly vital. Some are serving or erstwhile police officers, or civilian police staff. Others have a much broader background. Their terms and conditions are not standard, nor are their job descriptions, roles, and responsibilities.
15.André Rebello, Honorary Secretary of the Coroners’ Society of England and Wales, confirmed the importance of the role played by coroners’ staff:
A coroner’s officer works as a family liaison officer as well as a coroner’s officer. The family is contacted by the coroner’s officer who, certainly in my area, gathers all the issues and concerns of the family, and, where we can, we include those issues within the investigation [ … ] the coroner’s officer is often the mainstay support.
2 Coroners and Justice Act 2009, .
3 , 2013, revised November 2020.
4 , September 2013, paras 172–173
7 Coroners and Justice Act 2009, .
8 These include sex, date and place of birth, occupation, and usual address.
9 Coroners and Justice Act 2009, and for further details see , Briefing Paper Number 03981, House of Commons Library, February 2021, p 9
10 Chief Coroner of England and Wales HHJ Mark Lucraft QC (), para 96
11 , Briefing Paper Number 03981, House of Commons Library, February 2021, p4
15 Ministry of Justice, , May 2020, section 4
16 Ministry of Justice, , May 2020, table 7
17 Professor Nicola Padfield (Professor of Criminal and Penal Justice at University of Cambridge) (), para 1