16.There have been continued calls for more than 20 years for a national (‘national’ in this context means England and Wales) coroners’ service, including from Dame Janet Smith after the Harold Shipman inquiry and the Luce review, sponsored by the Home Office. The 2009 reforms created a national Chief Coroner, but not a national service. The Ministry of Justice clearly signalled during our inquiry that doing so remains unlikely.
17.Coroner services are not part of HM Courts and Tribunals Service but are administered and funded by local authorities. Section 24 of the CJA 2009 placed an obligation on local authorities to fund the Coroner Service, while the Ministry of Justice is responsible for providing extra resources for changes imposed through national legislation or centrally determined policy change, and for ensuring that the service is being resourced overall to meet standards centrally recommended by the Chief Coroner.
18.The CJA 2009 provides for the appointment of a Chief Coroner to give national leadership to the coroner. His Honour Judge Mark Lucraft QC, who served from 1 October 2016 until 30 September 2021 was Chief Coroner during the evidence-taking phase of this inquiry, and he was replaced by His Honour Judge Thomas Teague QC on 24 December 2020. The CJA 2009 also allows for the appointment of Deputy Chief Coroners, the first of whom, Derek Winter, Senior Coroner for the Sunderland coroner area, and Her Honour Judge Alexia Durran, were appointed in January 2019. They support the Chief Coroner while continuing in their respective wider roles.
19.The Chief Coroner must be a senior judge appointed after an open competition by the Lord Chief Justice (after consulting the Lord Chancellor). The Chief Coroner’s main responsibilities are to:
20.There have been substantial improvements to the Coroner Service since the 2009 Act was implemented in 2013, including guidance and mandatory training for all coroners and coroners’ officers, appraisals for Assistant Coroners, and improved consistency by amalgamation of smaller areas. Tom Luce CB, (Chair of the Luce Review) summarised his view of progress since that review:
it was customary to refer to [the Coroner Service] as “quasi-judicial”; I am now confident that the “quasi-” qualification should be dropped. It is developing into a properly judicial service and continues to deepen that essential characteristic of its work to an impressive extent worth public recognition.
André Rebello, Honorary Secretary of the Coroners’ Society of England and Wales, agreed:
The coroner service today, generally across the piece, cannot be recognised as the service I joined in 1994.
21.Mandatory annual two-day training was universally welcomed by those who submitted evidence as an important step forward. Deputy Chief Coroner, Derek Winter, told us about the training introduced since the CJA 2009:
The Chief Coroner, with the Judicial College, will set the course programme for coroners, who get two days’ residential compulsory training every year. Coroners’ officers take advantage of that as well. It is an opportunity for the Chief Coroner, with his training committee, to look at current topics.
22.We received evidence suggesting that this should be built on in future. Assistant Coroner, Dr Daniel Sharpstone, told us:
Unlike many other public services such as Medicine and the Police, the governance of education and training for all grades is comparatively still in its infancy. There is a yearly mandatory 2 day continuation training course for all coroners. However, there is no formal check on learning, education or keeping up to date.
23.André Rebello, Honorary Secretary of the Coroners’ Society of England and Wales, identified some problems with training for coroners’ officers:
There is a problem in that coroners’ officers are short in number in some areas. The Chief Coroner has had a little bit of a battle with some police authorities and local authorities in making sure that coroners’ officers are released for training.
The Coroners’ Society also pointed out that some Local Authorities do not pay Assistant Coroners and coroners’ officers to attend training.
24.The Chief Coroner, Judge Lucraft, told us about the importance of learning from the past:
You will know that Bishop James Jones wrote a very searching report about the Hillsborough inquest process [ …] I invited Bishop Jones to speak to all of the senior and area coroners [ … ] It seemed to me vital that as coroners we listen to people who are critical of the way in which an inquest has happened, which has not been great, and we learn from that.
25.Another development is a more open and transparent appointment process for coroners. Giles Adey from Kent County Council told us:
if I remember rightly, assistant coroners and assistant deputy coroners were the personal appointments of coroners… we [now] have a much more robust, open and transparent process uniform to all.
26.The CJA 2009 also required that all new coroners should be legally qualified. Before that they could be either doctors or lawyers. As a result, the proportion of coroners who are medically qualified has reduced. No statistics are available on the diversity of coroners.
27.Chief Coroner, Judge Lucraft, has recently introduced an annual appraisal process for Assistant Coroners carried out by their Senior Coroners. The emphasis is on improving performance though discussion and identification of training needs. It does not cover judicial conduct or misconduct. Judge Lucraft described how it works:
a large part of the work of a coroner is not in a court setting—it is not at an inquest—but it is dealing with the decisions that are made in the office. It is dealing with how you interact with families. You have to appraise that part of the job as much as you have to appraise what happens in the court setting.
The idea, in due course, is that we will roll it out annually for each assistant coroner, to be followed by an appraisal system for the salaried coroners. It has been slightly put back because of Covid.”
28.Alex Chalk, the Minister of Justice Minister currently responsible for the service, supported the appraisal scheme:
what we have through the appraisal scheme for coroners is a step change in the ability of coroners to provide that uniformity. It is a far less fragmented system than existed in the past.
29.The creation of a Chief Coroner followed by the introduction of guidance, mandatory training and appraisals for the most junior coroners are significant advances towards a more standardised Coroner Service than obtained a decade or so ago, even in the continued absence of a full England and Wales service. We encourage the new Chief Coroner to continue the work begun by his predecessor by extending appraisals to all coroners.
30.There were more than 127 coroner jurisdictions in England and Wales in 2004 when the Government responded to the Shipman Inquiry and the Luce Review. Since then the Chief Coroners have merged areas so that there are now 85. Merging areas helps to reduce local variations and inconsistencies. John Ellery, Coroner, Shropshire, Telford and Wrekin told us for example that in his area “a considerable amount of historic unevenness has been ironed out.”
31.There are some technical limitations, however, on how areas can be merged. Giles Adey, coordinator for the four coroner services in the Kent County Council and Medway Council area told us:
In Kent, we have four coroner areas and our plan is to merge those into one, but the way the legislation is written currently means we can merge those four areas only when we have vacancies for senior coroners in three of them.
The Chief Coroner has proposed a change to the CJA 2009 that would make mergers easier. The details are set out in his most recent annual report.
32.Reducing the number of coronial areas has helped increase consistency across the Coroner Service. The Ministry of Justice should amend the Coroners and Justice Act 2009 (as requested by the outgoing Chief Coroner) to make it easier to merge areas.
33.Section 40 of the Coroners and Justice Act 2009 (CJA 2009) which introduced a new process for appeals from coroners’ judicial decisions to the Chief Coroner was not brought into force and has since been repealed. The CJA 2009 contained provisions for the Coroner Service to be inspected by the Inspectorate of Courts Administration (excluding inspection of judicial decisions) and for a system of appeals to the Chief Coroner from coroners’ judicial decisions. Neither was implemented; each has since been repealed, and the Inspectorate of Courts Administration was abolished in 2011.
34.The Ministry of Justice reviewed the effectiveness of the CJA 2009 in 2015 but did not publish the result of that review and appears not to intend to. Alex Chalk told us:
for reasons that were a matter for the Minister at the time, that report was not prioritised. The position now is that a great deal has changed [ … ] Because of that change, the verdicts from that [review], for want of a better expression, will be of very limited import.
35.Several witnesses told us, however, that the review was important and relevant. For example, Lisa O’Dwyer from Action Against Medical Accidents (AvMA) told us:
Many of the points that we made in our response to that review are still very live issues. Nothing has changed really. There are still those inconsistencies. Those things [ … ] such as inconsistency of disclosure [ … ] are still as pertinent now as they were when we responded in 2015.
36.Tom Luce told us:
some important reform has occurred but with delay, compromise and significant gaps. This is characteristic of historic governmental lack of interest in and delay over modernising the socially, medically and judicially important regulatory systems concerned with deaths. Contemporary examples of this historic tendency include the serious breach of the Ministry of Justice’s undertaking to Parliament to report the outcome of the 2015 consultation on the reformed Coroner service.
37.Tom Luce, among others, has identified the Ministry of Justice decision not to publish its 2015 review of the operation of the 2009 Act as a serious breach of a commitment to do so. No good reason has been given for the non-publication of that review. The present Minister’s argument that it is now out of date is not sufficient reason for continuing to withhold it. At the very least, publication would allow that contention to be tested, and no harm can be done if the report’s conclusions truly are obsoleteWe recommend that the Ministy of Justice immediately publish its 2015 review of the effectiveness of the Coroners and Justice Act 2009.
21 , accessed 3 May 2021
22 HHJ Peter Thornton QC and HHJ Mark Lucraft QC. The current Chief Coroner is HHJ Thomas Teague QC who took up the post on 24 December 2020.
23 Tom LUCE (), para 10
26 Dr Daniel Sharpstone (Assistant Coroner at Suffolk) (), p 2
28 The Coroners’ Society of England and Wales (), section 5 of the Executive Summary
29 The Right Reverend James Jones KBE, The patronising disposition of unaccountable power, A report to ensure the pain and suffering of the Hillsborough families is not repeated, Home Office, HC 511, November 2017
32 Coroners and Justice Act 2009, , para 3(b)
35 Mr John Ellery (), para 1
37 , November 2020, paras 137–140
38 Coroners and Justice Act 2009,
39 Coroners and Justice Act 2009,
40 Coroners and Justice Act 2009,
43 Tom LUCE (), para 1