138.We were unable to find anyone who was able to provide an overview for us of coroner services from a local authority point of view. We were greatly helped by evidence provided to us by those working as individuals in local authority coroner services both in writing and in person. In 2013, HHJ Peter Thornton QC, the first Chief Coroner (2012–2016), described the complexity of coroner’s working relationships:
A senior coroner is appointed by the local authority but not employed by them, so their line manager is the Chief Coroner, or possibly the Lord Chief Justice. Then you have coroners’ officers, employed by the police. Their line manager is a detective sergeant, or some other officer. Then you have administrative staff, who are employed by the local authority, and line managed by someone there.
139.The Coroners’ Society of England and Wales told us of the fundamental importance of good relationships between Senior Coroners and their local authorities:
In some areas the relationship between the Senior Coroner and Local authority works exceptionally well promoting and funding the service to the benefit of the locally bereaved persons. However, in some areas lack of resources, lack of engagement, reluctance to recognise funding responsibility and poor communication mean the service is not as effective as it should be. Too many Local Authorities do not engage with the coroner’s service nor do they understand their statutory funding responsibilities.
140.Debbie Large, Head of the Kent Coroner Service explained to us how coroner services operate in practice:
In Kent, all the Coroner Service team are employed by Kent County Council. [ … ] [we] have very good working relationships with our coroner team. It is a difficult one because coroners direct all judicial activity and it is KCC staff who carry out their instructions, but [coroners] have no line management role.
She told us that the relationships can be difficult because of the complicated employment arrangements:
Because of my work with coroners’ officers, staff associations and years of training coroners’ officers, I am aware that that situation is not mirrored across the country. In practice, some coroners’ officers find it very difficult being employed by either the police or local authority but working under the direction of the coroner, because [their] employers do not always understand the role or relationship.
141.Judge Lucraft stressed the importance of Senior Coroners building relationships of mutual trust and respect with their local authorities:
It is very important that that relationship is understood; that the coroner is an independent judicial office holder. They very often have to make difficult decisions that may have ramifications for their funding authority. That relationship needs to be one that is respected and regarded both by the senior coroner with the local authority but by the local authority back with the senior coroner.
142.Birmingham and Solihull Coroners set out the conflicting pressures on senior coroners and their funding local authorities:
The Senior Coroner has to develop a relationship with their Local Authority for the purposes of planning, managing and running the Coroners service, yet they may have the same Local Authority as an interested person in their court. There is no other judicial office expected to undertake this balancing exercise which is caused by the Coroners service being funded by Local Authorities and not being part of a nationally funded service.
They also told us that relationships need to be continually renewed:
Management provided by the Local Authority for the Coroners service changes regularly and this can create difficulties as new staff do not understand the requirements of the service. This creates an additional burden on the Coroner having to educate new staff. A national service would avoid this pressure.
143.As described in Chapter 2 there have been repeated calls for a National Coroner Service. Both the first and second Chief Coroners supported the call for a National Coroner Service. Judge Lucraft, the second Chief Coroner, set out his views in his 2017–18 Annual Report:
There is much to be gained from such a move in terms of standardisation, consistency and implementation of reform. The operational infrastructure provided by a national service would address, over time, many of the issues about inconsistency of experience by bereaved families; that experience can occur in many situations outside the formality of the court room–for example in the interaction with the processes that follow immediately after a death is reported to the coroner.
He also set out problems with the current arrangement:
the localised nature of the present service produces inevitable inconsistencies between coroner areas. Coroners have to an extent worked in isolation, unsupported by a sound framework and network of coroner resilience [ … ] There is inconsistency in the provision of resources across coroner areas depending on the approach of individual local authorities. Some areas are well resourced in terms of the provision of coroners’ officers and support staff, others are not [ … ] Shortage of coroners’ officers adds to the stress on those staff in post with inevitable knock-on delays.
144.When Alex Chalk gave evidence to us, he argued in favour of keeping the current local system. He suggested that local services were more appropriate due to the way areas vary:
The benefits of devolution are that you allow local autonomy because people know their areas best [ … ] while one coroner area might be relatively straightforward in so far as there are no particular local institutions, there might be others that have a prison or, for example, a specialist children’s hospital. That is relevant because, if there are deaths, you might need specialist medical practitioners, consultant paediatricians or whatever.
He also recognised the risks:
There is some serious merit in having a local system, but you have to balance that with avoiding a fragmented system where, in effect, coroners are kings and queens of their own castle, doing their own thing and paddling their own canoe. Plainly, that is not a helpful system.
145.Alex Chalk acknowledged that provision of resources varied between local areas: “It is no secret that some local authorities have been more successful in providing local resources and others have been less successful.” He also suggested that local variations are inevitable and that it could never be guaranteed that nobody would have a bad experience: “even in a centralised system, people will have bad experiences. One should not assume that, therefore, every time someone has a bad experience, the solution is to have a centralised system.”
146.Alex Chalk posed the question whether a change to a national system should be avoided due to the expense and disruption involved:
is [it] worth the powder and shot to start sweeping all that aside, recognising that inevitably there will be some advantages for the sake of a centralised system. I think that would throw up new problems of its own. That is to say nothing of the fact—I make no apology for mentioning this—that it would be extraordinarily expensive to do [ … ] when all the magistrates courts were folded into HMCTS, that caused enormous angst, cost, difficulty, delay and problems [ … ] you have to be very sure, it seems to me, that it is worth smashing up the existing system to replace it. The case has to be, if not unarguable, absolutely compelling.
147.He argued that the better approach would be to continue to get the most out of the changes introduced by the Coroners and Justice Act 2009 (CJA 2009):
Let us, please, not lose sight of the fact that [ … ] the coronial service, has moved on enormously since 2010. This piece of legislation has evolved; it has adapted, not simply because of the black letter on the page but because of the skill, dedication and application of coroners. For that, both I and the Government are eternally grateful. [ … ] The way you strike this balance is through the guidance notes, training and also, frankly, reducing the number of coroner areas [ … ] If we can get high-quality people into the coronial service, which has been very good and continues to be good, ultimately, that has to be the centre of effort. We do not close our minds, eyes or ears to anything, but I also think we have to be clear-eyed about what makes the biggest difference to court users.
148.We also received evidence raising a note of caution that any new national service needs to be properly funded to avoid a ‘levelling-down’. For example, Ian Arrow, Senior Coroner for Plymouth, Torbay, South Devon argued for retention of a local service:
My concern is that passing responsibility for the organization of the Coroner service to a national body is likely to reduce what have been good locally provided services in currently well-resourced relevant areas. There will be a reduction to the lowest possible service provision [ … ] In my view the Coroner service’s strength is its local operation and a local knowledge of issues and concerns by both Coroners and Coroners Officers. The service weakness is the varied and sometimes inadequate funding /resourcing.
149.The Chief Coroner set out the rationale for a well-funded national coroner service as a means of improving consistency in his written submission to this inquiry. He too was concerned that it should be properly funded:
A properly funded national service may lead to greater consistency–but (as the saying goes) the devil would be in the detail. An underfunded national service may find it hard to make significant improvements.
150.Evidence from many witnesses emphasised the extent of unevenness of resourcing and how this can affect bereaved people. Birmingham and Solihull Coroners said:
Inevitably the mechanism to fund coronial services though their Local authorities does create a post code lottery. Those Councils with financial challenges will be less able to support their Coronial services and the families involved in those cases.
151.Dame Elish Angiolini said in her 2017 report of the independent review into deaths and serious incidents in police custody that:
The overall picture from a number of those who participated in the review meetings and focus groups is one of a coronial system under great pressure of resources, is ‘ad hoc’ and largely dependent on a ‘grace and favour’ relationship with other agencies.
152.Witnesses repeatedly told us of a service that is fragmented and under-resourced. Deborah Coles, Director of INQUEST, said that “because it is not a national service there are inconsistencies in resources, standards and practices across the system.” JUSTICE added: “local authority control with little centralisation means that standards and practices can vary greatly.” The Royal College of Pathologists supported the introduction of a National Coroners Service “to help ensure consistency across England and Wales through a single, reliable system.” Dr Mike Osborn, President of the Royal College of Pathologists told us:
one of the hospitals in which I work is covered by two coronial jurisdictions. In one I can pick up the phone and call somebody, get an answer in three seconds and everything is sorted out. In the other I have absolutely no idea how I would get in touch with somebody, other than send an email that, if I am lucky, might be answered in three or four days’ time. They are hugely different levels. I am a professional person who is adept at getting what I want and know the secret telephone numbers to which no one else has access. If I am a member of the public without access to the internet, who perhaps is not the most au fait with the system, I have real trouble accessing those things in some areas. In other areas, it is fantastic.
153.Victim Support’s National Homicide Service submitted evidence that draws on the National Homicide Service’s experience and is based on research carried out in July and August 2020 with staff and caseworkers from the service:
In our experience, coroners services can be patchy with bereaved families subjected to a postcode lottery, with different areas providing different levels of services. This can create uncertainty for families and those working with them, and make it difficult for professionals to provide support and advice around the process. [ … ] In our survey with Homicide Service staff 90% told us that they believed that one National Coroners Service would work better than the current system of 88 different areas operating across England and Wales. One Homicide Service caseworker said that a national service would be beneficial because: “if service was standardised, professionals could be more confident in the processes and what to expect and, in turn, families’ expectations could be managed more easily.”
154.André Rebello, Honorary Secretary of the Coroners’ Society emphasised the importance of consistent high standards across the Coroner Service: “When you work with the bereaved you have to get it right first time.” The Coroners’ Society said:
Some coroner’s services are well staffed … In others this is not the case and there are acute shortages and pressures on very small teams who have excessive workloads [ … ] Sickness and stress are common amongst coroners’ staff. Whilst the work can be very rewarding, the constant exposure of coroners and their staff to death, all it brings and those affected by death must not be underestimated. Inadequate staffing levels impact not only on the welfare of the workforce but also on the ability of the service to provide an efficient service to the bereaved.
155.André Rebello commented on the local authorities’ statutory obligation to fund the Coroner Service: “There are no teeth to enforce the duties under section 24 of the relevant authority to provide accommodation, staffing and resources to run the coroner service.”
156.The Chief Coroner, Judge Lucraft told us that “Some [local authorities] have the latest IT and the latest courts, but others do not. I see a properly funded national service as one way of addressing some of these inequalities on the resourcing that is currently provided.”
157.The majority of witnesses to our inquiry, two Chief Coroners, and almost everyone who has been commissioned to review aspects of the Coroner Service sees the need for a unified service for England and Wales. There is unacceptable variation in the standard of service between Coroner areas. The quality of each local coroner service should not have to depend on the local authority and the Senior Coroner having a shared understanding and priorities. The Ministry of Justice should unite coroner services into a single service for England and Wales.
158.We have also heard calls for the standards of the Coroner service to be policed, in the same way probation, prison and crown prosecution services are, by an independent inspectorate.
159.Alex Chalk highlighted for us the current difficulties in comparing performance between coroner areas:
you have to be careful about comparing apples with pears. Why? Because a local coronial area might have, for the sake of argument, a hospital, a prison or even a specialist hospital or specialist prison; therefore, there are different demands. Other areas may simply not have those pressures.
160.We heard evidence that an inspectorate would be a good way of assessing whether areas have the resources they need and that the quality of their performance. However, section 39 of the 2009 Act that had provided that the then Inspectorate of Courts Administration would also inspect and report to the Lord Chancellor on the Coroner System was repealed as this inspectorate was abolished under the Public Bodies Act 2011.
161.André Rebello, Honorary Secretary of the Coroners Association, told us that an inspectorate was needed:
We need a courts inspectorate under the Ministry of Justice. That courts inspectorate could then judge coroner areas by inspection, pretty much like Ofsted, and check that the model coroner area appended to the Chief Coroner’s annual report is being met; that resources have been provided to the coroner service; that the accommodation is suitable; that private space is given to bereaved families so they can have time with their loved ones; that coroners are working efficiently; and that the budgets are monitored.
162.Kent County Council coroner services manager, Giles Adey, also pressed for an inspectorate as a means of tackling substandard local services:
where things are not going right, either through lack of investment in the service or coroners having a particular way of working that does not necessarily fit with the local authority’s ethos, other than taking a complaint to the Judicial Conduct Office, it is very difficult. We have nowhere to go. I would certainly like to see some form of inspectorate, reviewing services and having some teeth in being able to make recommendations that local authorities and coroners would need to adopt.
163.Chief Coroner Judge Lucraft also supported an inspectorate: “I am very happy about an inspectorate. I see no difficulty with that and it would bring many positive aspects to it.”
164.The call for an inspectorate is long-standing. JUSTICE, in a recent report recommended “the establishment of a small Coroner Service Inspectorate. This recommendation once again develops a proposal in Luce’s 2003 Fundamental Review.” It also said that it need not be a large undertaking; Luce recommended that such an Inspectorate would require only six people. Given the moves toward fewer coroner areas and the work already undertaken by the Chief Coroner in producing annual reports for the Lord Chief Justice, the Working Party considers that this number is sufficient. [ … ] this recommendation would fill a sorely needed gap in quality control.
165.Alex Chalk, however, as the Minister responsible for the service, had reservations about the cost of an inspectorate, and its opportunity cost: “One can see there is a perfectly legitimate argument. Whether it is proportionate is something one has to consider. With endless resources, I can immediately see the point, but we have very difficult judgments to make.”
166.As with calls for a national service for England and Wales, there is an overwhelming and long-standing view that the Coroner Service would benefit from the presence of an inspectorate overseeing its work. As with those calls, we are merely repeating what others have repeatedly said by recommending that the Ministry of Justice should establish a Coroner Service Inspectorate to report publicly on how well each area accords with the Chief Coroner’s ‘Model Area’, its readiness in case of mass fatalities and the level of service provided to bereaved people. The Ministry of Justice should create a Coroner Service Inspectorate.
167.Consequent upon the establishment of a national service and an inspectorate, there should be a review of the mechanisms available for handling complaints against Coroners.
139 , accessed 3 May 2021
140 The Coroners’ Society of England and Wales (), section 1
141 Debbie Large is also Vice Chair of the South East Coroner Managers Regional Group, member of the Chief Coroners Training Group; and was Chair of the Coroners Officer and Staff Association (COASA) from 2010 to 2018, having been a Council Member of COASA since 2001. She started her career in the Coroner Service in 1998 as a Coroners Officer working for the Metropolitan Police Service.
145 Birmingham and Solihull Coroners () para 7
146 Birmingham and Solihull Coroners () para 8
147 , December 2018, pp 7–8
148 , December 2018, pp 7–8
155 HM Senior Coroner Plymouth Torbay South Devon Ian Arrow (), paras 10 and 14
156 Chief Coroner of England and Wales HHJ Mark Lucraft QC (), para 76
157 Birmingham and Solihull Coroners (), para 5
158 Dame Elish Angiolini, Report of the independent review into deaths and serious incidents in police custody, Home Office, October 2017, p.12
160 JUSTICE (), para 5
161 The Royal College of Pathologists (), section 1
163 Victim Support (), paras 4, 6 and 7
165 The Coroners’ Society of England and Wales (), section 1(b)
172 JUSTICE, When Things go Wrong, the response of the justice system, August 2020, pp24–25
173 JUSTICE, When Things go Wrong, the response of the justice system, August 2020, pp24–25