The Coroner Service Contents

6Public disasters

168.There is a particular type of inquest that place significant demands on the Coroner Service—the inquest into public disasters. Public disasters where there have been many fatalities are thankfully rare events but handling them well is an important part of the Coroner Service’s work. Examples of public disasters include the deaths at Hillsborough and the Manchester Arena, and smaller but equally shocking events such as the terrorist attacks on Westminster and London Bridge. These inquests may be required to investigate the broad circumstances of the deaths, including events leading up to the deaths in question, to comply with Article 2 of the European Convention on Human Rights (right to life).175

169.There has been considerable criticism of how these large-scale inquests have been handled in the past. The most important is that contained in the Hillsborough report.176 André Rebello, Honorary Secretary of the Coroners’ Society told us about the immense scale of the resources that may be needed for inquests following public disasters, citing for example the infrastructure to support the inquests into the 96 Hillsborough deaths. Under the current arrangements, as with all inquests, a local authority that suffers a public disaster is responsible for covering the costs of what is likely to be a long and complex inquest. This may place a substantial burden on the rest of the local Coroner Service and other local services more generally. The Ministry of Justice has occasionally provided additional funding for these kinds of inquests.

Legal aid

170.These inquests are almost always large and complex with a mass of evidence and many legally represented bodies involved. Yet bereaved people can only get legal aid if they can meet the exceptional funding criteria and pass the means test (or apply for this to be waived). Going through the means tests can be humiliating and distressing. Deborah Coles, Director of INQUEST told us about the barriers bereaved people face when applying for Legal Aid:

They can go through …[a] very protracted funding processes. Those who fed back to the Ministry of Justice review of legal aid for inquests spoke extremely eloquently about the distress of having to talk about whether you own any expensive jewellery and going through pages and pages. My answer really is, why on earth should families be put through that? Why can we not recognise that non-means tested public funding should be available, particularly in the most complex cases?177

171.We called in Chapter 3 for public funding for legal representation for bereaved people at inquests where other bodies that are involved are legally represented at public expense. This funding could come from a range of public bodies. For inquests following public disasters, however, we call on MoJ specifically to provide automatic non-means tested legal aid for the people that have been bereaved.

Judge-led inquests

172.The Chief Coroners have introduced a range of measures to improve the Coroner Service’s response to public disasters. These include the appointment of judges to conduct some inquests, specialist coroners and the use of pen portraits of the victims to emphasise the individuality and importance of each of the deceased. Chief Coroner, Judge Lucraft, told us that he had himself conducted the inquests in relation to Westminster Bridge and London Bridge and Borough Market.178

Specialist coroners

173.The Chief Coroner set out the approach of the specialist cadre of coroners in his written evidence including the emphasis on respect for the deceased and bereaved people:

The guiding principles are the provision of honest and, as far as possible, accurate information at all times and at every stage, respect for the deceased and the bereaved, a sympathetic and caring approach throughout and the avoidance of mistaken identification.179

174.Deputy Chief Coroner, Alexia, Durran, told us, that specialist coroners for public disasters are involved immediately: “There are coroners on call when there is a major incident and they are involved in managing the very beginning, where things have, perhaps, in the past gone wrong.”180

175.Judge Lucraft described the specialist training:

We have specialist training to make sure that the lessons that were not learned on these incidents before are not missed… We have some of the world leaders, I am pleased to say, in DVI disaster victim identification training, both in Howard Way and in Pete Sparks from the Met police who run that. They help us to keep our coroners up to date.181

176.The Coroners’ Courts Support Service acknowledged the support provided by the cadre of specialist coroners but suggested this level of consideration should be shown to all those who have been bereaved:

bereaved family members of people who have not died due to a mass fatality may feel that the death can be on a sliding scale where someone who dies in a very public or mass situation holds greater importance than those who die when only the family are aware of the death. It is important to recognise and acknowledge these deaths for the individual family as much as the multiple deaths.182

Pen portraits

177.Judge Lucraft told us how useful pen portraits can be in keeping the individuals who have died at the forefront of the inquest, and that he was in the process of drafting guidance183 on their use:

In more recent inquests, it [use of pen portraits] has played a key part in the process. We probably all saw some of the pen-portrait material at the beginning of the Manchester Arena inquiry. Pen-portraits now take the form not just of people reading testimonies but often of a video or music being played. It is important in every case, whether it is a high-profile case or not, that the family of that deceased person is treated the same.184

178.Deborah Coles, Director of INQUEST, also told us how vital pen portraits are: “… to humanise the process and to acknowledge the people who died, so that they are seen in life and not just in death.”185

179.There has been good progress in improving the Coroner Service’s response to public disasters. However, a National Coroner Service is needed to ensure that inquests into mass fatalities are properly managed and that the deceased and bereaved people are always given the respect they deserve.

180.It is unacceptable that the people who have been bereaved are not entitled to automatic non-means tested legal aid at inquests into multiple deaths following a public disaster. These inquests are complex and ‘equality of arms’ is a fundamental requirement to make sure those who have been bereaved can participate fully. The Ministry of Justice should introduce an automatic entitlement to non-means tested legal aid for legal representation for bereaved people at inquests into mass fatalities.

175 Coroners’ investigations and inquests, Briefing Paper Number 03981, House of Commons Library, February 2021, p 9

176 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

179 Chief Coroner of England and Wales HHJ Mark Lucraft QC (COR0081), para 100

182 The Coroners’ Courts Support Service (COR0061), section 2

183 Not yet published at 3 May 2021

Published: 27 May 2021 Site information    Accessibility statement