The Coroner Service Contents

Conclusions and recommendations

Improvements since the Coroners and Justice Act 2009 (CJA 2009)

1. 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.(Paragraph 29)

2. 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. (Paragraph 32)

3. 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 The present Minister’s argument that it is now out of date is not sufficient reason for continuing to withhold it.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 obsolete. We recommend that the Ministy of Justice immediately publish its 2015 review of the effectiveness of the Coroners and Justice Act 2009. (Paragraph 37)

Putting bereaved people at the heart of the Coroner Service

Reducing delays so the body can be released

4. The Chief Coroner’s guidance on when and how to expedite a case to meet with the requirements of the beliefs of the deceased is welcome, but whether the needs of faith communities will be met or not depends on how the Coroner Service responds locally. We encourage the new Chief Coroner to continue the work of his predecessor in liaising with stakeholders, including with faith representatives, so that any problems with expediting cases can be identified and addressed as they arise. (Paragraph 53)

Written guidance, advice, and support

5. The Ministry of Justice’s Guide to Coroner Services is good first step but more needs to be done to make sure that bereaved people know of its existence. We encourage all Senior Coroners to make sure that the updated Guide to the Coroner Service for Bereaved People is freely available both online and, where requested, in hard copy by post and is offered to people who have been bereaved as soon as it has been decided that a post-mortem is needed. (Paragraph 58)

6. Help and support for bereaved people depends on the priorities, capacity and skills of the local Coroner Service and local volunteers in the Coroners’ Courts Support Service. The Ministry of Justice should as a matter of urgency provide funding for support services for bereaved people at inquests, (such as those provided by the Coroners’ Courts Support Service), so that this support is available in every Coroner Area. (Paragraph 66)

Rights for bereaved people

7. We encourage Senior Coroners to make sure that bereaved people are made aware by their staff of the specialist support organisations that are available to them both locally and nationally. (Paragraph 67)

8. Bereaved people deserve a charter of rights setting out the standards of service they are entitled to receive from the Coroner Service. Setting out the standards they can ‘expect’ in the Guide to Coroner Services is inadequate. The Ministry of Justice should implement a statutory Charter of Rights for bereaved people, modelled on the criminal justice system’s victims’ code. (Paragraph 70)

Access to evidence and openness

9. Bereaved people are at a disadvantage when they do not have access to the evidence. It is important that the process for obtaining evidence is explained clearly to them as this is important for the fairness of the inquest. We encourage the new Chief Coroner to strengthen guidance and training on disclosure and pre-inquest reviews, emphasising to coroners that bereaved people should be told about their rights to documents early in the process. (Paragraph 73)

10. The failure of health and social care bodies to fulfil their duty of candour to bereaved people during coroners’ investigations and inquests is disappointing. The Ministry of Justice should amend the Coroners’ rules to make it patently clear that the duty of candour extends to the Coroner Service. The Government should consider whether a similar duty to be candid at inquests should be extended to all public bodies. (Paragraph 81)

Fairness for the bereaved

11. The Government’s steps to support the inquisitorial nature of inquests are welcome but are insufficient by themselves to prevent large multi-handed inquests, where individuals’ and organisations’ reputations are at stake, from becoming adversarial. (Paragraph 92)

12. Bereaved people should not be put through the difficult and time-consuming process of meeting the exceptional cases requirements and the means test for legal aid where public authorities are legally represented at public expense at the inquest into the death of their loved one. The Ministry of Justice should by 1 October 2021, for all inquests where public authorities are legally represented, make sure that non-means tested legal aid or other public funding for legal representation is also available for the people that have been bereaved.(Paragraph 103)

13. The current arrangements for challenging coroners’ decisions are unwieldy and cause unacceptable delays, stress and often expense, for bereaved people. The Ministry of Justice should introduce a system of appeals similar to that in Section 40 of the Coroners and Justice Act 2009 as originally enacted. (Paragraph 113)

14. There may be circumstances where with the consent of the bereaved people concerned, it would be sensible for the High Court to be able to direct that the particulars of the Record of the Inquest be amended as appropriate without ordering a fresh inquest. The Government should consider adopting the Chief Coroner’s proposed amendment to Section 13 with the caveat that the High Court could use the new power only with the consent of the interested party applying under Section 13. (Paragraph 116)

15. The Government consultation on coronial investigation of stillbirths was welcome but it is disappointing that it appears to have stalled. The Ministry of Justice should revive the consultation on coronial investigation of stillbirths and publish proposals for reform. (Paragraph 118)

Shortage of pathology services

16. Pathology services for coroners have been neglected over many years leading to serious problems.(Paragraph 134)

17. The Ministry of Justice should immediately review and increase Coroner Service fees for pathologists, so they are enough to ensure an adequate supply of pathology services to the Coroner Service. (Paragraph 135)

18. In the medium term the Ministry of Justice should work with the Department of Health and Social Care so that pathologists’ work for coroners is planned for within pathologists’ contracts with NHS trusts. (Paragraph 136)

19. In the longer term, the Ministry of Justice should broker an agreement between relevant government departments and the NHS (in England and Wales) for the establishment and co-funding of 12–15 regional pathology centres of excellence. (Paragraph 137)

A unified national Coroner Service for England and Wales

20. 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. (Paragraph 157)

21. 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. (Paragraph 166)

22. 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. (Paragraph 167)

Public disasters

23. 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. (Paragraph 179)

24. 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. (Paragraph 180)

Addressing fatal risks identified by coroners and inquest juries

25. The system for the Coroner Service to contribute to improvements in public safety is under-developed. The absence of follow up to coroners’ ‘prevention of future deaths reports’ is a missed opportunity. The Ministry of Justice should consider setting up an independent office to report on emerging issues raised by coroners and juries; and liaise with regulators, (for example the Health and Safety Executive, the Independent Office for Police Conduct, the Prisons and Probation Ombudsman, the Care Quality Commission, Highways Authorities, and Air and Rail safety bodies) and others, to follow up on actions promised to coroners and to report publicly where insufficient action has been promised or implemented. As an alternative a new Coroner Service Inspectorate could be given this role. (Paragraph 207)

26. The current arrangements for publishing coroners’ reports and responses to those reports require improvement. The information published is the bare minimum and is difficult to search and analyse. The Ministry of Justice should provide funding so information about the risks to public safety discovered by coroners and inquest juries is freely available online, along with the actions that have been proposed in response. The MoJ should ensure that this information is well-organised and easily searchable. (Paragraph 208)


27. The Coroner Service responded well to covid-19, and we express our thanks to all those involved under very difficult circumstances. A considerable number of inquests have been delayed because of the pandemic restrictions. We were unconvinced by the Minister’s response on how the MoJ will support the Coroner Service to reduce waiting times. The Ministry of Justice should liaise with the Chief Coroner and consider what central government support may be needed to help the Coroner Service to recover from the pandemic.(Paragraph 221)

28. We encourage the Chief Coroner to collect information from each Coroner Service Area on the challenges they face because of the pandemic and communicate the overall picture to the Ministry of Justice. (Paragraph 222)

Published: 27 May 2021 Site information    Accessibility statement