Government’s response to the Coroner Service Inquiry

The Government remains committed to its aims of putting bereaved people at the heart of the inquest and to ensuring that the inquest process is as sensitive as possible to their needs.

The House of Commons Justice Committee has recently published the Government’s response to their inquiry report on the Coroner Service (May 2021) which called for a legal ‘equality of arms’ and other major reforms.

The inquiry examined the effectiveness and the capacity of the Coroner Service, including whether enough progress has been made in improving bereaved people’s experience of the service since the reforms of Coroners and Justice Act 2009 which were implemented in 2013.  

The Justice Committee made significant and wide-ranging recommendations across a number of areas, focussed on putting bereaved people at the heart of the coroner service. It found that the service people received varied greatly across the country and called for the creation of a National Coroner Service to ensure better standards nationally. Each year around 40 per cent of all deaths are reported to coroner services in England and Wales giving rise to some 30,000 inquests.

We outline the key recommendations from the Committee’s report although 25 recommendations were made in total:

  • Create a National Coroner Service for England and Wales
  • Provide funding for support services for bereaved people at inquests, similar to the Coroners’ Courts Support Service, so that they are available in every area
  • Invest in pathology services, with three solutions proposed
  • New body to oversee the public safety risks that coroners and inquest juries find, and to monitor and take action to reduce these risks
  • Ensure legal aid is automatically available for the bereaved at the most complex inquests

In its response, the Government has accepted six recommendations and there are a number of recommendations where it has committed to undertake further work before coming to a firm decision. There are also an additional four recommendations which are addressed to the Chief Coroner, His Honour Judge Thomas Teague QC who will be responding to the Committee directly.

On the following significant areas where the Committee made recommendations, the Government accepts the recommendations made on:

Coroner area mergers

The government is supportive of the policy to reduce the number of coroner areas so that they are better placed to provide a consistent standard of service to bereaved families and economies of scale for local authorities who will be able to contract for mortuary, pathology and other services across larger areas. The Ministry of Justice is progressing amendments to the Coroners and Justice Act 2009 to make it easier to merge areas.

Fresh inquests

The government will seek to adopt the Chief Coroner’s proposed amendment to section 13 with the caveat that the High Court could only use the new power “ with the consent of the interested party applying user section 13”. It will seek to introduce this measure into legislation “when parliamentary time allows”.

Coronial investigation of stillbirths

The government is supportive of the proposal that the Ministry of Justice should revive the consultation on coronial investigation of stillbirths and publish proposals for reform.

Guide to coroner Services for Bereaved People

The Government  will work with the Chief Coroner to make sure that the Guide is available as widely as possible.

Non means tested legal aid for inquests

The government will be taking forward legislation to remove the means test for applications for Exceptional Case Funding in relation to legal representation at inquests. Beyond this, the government will be considering its approach to legal aid for inquests as part of its response to Bishop James Jones’ report of his review of the Hillsborough families’ experiences.

Pathology service reforms

The Committee made recommendations in three discrete areas. The government has accepted the need for the coronial pathology to become part of pathologists’ NHS contract, recognising that an integrated approach is likely to minimise the impact of shortages on both NHS and coroner services. However, the government rejected proposals to raise the fees paid to pathologists pending further enquiry. Similarly, on creating regional pathology centres of excellence, the government wishes to explore this further with other government departments and engage with the NHS. But it recognises that NHS England and Improvement would in principle support the development of a number of specialist pathology centres, which would be in line with published NHS England and Improvement aims for pathology.

However, the Government has deferred any defined action in the following areas:

  • Statutory duty of candour
  • A system for appealing coroners’ decisions
  • A charter of rights for bereaved people
  • Support services for bereaved people
  • Unified Coroner Service for England and Wales
  • A Coroner Service Inspectorate        
  • Handling coroner complaints
  • An independent office to report on emerging issues raised in Preventing Future Death reports, to liaise with regulators and others, to follow up on actions promised to coroners and to report publicly where insufficient action had been promised or implemented.

Judicial review and Courts Bill

In the next couple of weeks (18 October 2021), MPs will debate the Judicial Review and Courts Bill as it reaches its second reading in the House of Commons. This Bill currently proposes a series of reforms to the Coroner’s Service, including the phased transition to new coroner areas (as discussed above) and provision for more inquest hearings to be held remotely, as well as the possibility that juries may sit remotely. Other proposals provide for the discontinuance of investigation where the cause of death becomes clear and the power to conduct non-contentious inquests in writing.

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