Recommendations & Conclusions
28 items
1
Conclusion
1st Report - The Coroner Service
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 …
Government response. We would agree that the creation of Chief Coroner has been a key reform. The office of Chief Coroner was introduced in 2013 to provide judicial leadership, guidance and support to coroners and to promote consistency of standards and practice. …
Ministry of Justice
2
Conclusion
1st Report - The Coroner Service
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.
Government response. We accept this recommendation and indeed, this is currently in progress as one of the measures in the Judicial Review and Courts Bill.
Ministry of Justice
3
Recommendation
1st Report - The Coroner Service
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 …
Government response. We do not accept this recommendation. We take the view that the analysis carried out at the time is now some six years old and there would be very limited value, or wider public interest, in publishing it now – …
Ministry of Justice
4
Conclusion
1st Report - The Coroner Service
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 …
Government response. The Chief Coroner will respond to the Committee on his engagement with stakeholders.
Ministry of Justice
5
Conclusion
1st Report - The Coroner Service
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 …
Government response. We accept this recommendation and we will work with the Chief Coroner to make sure that the Guide is available as widely as possible. The Ministry of Justice informed all coroner’s offices when we published the Guide in January 2020 …
Ministry of Justice
6
Conclusion
1st Report - The Coroner Service
Help and support for bereaved people depend 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 58 The Coroner Service support services for bereaved people at …
Government response. We are currently unable to accept this recommendation as further detailed work needs to be undertaken to understand the affordability, and legal and commercial issues in delivering it.
Ministry of Justice
7
Conclusion
1st Report - The Coroner Service
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.
Government response. It will be for the Chief Coroner to provide a response to this recommendation.
Ministry of Justice
8
Conclusion
1st Report - The Coroner Service
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 …
Government response. We do not agree with the Committee’s views on the Guide which we consider provides detailed information on the standards that bereaved people can expect to receive from the inquest process, and at Section 8 sets out steps that they …
Ministry of Justice
9
Conclusion
1st Report - The Coroner Service
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 …
Government response. The Chief Coroner will however provide a detailed response to this recommendation.
Ministry of Justice
10
Recommendation
1st Report - The Coroner Service
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 …
Government response. The Charter for Families Bereaved through Public Tragedy proposed by Bishop James Jones contains a commitment by public bodies to approach inquests with candour and honesty, making full disclosure of relevant documents, material and facts in the search for truth …
Ministry of Justice
11
Conclusion
1st Report - The Coroner Service
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.
Government response. Whilst the Committee welcomed the Government’s steps to support the inquisitorial nature of inquests, it did not consider that these were enough to prevent large multi- handed inquests, where individuals’ and organisations’ reputations were at stake, from becoming adversarial. The …
Ministry of Justice
12
Conclusion
1st Report - The Coroner Service
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 …
Government response. Whilst the Committee welcomed the Government’s steps to support the inquisitorial nature of inquests, it did not consider that these were enough to prevent large multi- handed inquests, where individuals’ and organisations’ reputations were at stake, from becoming adversarial. The …
Ministry of Justice
13
Conclusion
1st Report - The Coroner Service
The current arrangements for challenging coroners’ decisions are unwieldy and cause unacceptable delays, stress and often expense, for bereaved people. The The Coroner Service 59 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.
Government response. Currently a coroner’s decision can be challenged by way of judicial review or in certain circumstances, through an application to the High Court, with the authority of or by the Attorney-General, to have an inquest conclusion quashed under section 13 …
Ministry of Justice
14
Recommendation
1st Report - The Coroner Service
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 …
Government response. We accept this recommendation; the Government will seek to introduce this measure into legislation when parliamentary time allows.
Ministry of Justice
15
Conclusion
1st Report - The Coroner Service
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
Government response. The Government accepts the Committee’s recommendation. The Department of Health and Social Care have been leading on a range of initiatives to improve maternity reviews and investigations of stillbirths, neonatal and maternal deaths and brain injuries that occur during labour …
Ministry of Justice
16
Conclusion
1st Report - The Coroner Service
Pathology services for coroners have been neglected over many years leading to serious problems.
Government response. The Committee noted that pathology services for coroners have been neglected over many years leading to serious problems and recommends that the Ministry of Justice should immediately review and increase pathologists’ fees to ensure an adequate supply of pathology services …
Ministry of Justice
17
Conclusion
1st Report - The Coroner Service
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.
Government response. The Committee noted that pathology services for coroners have been neglected over many years leading to serious problems and recommends that the Ministry of Justice should immediately review and increase pathologists’ fees to ensure an adequate supply of pathology services …
Ministry of Justice
18
Conclusion
1st Report - The Coroner Service
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.
Government response. We accept this recommendation on the basis that all these departments and others such as the Chief Coroner’s office should work together on this issue. NHS England and Improvement are supportive of working with departments on scheduling coroner commissioned post-mortems …
Ministry of Justice
19
Conclusion
1st Report - The Coroner Service
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
Government response. The Ministry of Justice together with other government departments with a key interest will engage with the NHS to consider this proposal, so we cannot accept this recommendation at this stage. Officials from NHS England and Improvement would in principle …
Ministry of Justice
20
Conclusion
1st Report - The Coroner Service
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 …
Government response. The Government acknowledges the calls for a national coroner service. However, it does not think that a single service would necessarily address the issues facing the coronial system or be the best solution. It does not accept this recommendation. Creating …
Ministry of Justice
21
Recommendation
1st Report - The Coroner Service
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 …
Government response. The Government acknowledges the calls for a national coroner service. However, it does not think that a single service would necessarily address the issues facing the coronial system or be the best solution. It does not accept this recommendation. Creating …
Ministry of Justice
22
Conclusion
1st Report - The Coroner Service
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
Government response. The Government’s position on the Committee’s recommendations on a national service and inspectorate are set out above. The Government acknowledges the concerns raised by bereaved people and others about the challenges they may face if they seek to make a …
Ministry of Justice
23
Conclusion
1st Report - The Coroner Service
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.
Government response. The Government acknowledges the calls for a national coroner service. However, it does not think that a single service would necessarily address the issues facing the coronial system or be the best solution. It does not accept this recommendation. Creating …
Ministry of Justice
24
Conclusion
1st Report - The Coroner Service
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 …
Government response. The Government believes that inquests should remain inquisitorial in nature and that legal representation should not be necessary at all inquests. However, the Government will be considering its approach to legal aid for inquests as part of its response to …
Ministry of Justice
25
Conclusion
1st Report - The Coroner Service
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 …
Government response. The Government considers that coroners’ PFD reports are a vital tool in ensuring that lessons are learnt and that mitigations are put in place to prevent the risk of future harm or deaths. We are also aware that government departments, …
Ministry of Justice
26
Conclusion
1st Report - The Coroner Service
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 …
Government response. We acknowledge that there are some issues in searching for completed reports on the judiciary website and we understand that the Chief Coroner’s office has already put in hand work to determine how best to ensure that PFD reports and …
Ministry of Justice
27
Conclusion
1st Report - The Coroner Service
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 …
Government response. The Government accepts this recommendation. The Government would also wish to add its own thanks to all coroners, their officers and staff, as well as the Chief Coroner and his staff, for their dedication and diligence in ensuring that death …
Ministry of Justice
28
Conclusion
1st Report - The Coroner Service
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) 62 The Coroner Service
Government response. This recommendation is for the Chief Coroner. However, at his recent meeting with Lord Wolfson, the Chief Coroner set out his strategy for recovery from the pandemic, including his continued engagement with senior coroners across England and Wales to identify …
Ministry of Justice