Recommendations & Conclusions
10 items
1
Recommendation
1st Report - The Coroner Service
Deferred
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 …
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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.
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Government response AI summary
The government redirects the recommendation, stating that appraisal of judicial office holders is a matter for the judiciary, not ministers, and the Chief Coroner will respond directly to the Committee.
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Ministry of Justice
4
Recommendation
1st Report - The Coroner Service
Deferred
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 …
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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
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Government response AI summary
The government states that the Chief Coroner will respond to the Committee regarding his engagement with stakeholders concerning expediting cases to meet the needs of faith communities.
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Ministry of Justice
7
Recommendation
1st Report - The Coroner Service
Deferred
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 AI summary
The government redirects the recommendation, stating that it will be for the Chief Coroner to provide a response.
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Ministry of Justice
8
Recommendation
1st Report - The Coroner Service
Deferred
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 …
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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
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Government response AI summary
The government disagrees that its current Guide to Coroner Services is inadequate but acknowledges it is considering what more could be provided to bereaved families, with a full response due in the Government’s response to Bishop James’ report.
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Ministry of Justice
9
Recommendation
1st Report - The Coroner Service
Deferred
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 …
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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.
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Government response AI summary
The government states that the Chief Coroner will provide a detailed response to the recommendation regarding strengthening guidance and training on disclosure and pre-inquest reviews.
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Ministry of Justice
10
Recommendation
1st Report - The Coroner Service
Deferred
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 …
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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
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Government response AI summary
The government will consider the recommendation to amend Coroners' rules and extend the duty of candour to all public bodies in conjunction with its response to Bishop James Jones’ report in due course.
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Ministry of Justice
13
Recommendation
1st Report - The Coroner Service
Deferred
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.
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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.
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Government response AI summary
The government acknowledges the merit in considering an additional mechanism for appealing coroners' decisions, specifically referencing the original Section 40 of the 2009 Act, but it is not responding to the recommendation at this stage.
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Ministry of Justice
19
Recommendation
1st Report - The Coroner Service
Deferred
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
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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
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Government response AI summary
The government states it cannot accept the recommendation at this stage but will engage with the NHS to consider the proposal for regional pathology centres, noting NHS England and Improvement's in-principle support for considering such developments.
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Ministry of Justice
25
Recommendation
1st Report - The Coroner Service
Deferred
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 …
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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.
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Government response AI summary
The government acknowledges the need for more to be done regarding Prevention of Future Deaths (PFD) reports and will consider options, including an Inspectorate of Coroner Services, but is not in a position to accept the recommendation at this stage.
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Ministry of Justice
26
Recommendation
1st Report - The Coroner Service
Deferred
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 …
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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) Covid-19
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Government response AI summary
The government acknowledges issues with searching for reports and notes the Chief Coroner's office is working on cataloguing; however, it is not in a position to accept the recommendation to provide funding for improved online accessibility and searchability at this stage, stating they will consider …
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Ministry of Justice