Source · Select Committees · Justice Committee
1st Report - The Coroner Service
Justice Committee
HC 68
Published 27 May 2021
Recommendations
3
Tom Luce, among others, has identified the Ministry of Justice decision not to publish its...
Recommendation
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 …
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Ministry of Justice
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10
The failure of health and social care bodies to fulfil their duty of candour to...
Recommendation
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 …
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Ministry of Justice
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14
Para 116
There may be circumstances where with the consent of the bereaved people concerned, it would...
Recommendation
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 …
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Ministry of Justice
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21
As with calls for a national service for England and Wales, there is an overwhelming...
Recommendation
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 …
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Ministry of Justice
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Conclusions (24)
1
Conclusion
Para 29
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 …
2
Conclusion
Para 32
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.
4
Conclusion
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 …
5
Conclusion
Para 58
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 …
6
Conclusion
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 …
7
Conclusion
Para 67
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.
8
Conclusion
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 …
9
Conclusion
Para 73
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 …
11
Conclusion
Para 92
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.
12
Conclusion
Para 103
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 …
13
Conclusion
Para 113
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.
15
Conclusion
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
Conclusion
Para 134
Pathology services for coroners have been neglected over many years leading to serious problems.
17
Conclusion
Para 135
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.
18
Conclusion
Para 136
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.
19
Conclusion
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
Conclusion
Para 157
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 …
22
Conclusion
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
Conclusion
Para 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.
24
Conclusion
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 …
25
Conclusion
Para 207
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 …
26
Conclusion
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 …
27
Conclusion
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 …
28
Conclusion
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