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F284

Appointment of assistant deputy coroners

Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013

Government responseDepartment of Health and Social Care: Accepted (Nov 2013)

DeliveryDHSC and NHS England say completed (Feb 2026)Department of Health and Social Care states no delivery position (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners.

Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →

Published evidence summary

AI-generated evidence summary

In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that action had been noted in response to it (DHSC and NHS England, Feb 2026). In February 2026, the Thirlwall Inquiry legal team found that the recommendation had been accepted and that the Ministry of Justice and the Chief Coroner had published guidance in July 2013 specifying details for assistant coroner appointments (The Thirlwall Inquiry legal team, Feb 2026).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

Report-level response context

Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.

Government response

●Department of Health and Social Care · Accepted · 19 Nov 2013

Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013

Accepted.
This has been taken forward by the Chief Coroner. Local Authorities are responsible for all coroner appointments with the consent of the Lord Chancellor and the Chief Coroner.
The Ministry of Justice and the Chief Coroner have developed guidance, The Appointment of Coroners (July 2013), for Local Authorities on coronial appointments, including the qualifications and process for all coroner appointments. The guidance specifies details for the appointment of assistant coroners based on the main process for senior coroners with an understanding that there may be a need for appropriate flexibility due to the volume of posts and the need to involve the senior coroner in the process.
This guidance is intended to ensure that the process for appointments is as robust, consistent and transparent as possible.

Response document: Hard Truths: The Journey to Putting Patients First. Volume Two of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry: Response to the Inquiry's Recommendations

Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.

Delivery

●DHSC and NHS England say completed · 27 Feb 2026

The Thirlwall Inquiry has noted action taken in response to this recommendation following the conclusion of the Mid-Staffordshire Inquiry 2013.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Closed”. Table row: section 18.2 No. 284, PDF page 576.

Site note: DHSC and NHS England's entry for this recommendation says that the Thirlwall Inquiry noted action taken on it. The entry gives no other account of what was done.

●Department of Health and Social Care states no delivery position · 11 Feb 2015

No further update is required. Please see response to the recommendation in Hard Truths

From: Culture Change in the NHS supporting Annex (annex to Culture change in the NHS: applying the lessons of the Francis Inquiries)

Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.

Site note: The Inquiry addressed this recommendation to the Ministry of Justice, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.

What other bodies have found

In their own words. These do not change the delivery statement above.

●Thirlwall Inquiry legal team · 27 Feb 2026

This recommendation was accepted by the Government.

In the January 2014 Hard Truths report, the Government said that the Ministry Of Justice and the Chief Coroner had published guidance titled ‘The Appointment of Coroners’ in July 2013, which specified details for the appointment of assistance coroners based on the main process for senior coroners.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team and/or DHSC and NHS England, that a recommendation has been clearly implemented. Table row: section 18.2 No. 284, PDF page 576.

Earlier findings (1)

●Thirlwall Inquiry legal team · 15 May 2024

This recommendation was accepted by the Government.

In the January 2014 Hard Truths report, the Government said that the Ministry of Justice and the Chief Coroner had published guidance titled ‘The Appointment of Coroners’ in July 2013, which specified details for the appointment of assistance coroners based on the main process for senior coroners.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 16.2 No. 284, PDF page 529.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.