6th Feb 2024

The position of the coroner is the oldest surviving judicial office in England and Wales: So said the Chief Coroner, HHJ Thomas Teague KC is his recent lecture “Death and Taxes: the past, present and future of the coronial service”.

That lecture (https://www.youtube.com/watch?v=Je6vUQwWcUo), provides a fascinating history of the system of coronial law and the genesis of the modern office of the coroner. It marked the 10th anniversary of the implementation of the Coroners and Justice Act 2009. The Act introduced an element of central oversight of the coronial service through the new office of Chief Coroner. It improved aspects of organisation of the service. Not least, Coroners were made subject to the same professional standards as their judicial colleagues in other jurisdictions. The policy of all three Chief Coroners, who have held this office since 2013, has been to use this reformed structure to create a more modern, consistent, open and just service. 

Their collective aim, to reduce unnecessary delays, and, to put bereaved families at the heart of the service has yet to be fully accomplished. The present Chief Coroner conducted a national tour of the coronial service ending in March 2023. His assessment is that, despite the considerable improvements since 2013, the description of the coroner’s system as a “largely forgotten service remains recognisable. The fact is, that the system is understaffed and over-worked. There are a lack of pathologists, inadequate facilities, general underfunding and delay.

Campaigners and legal professionals alike have expressed concerns around openness and efficiency. As long ago as 2017-18, the then Chief Coroner HHJ Mark Lucraft KC, proposed that there should be a national coroner’s service. That national service envisaged that coroners be appointed, and the service funded and run centrally, like any other judicial service. The need for a centralised service is ever more urgent when one considers that the number of inquests open for more than two years has increased more than fourfold, from 378 in 2017, to 1,760 in 2022. This increase in work has been compounded by a corresponding increase in case complexity. The increased professionalism of the coroner service has imposed more stringent processes and demands. The introduction of the medical examiner system means that complex cases (in which reportable factors might previously have been missed) are now rightly being identified. Coroners also face increased demand to expand the scope of their investigations in the more contentious inquests.

Whilst it is not possible to overlook the effect of the Covid-19 pandemic, the problems that beset the system pre-date the pandemic, and that system is in now in crisis. As the Times reported in July 2023 ‘Ordinary members of the public can hardly be expected to understand a tangled structure whereby the Judiciary appoints coroners, local authorities are responsible for funding and police share responsibility for staffing. This baroque arrangement is almost guaranteed to create friction.’ 

It is, of course, the bereaved families, who should be at the very heart of the system, and who are experiencing delay which further exacerbates their grief and anguish. I have represented the bereaved family of a man whose inquest was delayed by an extraordinary 10 years after his death. My client reported that “The delays caused us many problems, getting legal representation was one of them as plans change and people move on to different things… My wife has had poor mental health since her father dies, and for years just wanted the inquest over. She says she grieved four times for her father, once when he was diagnosed with dementia, once when he actually died, once when his death was investigated, and finally, after years, at the inquest”.  

This government, or the next, must surely address the need for further reform for the benefit of the coroner’s service?

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