Call for Consistency Across Coronial Areas
This article was first published on Lexis®PSL Corporate Crime on 13 December 2017.
Corporate Crime analysis: As the coroner service comes under the spotlight in the Chief Coroner’s annual
report 2016—17, Alexandra Tampakopoulos, points out that while calls for a national coroner service and the provision of legal aid for families fall on deaf ears, it is difficult to see significant progress being made.
MoJ publishes Chief Coroner’s fourth annual report, LNB News 01/12/2017 123
The Ministry of Justice has published the Chief Coroner’s fourth annual report to the Lord Chancellor under section 36 of
the Coroners and Justice Act 2009 (CJA 2009), which covers the Chief Coroner’s work in 2016—17. The report sets out
the progress in promoting consistency in coroner practices across England and Wales, guidance for coroners and the
training he has facilitated for coroners and their officers, supported by stakeholder events for local authorities and
bereavement support organisations, positive developments, issues of concern and recommendations to improve coroner
What are the key highlights or positive developments for coroners’ inquests this year?
A number of positive developments for 2016—17 are set out within the fourth annual report to the Lord Chancellor, the
first such report from the second Chief Coroner of England and Wales, His Honour Judge Mark Lucraft QC.
A key development has been the marked decrease in cases completed beyond 12 months. The wording of CJA 2009
and rule 8 of the Coroners (Inquests) Rules 2013, SI 2013/1616, reflects the concern of the public and Parliament that in
the past cases had not been concluded in a timely fashion.
In 2014, the figure was 2,673. In 2017, the number of cases not completed within 12 months had reduced to 1,508.
Furthermore, the average time of all cases from death to inquest continued its downward trend. The figure in 2014 was
28 weeks. For the 2016—17 period, the figure was 18 weeks. However, as is discussed below, the overall number of
cases reported to coroners in 2016 was the highest figure to date.
What particular concerns are highlighted in the report and are there plans to address these?
A number of concerns affecting the coroner service remain unresolved in 2016—17. As with previous reports, the lack of
consistency across coronial areas is a prominent theme. The report observes that the coroner service remains an
essentially local service without national structure. Coroners are appointed and paid locally, the service is funded locally
including the provision of courts and other accommodation, and coroners’ officers and support staff are employed locally
by police or local authorities. As a result, there are inevitable inconsistencies between coroner areas. While some areas
are well resourced in terms of the provision of coroners’ officers and support staff—others are simply not. By way of
illustrative example, where there are approximately 2,500—3,000 deaths reports to the coroner each year, the number of
coroners’ officers ranges from two to 11. The second Chief Coroner, as did his predecessor, makes clear his support for
a national service in order to achieve standardisation and consistency across England and Wales.
Another area of concern relates to the lack of statutory or other clear criteria for medical practitioners reporting deaths to
coroners. As a result, there is an inconsistency of practice across coroner areas. This is a clear and troubling lacuna in
the law and a matter for Parliament to regulate. Notably, the fact that doctors need clear statutory guidance for reporting
deaths to a coroner was made the subject of a recommendation in the 2013 Francis Report (recommendation 277).
The number of hearings is higher than any other comparable jurisdiction internationally. Why is this, and what recommendations are made to reduce numbers?
In so far as the overall figures are concerned, the provisional figure for the number of registered deaths in 2016 was
524,723. Most of these deaths are from natural causes but where it is not clear that this is the cause, the death must be
reported to the coroner. In 2016, a total of 241,211 deaths were reported to coroners, the highest figure to date. The
number of cases that required investigation and inquest in 2016 was 40,504. The report notes that the number has
increased as a result of cases where the deceased was under deprivation of liberty safeguards (DoLS) at the time of
death. Notwithstanding the contribution of DoLs cases, the number of hearings is very much higher than any other
comparable jurisdiction internationally as a result of the coronial statutory regime, which requires a hearing in cases of
non-natural death. The Chief Coroner recommends that the number could be substantially reduced by the introduction of
a special procedure for non-contentious cases. Cases where the facts are not contentious, no witnesses are required to
attend, the outcome is clear (at least on the balance of probabilities), the family do not want an inquest and there is no
other public interest for conducting a public hearing it is recommended that a change in the law should allow for such a
case to be concluded by a decision ‘on papers’ with a written ruling.
How can reports to prevent future deaths be utilised to have maximum impact?
Coroners are required to submit a report to prevent future deaths (PFD) where anything revealed by their investigation
gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist and in the
coroner’s opinion, action should be taken to prevent this. Between July 2016 and June 2017, 375 reports were issued.
The Chief Coroner makes clear that all coroners are encouraged to write and submit PFD reports where appropriate. All
reports are published by the Chief Coroner on the judiciary website and are therefore public and accessible. It is the very
public nature of these reports and the reputational effect that gives PFDs their teeth. Accordingly, the level of impact of
these reports very much depends on those who have an interest in highlighting the concerns raised.
What does the report have to say about some of the notable cases handled by coroners this year—both internationally and in the UK?
Following the deaths of 30 British holidaymakers in Sousse, Tunisia, in a terrorist attack on 27 June 2015, the Chief
Coroner requested that the Lord Chief Justice nominate a judge for the inquest. His Honour Judge Nicholas Loraine-
Smith was appointed and conducted the proceedings at the Royal Courts of Justice, London with the hearings made
available through various satellite courtrooms in England and Wales to enable families living a distance from London to
more fully participate. Conclusions of unlawful killing were returned in relation to each death.
The Chief Coroner continued to have oversight of the arrangements made in Leicester City and South Leicestershire
coroner area following the Malaysian Airlines Flight MH17 disaster over Ukraine in July 2014 and the arrangements in
the Kingston-Upon-Hull and east Riding coroner area following the Lufthansa Germanwings Flight 4U9525 in the French
Alps in March 2015.
Mass fatalities at home, the terrorist attacks at Westminster Bridge, Manchester Arena, London Bridge and Borough
Market, as well as the tragic fire at Grenfell Tower, have also had extensive involvement of the coroner service and of the
local senior coroner in the, often, lengthy process of identifying the victims. The site where the incident takes place may
not be safe and where terrorist activity is the cause, there may be a live investigation and the police will need to have an
eye on securing evidence for any prosecution that may ensue. If the incident is an explosion or a fire it may have caused
substantial damage to the fabric of the building where it has taken place as well as causing substantial disruption to the
bodies of those killed. The Chief Coroner continues to work closely with each of the senior coroners in the coroner areas
where these incidents have taken place.
What legislative recommendations are made? Do you have any predictions for further developments?
The Chief Coroner identifies a number of changes in the law to improve the service, all of which have appeared in
previous reports. As referred to above, the call for a national service with proper funding resounds in this report as in
previous reports. A further recommendation, made by his predecessor, is that the Lord Chancellor gives consideration to
amending the Exceptional Funding Guidance (Inquests) so as to provide exceptional findings for legal representation for
the family where the state has agreed to provide separate representation for one or more interested person. The report
observes that ‘in some cases the inequality of arms may be unfair or may appear unfair to the family. It may also mean
that the coroner has to give special assistance to the family which may itself give the appearance of being unfair to
While calls for a national coroner service and the provision of legal aid for families fall on deaf ears, it is difficult to see
significant progress being made. As the report acknowledges, there is still much to be done.
Alexandra Tampakopoulos has cultivated a diverse practice flowing from her extensive experience defending and
prosecuting serious crime. She has developed an expertise in inquests and public inquiries and has been instructed in a
number of complex and high-profile cases including in relation to Alexander Litvinenko, Hillsborough, the ‘SAS Inquest’
involving the death of three army reservists from heat illness in the Brecon Beacons and, most recently, the Grenfell
Tower Public Inquiry.
Interviewed by Kate Beaumont.
The views expressed by our Legal Analysis interviewees are not necessarily those of the proprietor.