Newsletters Inquests & Public Inquiries 6th Dec 2017

Publication of The Fourth Annual Chief Coroner’s Report for 2016 to 2017

Last week, the fourth annual Chief Coroner’s Report (2016 to 2017) to the Lord Chancellor was published as required under Section 36 of the Coroners and Justice Act 2009. This report is the the first from the second Chief Coroner, His Honour Judge Mark Lucraft QC, appointed to replace His Honour Sir Peter Thornton QC, on 30th September 2016, following the completion of his term in office. The report provides an assessment of the current state of the coroner service and makes recommendations for the future direction and progress of the service.

The Coroner Service

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. As a result, there are inevitable inconsistencies between coroner areas. Whilst some areas are well resourced in terms of the provision of coroners’ officers and support staff others are not. The second Chief Coroner, as did his predecessor, supports calls for a national service in order to achieve standardisation and consistency across England and Wales.

It is reported that the Chief Coroner is devising an appraisal scheme for coroner to help improve a consistent approach to practice and procedures as well as consistency in outcomes. The scheme will apply initially to all assistant coroners and will then be extended to area and senior coroners.

Positive Developments

Acknowledging the existing problems with a local as opposed to a national coroner system, the report details a number of positive developments including:

Cases over 12 months: Following the introduction by the Chief Coroner (in 2014) of a standard procedure for reporting on cases over 12 months, there has been a marked decrease in the numbers of cases outstanding. There has been a reduction from 2,673 cases first reported in 2014 to 1508 cases reported in 2017.

Average time to inquest: The average time of all cases from death to inquest completed has fallen to 18 weeks. The figure in 2014 was 28 weeks and so there has been a drop of 35.7%.

Issues of Concern

A number of issues affecting the coroner service remain unresolved. One such issue, highlighted in the Third Annual report, concerns the lack of statutory or other clear criteria for medical practitioners reporting deaths to coroners. It remains the case that there are no statutory criteria available for doctors on when to report a death to a coroner a clear lacuna in the law. Doctors need clear statutory guidance for reporting deaths to a coroner as recommended in the Francis Report (Recommendation 277).

Recommended law changes

The Chief Coroner identifies a number of changes in the law to improve the service, all of which have appeared in previous reports. These include:

Inquests without a hearing: The report observes that there is no need for all inquests to be concluded with a hearing. “In a case 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.

Representation for families: It is again recommended that the Lord Chancellor gives consideration to amending the Exceptional Funding Guidance(Inquests) so as to provide exceptional finding 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 others”.


The report concludes that significant progress has continued to be made in 2016-2017 but as is acknowledged there is still much to be done. Whilst calls for a national service and legal aid for families fall on deaf ears it is difficult to see the rate of progress improving or to envisage achieving standardisation and consistency across England and Wales.

Alex Tampakopoulos 

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