The Annual Chief Coroner’s Report

HHJ Thomas Teague KC recently came to the end of his tenure as Chief Coroner, delivering his final annual report to the Lord Chancellor in May. As ever it is requisite reading for those who practise in coronial courts.

Of particular note is the Chief Coroner’s exploration of the intellectual foundation of the coroner service with the aim of reinforcing the principle that an inquest is a summary medico-legal investigation into the immediate cause of an unnatural death rather than a more “exhaustive exploration of the wider circumstances, seeking to explain not just how each deceased person died, but why”.

The Chief Coroner reiterated that is it clear from the statutory framework that the coroner’s role is to investigate not to adjudicate, and “an inquest should remain a hearing that is narrowly focused on establishing a person’s immediate cause of a death, as opposed to in effect becoming a surrogate public inquiry”. He considered that there is “a deep truth in the idea that bereaved families owe a posthumous duty to care for their deceased relatives and that the state in turn is under an obligation to do what it reasonably can to enable them to discharge that duty”. From this “deep truth” he draws the following conclusions:

1. “The purpose of a coroner’s investigation is not simply defined by the statutory rules and regulations that coroners must apply. The death investigation process has a profound human significance and there is a clear moral basis for placing the deceased at its heart.
2. The existence of a posthumous duty to the dead lends an enhanced dignity to the right of the bereaved to be involved in coronial investigations, but it also defines the limits of their involvement.
3. It is this posthumous duty owed to the deceased by the family and the state that ultimately explains and justifies the need for the focus of each investigation to be on the deceased person, not on the wider issues that are explored during a public inquiry.”

In his final analysis, the Chief Coroner draws the following practical conclusions:

• The scope of inquests should be narrowly focused on the death of the deceased – the coroner’s investigation should not be conducted as a surrogate public inquiry to examine extraneous issues of concern.
• The inquisitorial nature of the coroner service should be protected– an inquest should not be a forum for individuals and organisations intent on avoiding reputational or financial damage to present competing versions of events. It should be an investigation controlled by the coroner and focused on discovering the truth about the death of the person at its heart.
• Issuing prevention of future death (PFD) reports is an ancillary duty – PFD reports provide a way for the coroner to draw attention, without recommending any specific solution, to the existence of matters on which action could be taken to prevent future deaths. PFDs are very important and can achieve a great deal when properly used, but the prevention of future deaths is not the primary function of a coroner’s investigation, which is to focus on the death of the deceased person.
• Coroner cases should be conducted without delay – and avoiding unnecessary delay must therefore be a key priority for the coroner service.

Comment: As he has throughout his tenure, the Chief Coroner continues to place great emphasis on what he describes as “protecting the narrow inquisitorial approach” (see Morahan). This approach has come under significant and consistent pressure from families in the higher courts. This is perhaps unsurprising given the inherent tension between the statutory framework and the “posthumous duty owed to the deceased by the family and the state” infused as it is with “profound human significance”. And in many cases, the inquest process will be the final opportunity to learn as much as possible of the circumstances of a family or friend’s death and to find the truth. It is unlikely therefore that the pressure to broaden the ambit of inquests will ever abate.

Alexandra Tampakopoulos