Chief Coroner’s updated Bench Guidance

Nearly a decade after its first publication, the Coroner’s “Bench Book” has been updated and was published on 1 January 2025. Whilst titled “Chief Coroner’s Guidance for Coroners on the Bench”, this is to be referred to in short as the “Bench Guidance”, and can be found here:

Chief Coroner’s Guidance for Coroners on the Bench - Courts and Tribunals Judiciary

Although the guidance is used by Coroners to assist with understanding their duties in the investigation of deaths, it is of equal importance to inquest practitioners when navigating the legal framework surrounding inquests and the Coroner’s powers during complex coronial proceedings. 

The guidance holds the same status as the Chief Coroner’s existing guidance notes and law sheets. Importantly, where there are any inconsistences between existing guidance notes (where not yet withdrawn) and the Bench Guidance, the latter will prevail. 

The Chief Coroner, HHJ Alexia Durran, has confirmed the guidance should be viewed as a ‘live’ document which will be regularly reviewed and updated.  

Key updates in the Bench Guidance include:

1. The right to interested person status
    
   The new Bench Guidance highlights that where an organisation is afforded Interested Person (IP) status because of an individual employee’s actions or omissions, ‘that employee will invariably be entitled to IP status in their own right’.
    
   The guidance goes on to explain that all employees should be informed of their individual right to IP status, even if their employer already has corporate IP status. Significantly, the guidance makes it clear that separate IP status for an employee is not founded upon any conflict of interest. 
    
   Understandably, this will be a daunting prospect for employees and will need to be managed carefully by organisations to ensure employees are both adequately informed of their rights, and supported appropriately. 
    

2. Correspondence with other interested persons
    
   The guidance reminds advocates that any submissions/correspondence relating to matters of substance made to a Coroner (unless uncontentious or administrative) should be served on all other IPs at the same time as they are filed with the court. 
    
   This responsibility falls on the person making the submission or application, not the coroner’s office. 
    

3. Witness statement template 
    
   At Appendix 4.2 of the guidance, a standard witness statement template has helpfully been provided. The template ensures that statement makers include their professional qualifications/relevant experience; set out the sources of information considered in preparing the statement and avoid providing opinion or comment. The template is also verified by a Statement of Truth.
    
   Witnesses should be advised of the above statement template when asked to prepare a written statement for an inquest. 
    

4. Expressions and terms to avoid
    
   Numerous expressions and terms which should not be used at inquests are listed in the guidance. For example, Coroners, and advocates, should avoid the following:
     

   1. ‘Committed suicide’ as this suggests a criminal act. The words ‘died by suicide’ are more acceptable.
       

   2. ‘Successful’ or ‘unsuccessful’ or ‘failed’ suicide attempt: this may distress the bereaved.
       

   3. ‘Addict’, ‘drug abuser’, ‘clean’ to be avoided and instead use ‘has a substance misuse disorder’, ‘has an addiction’, ‘is abstinent from drugs/in recovery’.
       

   4. Talking about people as if they are medical conditions: for example, avoid saying ‘a dyslexic’ or ‘a diabetic’ – use instead ‘a person with dyslexia/diabetes’.
       

   5. Avoid negative terms such as ‘suffers from’ – use instead ‘has’, ‘experiences’ or other more neutral terminology.
       

5. Record of inquest 
    
   As part of the four questions to be answered at an inquest, the Coroner must record ‘who’ has died under Part 1 of the Record of Inquest. This should be the full name that the deceased was known by at their death, which may be different from their given name at birth, for any reason.
    
   Significantly, the guidance stipulates that neither a deed poll, marriage or a Gender Recognition Certificate (GRC) will change one’s name - a person has no ‘legal name’ to be changed in the first place. 
    
   The deceased’s name will be a matter of evidence, for the Coroner to decide upon on the balance of probabilities. Although the deceased’s wishes and values should be at the forefront of any decision.
    

6. Lesson learning/Prevention of Future Deaths (PFD) evidence
    
   In some inquests being heard by a jury, the practice is to hear Prevention of Future Deaths (“lesson learning”) evidence by the Coroner alone, once the jury has retired.  The new Bench Guidance makes it clear that this would be unusual and that all evidence should be heard before a jury.  Many Coroners will accept written evidence as to organisation learning, negating the need to hear live evidence from a witness.  This would benefit organisations by avoiding jury confusion as to whether changes made since meant that there was a gap in care at the time.  Organisations may wish to consider providing (brief) written evidence of the current position as to any learning in advance of the inquest, to then explore this option with the Coroner at the inquest itself.