Extraordinary Report of the Chief Coroner

The Chief Coroner’s Extraordinary Report on the impact of the reforms of the coroner service, 10 years post-reform, was published on 11 January 2024.

On 25 July 2013, most of the reforms introduced by the Coroners and Justice Act 2009 came into force. The primary aim of the 2009 Act was to modernise the coronial service to create a more coherent, consistent, and responsive system for investigating deaths and conducting inquests. The recent report identifies that since then, whilst significant improvements have been made, there are areas where considerable problems remain:

1. Insufficient personnel, coroners’ officers are generally understaffed and overworked. The target caseload for each coroner’s officer should be approximately 25 inquest files, no coroner area is presently meeting this expectation.
     
2. The provision of material resources varies widely between local authorities with primary concerns in relation to:
       
   1. Dilapidated buildings. 
        
   2. Insensitively sited accommodation.
        
   3. A lack of dedicated courtrooms
          
3. There is a need for more salaried coroners.
     
4. There are operational difficulties caused by the ‘triangle of responsibility’. The fact that coroner’s officers and other staff work to the direction of the coroner yet are formally employed and line-managed by either the local authority or police force, causes confusion and conflict. 
     
5. The current resourcing structure potentially impacts judicial independence with problem areas including:
       
   1. Local authorities taking inappropriate action in relation to capability concerns instead of going through the appropriate court processes.
       
   2. Disagreements over staff direction with the police and local authorities.
       
   3. Inappropriate funding. 
         
6. Court security arrangements vary and the Chief Coroner ‘…rarely found adequate security measures in place at the coroners’ courts…’
     
7. An increase in workload.
     
8. Avoidable delays being at an unacceptable level with ‘…much of it resulting from matters outside coroners’ control’.
     
9. Judge led inquests where a judge has effectively been borrowed from a different jurisdiction for a case eg, where the case is particularly sensitive or complex or contains sensitive information are also funded by the local authority. In addition to funding the judge’s fee, the local authority must fund a legal team and pay other costs such as venue costs for large hearings. This can impact on the funding available for the coroner area’s routine work.
     
10. Coroners are appointed by local authorities and the interests of the local authority, and the coroner service are not always in alignment.
      
11. Limited specialist support is available to coroners eg in relation to security, press and Human Resources.

The Chief Coroner details the actions he is taking to encourage improvements in relation to the problems he has identified but concludes that:

• Structural changes are required. 
• The best working practices of other jurisdictions should be replicated.  
• The shortage of pathologists requires urgent action.
• In his view, there are limitations to what is achievable under the 2009 Act, but the structure, purpose and funding of the coroner service are matters for Parliament and the Government and as a judge, he cannot make policy recommendations.

On 30 January 2024, the Chief Coroner summarised the findings from his tour when he gave oral evidence to an inquiry launched by the Justice Committee to examine the changes made to the coroner service since 2021. The inquiry is ongoing and details of the coroner service inquiry can be found in this article.

The past decade has seen the coroner service undergo significant transformation, embracing modernisation and making substantial advancements in its operations. The Chief Coroner’s acknowledgment of the progress made is commendable, recognising the commitment to excellence within the service. However, there is a palpable candid awareness that the improvement journey is ongoing. The coroner service continues to evolve, with a clear recognition that further enhancements are essential to meet the evolving needs of society and provide solace to those affected by loss. As the service remains dedicated to its mission, the Chief Coroner’s commitment to continuous improvement signals a promising future for a system that plays a pivotal role in upholding justice and compassion during difficult times.

This article was authored by Sheyanne Lee.