The Justice Committee launch new inquiry into the Coroner Service to examine the changes made since 2021

The Coroners and Justice Act 2009, which was implemented in 2013, aimed to deliver a ‘more effective, transparent and responsive justice and coroner services’. Examining the effectiveness of this Act, a cross-party committee of MPs conducted an inquiry examining the effectiveness and capacity of the Coroner Service during the 2019-21 session of Parliament. The central aim of the inquiry was to investigate whether enough progress had been made on improving bereaved people’s experience of the Coroner Service. 

The new inquiry is particularly pertinent at present, as in 2022, 208,400 deaths were reported to coroners, the highest since 2019, and up 7% compared to 2021. This figure represents 39% of all registered deaths, at its highest level since 2019 and 43% of these deaths led to post-mortems. In 2022, 35,600 inquest conclusions were recorded in total, up 10% since 2021. The inquiry will build on the Committee’s previous findings and consider what changes have occurred since 2021, looking at the progress made on the earlier recommendations.

The Justice Committee has invited submissions on 9 areas (detailed below) by Monday 15 January 2024 – creating consistency across coronial jurisdictions was a key focus of the 2021 Committee and is an issue which we encounter on a regular basis. If you are planning on sending a submission, or you would like to contribute to a joint submission, please do not hesitate to get in contact with us.

By way of a recap, the earlier recommendations accepted by the Government were: 

• To make it easier for coroner areas to merge on the basis that a reduced number of areas increases consistency. 
• To do more to ensure bereaved people are aware of the ‘Guide to Coroner Services for Bereaved People’
• To introduce measures into legislation to allow the High Court to direct that a Record of Inquest be amended as appropriate without ordering a fresh inquest (suggested amendment to section 13 of the Coroners Act 1988)
• Revive the consultation on coronial investigation of stillbirths and publish proposals for reform.
• In the medium term the Ministry of Justice should work with the Department of Health and Social Care so that pathologists’ coronial work is planned for within their NHS contracts. With the aim of an integrated approach minimising the impact of shortages on both NHS and coroner services. 
• The Ministry of Justice should liaise with the Chief Coroner and consider central government support needed to help the Coroner Service recover from the pandemic. 

The Justice Committee Chair, Sir Bob Neill MP, stated the following:

“Since the Committee’s earlier inquiry examining the effectiveness and capacity of the Coroner Service, there has been a notable rise in deaths reported to coroners and inquests held. It is right the Committee follows up its previous recommendations and checks on the progress made across the Coroner Service since 2021, particularly in light of this increased demand.

We intend to visit coroners to see how bereaved families’ experiences vary, examining in particular any regional disparities, delays and Coroners’ responsiveness to the particular requirements of faith burials and funerary practices.”

The Justice Committee is currently inviting written submissions addressing the following questions:

1. What progress has been made towards the goal of placing bereaved families at the heart of the Coroner Service.
2. What progress has been made by the Government in implementing those of the Committee’s earlier recommendations which it accepted in September 2021.
3. What progress has been made by the Government in responding to those of the Committee’s recommendations which it was unable to address in September 2021.
4. Given that the Government has rejected the Committee’s recommendation to unite local coroner services into a single service, what more can be done to reduce regional variation and ensure that a consistent service operates across England and Wales
5. Whether more can be done to make best use of the Coroner Service’s role in learning lessons and preventing future deaths. In particular:
   1. are Coroners across England and Wales making consistent use of their power to issue Prevention of Future Death (PFD) reports? ​​​​
   2. could the way PFD reports are being used to help prevent future deaths be improved?
6. How are Coroners responding to the requirements of faith burials and funerary practices, especially in relation to early release of bodies and provision of non-invasive autopsies? Is there a consistent and satisfactory approach across England and Wales?
7. Whether there is evidence that inquests are taking too long to be completed, and if so why, and what can be done in response.
8. Whether the Coroners’ Service has recovered from the challenges of the Covid-19 pandemic, and what lessons can be drawn from it.
9. Whether there are any other changes to the way the Coroner Service operates that could be made to improve its effectiveness.

We look forward to hearing from you and understanding your views on these important issues.

This article was written by Legal Director Rebecca Sharrock and Associate Mehren Sulaman.