National coroner service would iron out inconsistencies, says chief coroner

The chief coroner's annual report (75 page / 1.67MB PDF) said the localised nature of the coroner service continued to produce “inevitable inconsistencies” between coroner areas. The report said careful planning by local authorities, such as merging areas together, tendering for services, sharing resources and working collaboratively with other areas, would help to reduce costs and generate greater resilience.

Health and safety expert Alex Hudson of Pinsent Masons, the law firm behind Out-Law.com, said: “A national service would be welcomed by all interested parties. It would promote a standardised and consistent approach to inquests and coroner investigations."

“In particular a national service would also provide more support and resources for coroners. At a time when public spending is being cut, a single national system would also reduce the costs associated with the coroner service through shared resources and collaborative working,” Hudson said.

The chief coroner recommended that a number of legislative changes should take place. The report said the changes had already been proposed in previous annual reports but had not been taken forward.

A number of mergers between local coroner areas are currently under consideration as part of a plan to reduce the number of areas to 75, from 110 in July 2013. However a change in the law is required to provide greater flexibility.

Other legislative changes backed in the report include the ability to carry out an inquest into a death without a hearing taking place. It is also proposed that the High Court should be able to alter the record in a case without having to order a new inquest, as is currently required.

Hudson said the chief coroner had also proposed an amendment to 2009's Justice Act so that a senior coroner may discontinue an investigation where the coroner thinks that it is no longer necessary to continue. At the moment an investigation can only be discontinued where the cause of death is revealed by a post-mortem examination but the coroner has no power to discontinue an investigation where, for example, medical records that had not been available earlier reveal the cause of death. 

“These changes to the existing legislation would also be welcomed. Inquests can often be distressing, costly and time consuming for the parties involved – not least of all for the family and friends of the deceased,” Hudson said. “Considerable court and coroner resources would also be saved if coroners could discontinue investigations or deal with inquests without a hearing.”

The report said the chief coroner was also in the process of devising an appraisal scheme for coroners which would apply initially to assistant coroners before being extended. The scheme should improve consistency in practices and outcomes and help bed in national training.

According to the report, the average time of cases from the date of a death to inquest completed has fallen to 18 weeks, from 28 weeks in 2014. A total of 241,211 deaths were reported to coroners in 2016, but the report said this was “almost certainly due” to an increase in the number of deaths involving deprivation of liberty safeguards, which rose by 58% between 2015 and 2016.

Hudson said the current rules required an inquest to be completed within six months of the date on which the coroner is made aware of the death, or as soon as reasonably practicable after that date. 

“Although the average time of all cases from death to inquest completed has fallen to 18 weeks, often police or Health & Safety Executive investigations, in particular for manslaughter or health and safety offences, can take several years and inquests are put on hold pending the outcome of those investigations. Depending on the coroner area, resourcing can also delay proceedings,” Hudson said.