Coroner Service Reform

The aim of the draft Coroners Bill, published on 12 June 2006, is simple: to modernise the existing coroner system and ensure that it better serves the needs of bereaved people.

The current process of reform began some four months earlier when, on 6 February 2006, the Minister of State for Constitutional Affairs, Harriet Harman MP, outlined proposals to change the present coroner system. So, why is the system in need of change? It is worth taking a few moments to consider the recent developments.

Need for change

In recent years, the coroner and death certification system has been the focus of some scrutiny. Public inquiries into Bristol Royal Infirmary and Alder Hey hospitals, the Marchioness disaster and the Shipman murders all identified shortcomings within the system. The latter really brought to the fore imperfections in the death certification system.

In July 2001, the Government commissioned a fundamental review of death certification and coroner services under the chairmanship of Tom Luce CB. The review made recommendations aimed at improving the efficiency of the coroner service and restoring public confidence in the death certification process. The report of the fundamental review was published in June 2003 and identified the need for radical change.

The third report of the Shipman Inquiry, chaired by Dame (now Lady Justice) Janet Smith, considered the work of coroners and the death certification system. The report, published in July 2003, made a number of recommendations, including the need for a cohesive, independent system of death investigation that is truly accessible to and understood by the public.

In 2003 and in response to each of these, the government took steps to identify ways in which the system for death certification and coroner investigation could be improved. Drawing heavily upon these recommendations, the government published its own position paper in March 2004, 'Reforming the Coroner and Death Certification Service'.

Among the recommendations contained within the paper was a need to establish a more uniform system under the responsibility of a chief coroner supported by a coronial council, to deliver real benefits to bereaved families and better meet their needs, and to streamline the coroner system by reducing the number of coroners to between 40 and 60, with dedicated and medically trained support.

Approaches to reform

When plans were announced to push on with reform in February 2006, the proposed changes were targeted at granting greater rights to bereaved people (underpinned by a charter), establishing national leadership and support (but not a national system) and creating a streamlined and modern system made up of full-time coroners. There was perceived to be a need for greater medical support for coroners at local level, and more guidance at national level. The sense is one of national leadership and national standards to achieve a better and more uniform system, while retaining the best features of a locally based service.

The Bill will replace the whole of the Coroners Act 1988. The draft Bill intends to give an improved service for bereaved people and others who come into contact with the coroner service. There will be national leadership, but efforts will be made to retain a well founded, locally based service. Finally, coroners' investigations and inquests will be made more effective.

There are five key reforms:

• Bereaved people will be able to contribute to coroners' investigations to a greater extent.
• There will be a new chief coroner and advisory coronial council.
• Coroners will become full-time and boundaries will be re-drawn.
• Coroners will have new powers to ensure better investigations and inquests.
• To minimise the grief and pain of the bereaved, coroners will have new powers to impose reporting restrictions where public interest would not be best served by doing so (for example, apparent suicides and child deaths).

This article examines the first four key reforms and will not consider changes to the role of coroners in treasure cases.

A greater role for the bereaved

Under a reformed system, bereaved people will have a clear legal standing in the investigation and inquest process.

There will be a new coroners' charter which will set out the standards that bereaved families can expect from the coroner service. An illustrative, draft charter has been produced to accompany the draft Bill.

The charter's objectives are telling. Most seek to improve communication between the coroner service and bereaved families. For example, the charter is designed to help bereaved people better understand the cause of death and to receive information about the role of the service and the powers of the coroner. Bereaved people will also be told at an early stage about their rights and responsibilities during the investigation or inquest process.

Practitioners should be aware that 'interested parties' (including close relatives, civil partners and personal representatives of the deceased) will be consulted by the coroner about certain decisions taken in cases, if they wish. These include decisions about whether there will be an investigation by the coroner, the scope of an inquest and which witnesses will be called to give evidence at the inquest (including expert witnesses).

Importantly, if a bereaved family member is unhappy with the way the coroner intends to proceed, he can ask the coroner to review that decision. If that person cannot resolve those concerns through discussion with the coroner, he can appeal directly to the chief coroner. Appeals can also be made to the chief coroner against decisions made about the cause of death (following an investigation but no inquest), or the coroner's decision at the end of an inquest.

The same is true of complaints, where resolution through discussion with the coroner is positively encouraged, failing which, the complaint may be directed to the chief coroner. It is envisaged that the charter will set out a more detailed complaints procedure.

National leadership

A chief coroner supported by a coronial council will provide the service with national, professional leadership. The chief coroner will be accountable to Parliament and will develop national standards and provide guidance and support for coroners. The chief coroner will also have access to a new chief medical adviser who will advise on strategic medical issues.

The chief coroner will raise standards within the service, monitor performance standards, arrange training for coroners, consider appeals against coroners' decisions and deal with complaints about the service. The chief coroner will be supported by a full-time deputy coroner, although there will be the facility to draw on other judicial figures to assist (for example, with appeals).

The appeal process is new. Under the present system, applications can be made to the High Court to compel a coroner to hold an inquest (if he refuses to hold one), or to quash a coroner's verdict and hold a fresh inquest. Judicial review of a coroner's decision is also possible.

Under the new system, the chief coroner will be able to determine appeals in relation to a number of matters, from decisions about whether to hold a postmortem, to compelling coroners to hold an inquest or quashing a coroner's verdict and ordering a fresh inquest to be held (replacing the present system of applying to the High Court). The appeal route will be much simpler for the family.

The new coronial council will have an advisory role. It will be made up in part from publicly recruited lay members who have had recent experience of bereavement, perhaps with a view to making the service more responsive to the needs of bereaved people who come into contact with the service.

Appointment of coroners

The service will be made up of around 60 to 65 full-time coroners and all new coroners will have to be legally qualified. The current titles of coroner, deputy coroner and assistant deputy coroner will be replaced by senior coroner, area coroner and assistant coroner.

The Lord Chancellor will now consent to the appointment of all senior and area coroners by the appropriate local authority and will be able to determine the size and boundaries of coroners' areas to make sure that the service operates effectively and in a co-ordinated fashion with other statutory services.

Coroners will be funded to 'buy in' medical support in consultation with the local authority.

Effective investigations

The aim is to modernise the process for coroner investigations and inquests.

A distinction is drawn in the draft Bill between the duty to investigate a death and the duty to hold an inquest (a small proportion of investigations result in an inquest), the inquest representing the final stage in the investigation. Commentary on the draft Bill suggests that it is not anticipated that the number of inquests will increase under the new Bill.

The circumstances in which a death must be investigated under a reformed system are similar to the present system, but the requirement that a death be 'sudden' as well as a 'cause unknown' has been removed from the Bill. The Bill permits the coroner to discontinue his investigation if, following the postmortem, the cause of death is determined and he no longer considers it necessary to continue.

Coroners will have new powers to arrange for the deceased's body to be moved to any place for postmortem. Currently, the coroner can only arrange for the body to be moved within his area or a neighbouring coroner area. This has caused practical difficulties in the past where there have been several deaths resulting from a major incident. This will also allow the service to make better use of specialist pathology services and equipment.

The chief coroner will have the power to intervene to direct that cases be transferred between coroners, to ensure a co-ordinated approach to incidents resulting in mass fatalities spanning more than one coroner area, and to re-allocate work between coroners where there are disparities in workload.

Juries will be reduced in size (to between five and seven members) and will be required only where the deceased died in prison or while lawfully detained in custody or as the result of an act or omission of a (service) police officer in the purported execution of his duty. The coroner will have discretion to use juries in other cases.

Significantly, coroners will have new powers to enter and search premises and to seize items if they believe those items to be relevant to the investigation. The coroner must have been unable to obtain permission to enter the premises (or reasonably believes this will be refused). The coroner can seize anything on the premises, or inspect or take copies of any document, relevant to the investigation.

An end to the system's weaknesses?

The Bill will make coroner investigations more effective, it will create a new structure of governance with the appointment of a chief coroner supported by the coronial council and, significantly, will bring the role of bereaved people to the fore. This is a real attempt to tackle the weaknesses in the system that have been identified in recent years, ending a period of uncertainty for the coroner service.

Practitioners should be aware that the service will pay more attention to the wishes of the deceased's family at key stages of the investigation and inquest process. They will have the right to be consulted on key issues from the requirement for a postmortem to the scope of the inquest and the need for certain witnesses to be called. There will also be a new right of appeal directly to the chief coroner, not just in relation to the coroner's verdict, but also in relation to matters dealt with at the pre-inquest hearing. This could result in prolonging the duration of the process and increasing the costs associated with it.

Andrew Alonzi is a solicitor and Senior Lecturer in Law, Nottingham Law School, Nottingham Trent University Andrew.Alonzi@ntu.ac.uk