The Coroner Service

Justice Committee Closed Inquiry
Opened: 7 Jul 2020 Closed: 1 Dec 2021 Parliament page
This inquiry examined the effectiveness and capacity of the Coroner Service. It also looked at whether enough progress has been made in improving bereaved people's experience of the Coroner Service. The Coroners and Justice Act 2009 introduced changes to the service which were implemented in 2013. This included the appointment … Read more
26 Recommendations
2 Conclusions
1 Report
4 Oral sessions
1 Letter
4 Events
Activity timeline 7 events
22 Feb
2022
Correspondence
10 Sep
2021
Report published
27 May
2021
Report published
17 Nov
2020
Oral evidence
20 Oct
2020
Oral evidence
6 Oct
2020
Oral evidence
8 Sep
2020
Oral evidence
Oral evidence sessions 4 sessions
17 Nov 2020
View on parliament.uk
Alex Chalk MP · Ministry of Defence Derek Winter DL, Deputy Chief Coroner for England and Wales Her Honour Judge Alexia Durran, Deputy Chief Coroner for England and Wales His Honour Judge Mark Lucraft QC, Chief Coroner of England and Wales Judith Bernstein · Ministry of Justice
20 Oct 2020
View on parliament.uk
Debbie Large · Kent Coroner Service Giles Adey · Kent County Council Lisa O'Dwyer · Action against Medical Accidents Victoria Lebrec · Roadpeace
6 Oct 2020
View on parliament.uk
Debbie Large · Kent Coroner Service Giles Adey · Kent County Council Lisa O’Dwyer · Action against Medical Accidents Victoria Lebrec · Roadpeace
8 Sep 2020
View on parliament.uk
André Rebello OBE Senior Coroner Liverpool and Wirral Area · The Coroners' Society of England and Wales Andrew McCulloch Dr Mike Osborn · Royal College of Pathologists
Title HC No. Published Items Response
1st Report - The Coroner Service HC 68 27 May 2021 28 Response document linked
Recommendations & Conclusions
28 results
1 Recommendation
1st Report - The Coroner Service
The creation of a Chief Coroner followed by the introduction of guidance, mandatory training and...
The creation of a Chief Coroner followed by the introduction of guidance, mandatory training and appraisals for the most junior coroners are significant advances towards a more standardised Coroner Service than obtained a decade or so ago, even in the … Read more
Ministry of Justice
View details
2 Recommendation
1st Report - The Coroner Service
Reducing the number of coronial areas has helped increase consistency across the Coroner Service.
Reducing the number of coronial areas has helped increase consistency across the Coroner Service. The Ministry of Justice should amend the Coroners and Justice Act 2009 (as requested by the outgoing Chief Coroner) to make it easier to merge areas.
Ministry of Justice
View details
3 Recommendation
1st Report - The Coroner Service
Tom Luce, among others, has identified the Ministry of Justice decision not to publish its...
Tom Luce, among others, has identified the Ministry of Justice decision not to publish its 2015 review of the operation of the 2009 Act as a serious breach of a commitment to do so. No good reason has been given … Read more
Ministry of Justice
View details
4 Recommendation
1st Report - The Coroner Service
The Chief Coroner’s guidance on when and how to expedite a case to meet with...
The Chief Coroner’s guidance on when and how to expedite a case to meet with the requirements of the beliefs of the deceased is welcome, but whether the needs of faith communities will be met or not depends on how … Read more
Ministry of Justice
View details
5 Recommendation
1st Report - The Coroner Service
The Ministry of Justice’s Guide to Coroner Services is good first step but more needs...
The Ministry of Justice’s Guide to Coroner Services is good first step but more needs to be done to make sure that bereaved people know of its existence. We encourage all Senior Coroners to make sure that the updated Guide … Read more
Ministry of Justice
View details
6 Recommendation
1st Report - The Coroner Service
Help and support for bereaved people depend on the priorities, capacity and skills of the...
Help and support for bereaved people depend on the priorities, capacity and skills of the local Coroner Service and local volunteers in the Coroners’ Courts Support Service. The Ministry of Justice should as a matter of urgency provide funding for … Read more
Ministry of Justice
View details
7 Recommendation
1st Report - The Coroner Service
We encourage Senior Coroners to make sure that bereaved people are made aware by their...
We encourage Senior Coroners to make sure that bereaved people are made aware by their staff of the specialist support organisations that are available to them both locally and nationally.
Ministry of Justice
View details
8 Recommendation
1st Report - The Coroner Service
Bereaved people deserve a charter of rights setting out the standards of service they are...
Bereaved people deserve a charter of rights setting out the standards of service they are entitled to receive from the Coroner Service. Setting out the standards they can ‘expect’ in the Guide to Coroner Services is inadequate. The Ministry of … Read more
Ministry of Justice
View details
9 Recommendation
1st Report - The Coroner Service
Bereaved people are at a disadvantage when they do not have access to the evidence.
Bereaved people are at a disadvantage when they do not have access to the evidence. It is important that the process for obtaining evidence is explained clearly to them as this is important for the fairness of the inquest. We … Read more
Ministry of Justice
View details
10 Recommendation
1st Report - The Coroner Service
The failure of health and social care bodies to fulfil their duty of candour to...
The failure of health and social care bodies to fulfil their duty of candour to bereaved people during coroners’ investigations and inquests is disappointing. The Ministry of Justice should amend the Coroners’ rules to make it patently clear that the … Read more
Ministry of Justice
View details
11 Conclusion
1st Report - The Coroner Service
The Government’s steps to support the inquisitorial nature of inquests are welcome but are insufficient...
The Government’s steps to support the inquisitorial nature of inquests are welcome but are insufficient by themselves to prevent large multi-handed inquests, where individuals’ and organisations’ reputations are at stake, from becoming adversarial.
Ministry of Justice
View details
12 Recommendation
1st Report - The Coroner Service
Bereaved people should not be put through the difficult and time-consuming process of meeting the...
Bereaved people should not be put through the difficult and time-consuming process of meeting the exceptional cases requirements and the means test for legal aid where public authorities are legally represented at public expense at the inquest into the death … Read more
Ministry of Justice
View details
13 Recommendation
1st Report - The Coroner Service
The current arrangements for challenging coroners’ decisions are unwieldy and cause unacceptable delays, stress and...
The current arrangements for challenging coroners’ decisions are unwieldy and cause unacceptable delays, stress and often expense, for bereaved people. The The Coroner Service 59 Ministry of Justice should introduce a system of appeals similar to that in Section 40 … Read more
Ministry of Justice
View details
14 Recommendation
1st Report - The Coroner Service
There may be circumstances where with the consent of the bereaved people concerned, it would...
There may be circumstances where with the consent of the bereaved people concerned, it would be sensible for the High Court to be able to direct that the particulars of the Record of the Inquest be amended as appropriate without … Read more
Ministry of Justice
View details
15 Recommendation
1st Report - The Coroner Service
The Government consultation on coronial investigation of stillbirths was welcome but it is disappointing that...
The Government consultation on coronial investigation of stillbirths was welcome but it is disappointing that it appears to have stalled. The Ministry of Justice should revive the consultation on coronial investigation of stillbirths and publish proposals for reform. (Paragraph 118) … Read more
Ministry of Justice
View details
16 Recommendation
1st Report - The Coroner Service
Pathology services for coroners have been neglected over many years leading to serious problems.
Pathology services for coroners have been neglected over many years leading to serious problems.
Ministry of Justice
View details
17 Recommendation
1st Report - The Coroner Service
The Ministry of Justice should immediately review and increase Coroner Service fees for pathologists, so...
The Ministry of Justice should immediately review and increase Coroner Service fees for pathologists, so they are enough to ensure an adequate supply of pathology services to the Coroner Service.
Ministry of Justice
View details
18 Recommendation
1st Report - The Coroner Service
In the medium term the Ministry of Justice should work with the Department of Health...
In the medium term the Ministry of Justice should work with the Department of Health and Social Care so that pathologists’ work for coroners is planned for within pathologists’ contracts with NHS trusts.
Ministry of Justice
View details
19 Recommendation
1st Report - The Coroner Service
In the longer term, the Ministry of Justice should broker an agreement between relevant government...
In the longer term, the Ministry of Justice should broker an agreement between relevant government departments and the NHS (in England and Wales) for the establishment and co-funding of 12–15 regional pathology centres of excellence. (Paragraph 137) A unified national … Read more
Ministry of Justice
View details
20 Recommendation
1st Report - The Coroner Service
The majority of witnesses to our inquiry, two Chief Coroners, and almost everyone who has...
The majority of witnesses to our inquiry, two Chief Coroners, and almost everyone who has been commissioned to review aspects of the Coroner Service sees the need for a unified service for England and Wales. There is unacceptable variation in … Read more
Ministry of Justice
View details
21 Recommendation
1st Report - The Coroner Service
As with calls for a national service for England and Wales, there is an overwhelming...
As with calls for a national service for England and Wales, there is an overwhelming and long-standing view that the Coroner Service would benefit from the presence of an inspectorate overseeing its work. As with those calls, we are merely … Read more
Ministry of Justice
View details
22 Recommendation
1st Report - The Coroner Service
Consequent upon the establishment of a national service and an inspectorate, there should be a...
Consequent upon the establishment of a national service and an inspectorate, there should be a review of the mechanisms available for handling complaints against Coroners. (Paragraph 167) Public disasters
Ministry of Justice
View details
23 Conclusion
1st Report - The Coroner Service
There has been good progress in improving the Coroner Service’s response to public disasters.
There has been good progress in improving the Coroner Service’s response to public disasters. However, a National Coroner Service is needed to ensure that inquests into mass fatalities are properly managed and that the deceased and bereaved people are always … Read more
Ministry of Justice
View details
24 Recommendation
1st Report - The Coroner Service
It is unacceptable that the people who have been bereaved are not entitled to automatic...
It is unacceptable that the people who have been bereaved are not entitled to automatic non-means tested legal aid at inquests into multiple deaths following a public disaster. These inquests are complex and ‘equality of arms’ is a fundamental requirement … Read more
Ministry of Justice
View details
25 Recommendation
1st Report - The Coroner Service
The system for the Coroner Service to contribute to improvements in public safety is under-developed.
The system for the Coroner Service to contribute to improvements in public safety is under-developed. The absence of follow up to coroners’ ‘prevention of future deaths reports’ is a missed opportunity. The Ministry of Justice should consider setting up an … Read more
Ministry of Justice
View details
26 Recommendation
1st Report - The Coroner Service
The current arrangements for publishing coroners’ reports and responses to those reports require improvement.
The current arrangements for publishing coroners’ reports and responses to those reports require improvement. The information published is the bare minimum and is difficult to search and analyse. The Ministry of Justice should provide funding so information about the risks … Read more
Ministry of Justice
View details
27 Recommendation
1st Report - The Coroner Service
The Coroner Service responded well to covid-19, and we express our thanks to all those...
The Coroner Service responded well to covid-19, and we express our thanks to all those involved under very difficult circumstances. A considerable number of inquests have been delayed because of the pandemic restrictions. We were unconvinced by the Minister’s response … Read more
Ministry of Justice
View details
28 Recommendation
1st Report - The Coroner Service
We encourage the Chief Coroner to collect information from each Coroner Service Area on the...
We encourage the Chief Coroner to collect information from each Coroner Service Area on the challenges they face because of the pandemic and communicate the overall picture to the Ministry of Justice. (Paragraph 222) 62 The Coroner Service
Ministry of Justice
View details
Correspondence 1 letter
22 Feb 2022 To committee Response from Chief Coroner on coroner service report
Parliament page