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
1 Letter
4 Events
Activity timeline 3 events
22 Feb
2022
Correspondence
10 Sep
2021
Report published
27 May
2021
Report published
Title HC No. Published Items Response
1st Report - The Coroner Service HC 68 27 May 2021 28 Responded
Recommendations & Conclusions
28 results
1 Recommendation Deferred
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
Government Response
The government redirects the recommendation, stating that appraisal of judicial office holders is a matter for the judiciary, not ministers, and the Chief Coroner will respond directly to the Committee.
Ministry of Justice
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2 Recommendation Accepted
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.
Government Response
The government accepts the recommendation to amend the Coroners and Justice Act 2009 to facilitate mergers of coronial areas, noting this is currently in progress as part of the Judicial Review and Courts Bill.
Ministry of Justice
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3 Recommendation Rejected
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
Government Response
The government rejects the recommendation to immediately publish its 2015 review of the Coroners and Justice Act 2009, stating the analysis is outdated and bringing it to a publishable standard would require disproportionate resources.
Ministry of Justice
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4 Recommendation Deferred
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
Government Response
The government states that the Chief Coroner will respond to the Committee regarding his engagement with stakeholders concerning expediting cases to meet the needs of faith communities.
Ministry of Justice
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5 Recommendation Accepted
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
Government Response
The government accepts the recommendation, committing to work with the Chief Coroner to ensure the Guide to the Coroner Service for Bereaved People is widely available online and, where justified, will provide hard copies while reviewing this policy annually.
Ministry of Justice
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6 Recommendation Rejected
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
Government Response
The government rejects the recommendation to provide urgent funding for support services for bereaved people at inquests, citing the need for further detailed work on affordability and legal/commercial issues.
Ministry of Justice
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7 Recommendation Deferred
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.
Government Response
The government redirects the recommendation, stating that it will be for the Chief Coroner to provide a response.
Ministry of Justice
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8 Recommendation Deferred
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
Government Response
The government disagrees that its current Guide to Coroner Services is inadequate but acknowledges it is considering what more could be provided to bereaved families, with a full response due in the Government’s response to Bishop James’ report.
Ministry of Justice
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9 Recommendation Deferred
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
Government Response
The government states that the Chief Coroner will provide a detailed response to the recommendation regarding strengthening guidance and training on disclosure and pre-inquest reviews.
Ministry of Justice
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10 Recommendation Deferred
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
Government Response
The government will consider the recommendation to amend Coroners' rules and extend the duty of candour to all public bodies in conjunction with its response to Bishop James Jones’ report in due course.
Ministry of Justice
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11 Conclusion Acknowledged
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.
Government Response
The government implicitly acknowledges the committee's conclusion that multi-handed inquests can become adversarial and details steps to address related issues such as providing non-means tested legal aid for Exceptional Case Funding.
Ministry of Justice
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12 Recommendation Accepted in Part
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
Government Response
The government commits to introducing legislation to remove the means test for Exceptional Case Funding (ECF) in relation to legal representation at inquests and provide non-means tested legal help where ECF is granted, while deferring the wider issue of legal aid to its response to Bishop James’ report.
Ministry of Justice
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13 Recommendation Deferred
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
Government Response
The government acknowledges the merit in considering an additional mechanism for appealing coroners' decisions, specifically referencing the original Section 40 of the 2009 Act, but it is not responding to the recommendation at this stage.
Ministry of Justice
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14 Recommendation Accepted
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
Government Response
The government accepts the recommendation and will seek to introduce the proposed amendment to Section 13 into legislation when parliamentary time permits.
Ministry of Justice
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15 Recommendation Accepted
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
Government Response
The government accepts the recommendation and plans to publish a joint response to the consultation on coronial investigation of stillbirths as soon as possible.
Ministry of Justice
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16 Recommendation Rejected
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.
Government Response
The government rejects the recommendation to immediately review and increase pathologists’ fees, arguing that fees are not the sole cause of shortages and there's no evidence that raising them would address the problem. It will, however, keep the issue under consideration and engage with relevant bodies to find a sustainable solution.
Ministry of Justice
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17 Recommendation Rejected
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.
Government Response
The government rejects the recommendation to immediately review and increase Coroner Service fees for pathologists, arguing it's not the sole reason for shortages, and an increase alone lacks evidence to solve the problem; it will keep the issue under consideration and engage to find a sustainable solution.
Ministry of Justice
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18 Recommendation Accepted
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.
Government Response
The government accepts the recommendation to work with the Department of Health and Social Care to plan pathologists’ work for coroners within NHS contracts, noting NHS England and Improvement's support for scheduling post-mortems into job plans to minimise impact on services.
Ministry of Justice
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19 Recommendation Deferred
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
Government Response
The government states it cannot accept the recommendation at this stage but will engage with the NHS to consider the proposal for regional pathology centres, noting NHS England and Improvement's in-principle support for considering such developments.
Ministry of Justice
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20 Recommendation Rejected
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
Government Response
The government rejects the recommendation to unite coroner services into a single national service, citing the massive change project involved, complex negotiations, and its belief that it would not necessarily be the best solution; instead, it will continue to support local authority mergers of coroner areas.
Ministry of Justice
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21 Recommendation Rejected
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
Government Response
The government rejects the recommendation for a Coroner Service Inspectorate, arguing that a single national service would be a massive, complex change project and not necessarily the best solution, preferring to support local authority mergers of coroner areas.
Ministry of Justice
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22 Recommendation Rejected
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
Government Response
The government rejects the recommendation for a review of coroner complaint mechanisms, stating that coroners are independent judicial office holders and the existing Judicial Conduct Investigations Office provides a robust and consistent process for complaints.
Ministry of Justice
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23 Conclusion Rejected
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
Government Response
The government rejects the idea that a National Coroner Service is needed, stating it would be a massive change project and not necessarily the best solution, and instead will continue working with local authorities to identify opportunities for coroner area mergers.
Ministry of Justice
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24 Recommendation Accepted in Part
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
Government Response
The government will take forward legislation to remove the means test for applications for exceptional case funding (ECF) for legal representation at inquests and proposes non-means tested legal help where ECF has been granted. It does not commit to automatic entitlement for all mass fatalities.
Ministry of Justice
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25 Recommendation Deferred
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
Government Response
The government acknowledges the need for more to be done regarding Prevention of Future Deaths (PFD) reports and will consider options, including an Inspectorate of Coroner Services, but is not in a position to accept the recommendation at this stage.
Ministry of Justice
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26 Recommendation Deferred
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
Government Response
The government acknowledges issues with searching for reports and notes the Chief Coroner's office is working on cataloguing; however, it is not in a position to accept the recommendation to provide funding for improved online accessibility and searchability at this stage, stating they will consider resources.
Ministry of Justice
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27 Recommendation Accepted
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
Government Response
The government accepts the recommendation, detailing ongoing engagement with the Chief Coroner's office and committing to include four coroner-related measures in the Judicial Review and Courts Bill to support the Coroner Service's recovery from the pandemic.
Ministry of Justice
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28 Recommendation Accepted
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
Government Response
The government notes the recommendation is for the Chief Coroner, who is already engaged with senior coroners to identify and address pandemic-related issues, and the Ministry of Justice will continue to support this work.
Ministry of Justice
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Government Response AI assessment · 28 of 26 classified
Accepted 7
Accepted in Part 2
Acknowledged 1
Deferred 10
Rejected 8
Total 26 recs + 2 conclusions
Correspondence 1 letter
22 Feb 2022 To committee Response from Chief Coroner on coroner service report
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