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The coroner service

The coroner service of England and Wales is essentially a local service; there are 85 coroner areas funded by local authorities. National leadership is provided by the Chief Coroner.

A coroner is a judicial office holder who must investigate a death when they have reason to suspect that:

  • the deceased died a violent or unnatural death,
  • the cause of the death is unknown, or
  • the deceased died while in custody or state detention.

A coroner investigates a death to ascertain who the deceased was; how, when and where the deceased came by his or her death; and the particulars (if any) required to register the death.

The Chief Coroner has set out the coroner’s two main purposes in investigating deaths:

  • to explain the unexplained, both for the benefit of the family and for the public at large; and
  • to report, where appropriate, with a view to preventing future deaths.

Judicial Review and Courts Bill

The Judicial Review and Courts Bill (the Bill) was introduced in the House of Commons on 21 July 2021. Clauses 37 to 41 deal with coroners. The Bill would:

  • broaden the circumstances in which a coroner might discontinue an investigation. A coroner could do this if satisfied that the cause of death has become clear in the course of the investigation, and an inquest into the death has not yet begun. At present, unless the cause of death has been revealed by a post-mortem examination, once an investigation has been started, the coroner has no power to discontinue it and there must be an inquest. It would continue to be the case that a coroner may not discontinue an investigation if they suspect that the deceased died a violent or unnatural death or died while in custody or otherwise in state detention;
  • enable a coroner to decide to hold an inquest in writing, without a hearing, in specified circumstances;
  • enable rules to be made which would allow all participants, including the coroner, to participate remotely in pre-inquest reviews and inquests.
  • replace and replicate the effect of a provision in the Coronavirus Act 2020 (which is due to expire in March 2022) to provide that Covid-19 is not a notifiable disease for the purposes of the requirement for the coroner to sit with a jury. This would enable coroners to hold inquests without a jury where they have reason to suspect a death has been caused by Covid-19;
  • enable the Lord Chancellor to merge two or more coroner areas within a local authority where the new area will not be the entire local authority area. At present, where a new coroner area is created by combining two or more old coroner areas, the new area must consist of the whole of one local authority area or the whole of two or more local authority areas. It is not possible to merge coroner areas within a local authority, if that would result in a new coroner area consisting of less than the area of the local authority.

Recommendations for further action and reform

Recommendations for further action and reform have been made by:

Recommendations include:

  • creating a statutory charter for the bereaved;
  • providing the bereaved with non-means tested legal aid for all inquests where public authorities are legally represented;
  • reforming the process of challenging coroner’s decisions;
  • reforms related to pathology services for coroners;
  • creating a national coroner service;
  • creating a Coroner Service Inspectorate;
  • following up on actions promised in response to prevention of future deaths reports and improving accessibility of reports and responses.

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