Tuesday, 18 September 2012

Coroners - Chief Coroner and updating the system

Chief Coroner - Peter Thornton QC
Coroners and Justice Act 2009

On 17th September, the new Chief Coroner for England and Wales (Judge Peter Thornton QC) finally took office.  As the government cogitated about implementation of the 2009 Act, he was appointed - "unappointed" - and then appointed again!
The Coroners and Justice Act 2009 ('the 2009 Act') contained the almost inevitable provision for "commencement orders" which leave Ministers with the power to implement provisions at times of their choosing - e.g. when necessary resources are in place.  The "flip side" of such orders is that Ministers can avoid implementation and this has happened with several aspects of Part 1 of the 2009 Act which was put in place to bring about some reform of the system of Coroners and Certification of Death.  Coroners Courts are a long-standing system of locally-based courts and they have proved resistant to reform despite serious criticisms being raised from time-to-time. The change of government in 2010 resulted in yet more delay to bringing in the much needed reforms already provided for in the 2009 Act.

Reports leading to the 2009 Act:

Part 1 of the 2009 Act came about following severe criticism of the Coroner and Death certification systems system in reports such as the Fundamental Review of Death Certification and Investigation (2003) and the Shipman Inquiry - Third Report (2003).  A draft Coroners Bill was published in 2006 and received over 150 responses with a summary published in February 2007. The Bill underwent pre-legislative scrutiny with a further report published in November 2006.  There were several other consultations relating to matters such as death certification.  The full list is set out in the explanatory notes to the 2009 Act.

Only limited implementation so far:

On 17th September, the new Chief Coroner for England and Wales (Judge Peter Thornton QC) took office. 

On 24th September 2012, under Commencement Order No.10, provisions come into force to allow an investigation in Scotland into deaths of service personnel when they are killed during service abroad.  On this see Community Justice Portal.

Nevertheless, much remains to be done.  Of the 51 sections in Part 1 of the 2009 Act, only section 35 (Chief Coroner) and section 12 and 50 (Transfer to Scotland) have so far been brought into force.  The government does not intend to implement certain of the provisions - section 25 Coroner for Treasure, section 38 Medical Adviser to Chief Coroner, section 39 Inspection of the coroner system and section 40 appeals.

It seems particularly poor that the system of appeals which was set out in section 40 of the 2009 Act will not come about.  The government announced this in January 2012 and the Public Bodies Act 2011 section 33 repealed the provisions in the 2009 Act relating to appeals (including section 40).  This still means that the only way of challenging a Coroner's decision remains judicial review in the High Court or by the process of asking the Attorney-General to go to the High Court to ask for a new inquest (Coroners Act 1988 section 13).  Parliament July 2012 - Briefing Note -  Challenging Coroner's Decisions

In January 2012, The Government‟s stated aim was to raise public awareness of these avenues of redress through the national Guide to Coroners and Inquests and Charter for coroner services, March 2012.   The Government believes that this will allow greater focus on raising the standards of coroners‟ inquiries and inquests to ensure that bereaved families are satisfied with the whole process, without the need for new appeal rights and expensive litigation.

The removal of the simpler and cheaper system of appeals beggars belief.  Straightforward and cost-effective appeal machinery should always be available from decisions of inferior courts (such as Magistrates, County Courts and Coroners).

Legal aid is a further problematic area.

Legal Aid is not generally available for representation at inquests because, the government argues, an inquest is a fact-finding process  - (see para. 21 of the Guide). Unlike other proceedings for which Legal Aid might be available, there are no parties in inquests, only the properly interested persons, and witnesses are not expected to present legal arguments. The coroner ensures that the process is impartial and thorough, and he or she should assist families to ensure that their relevant questions are answered.  This argument is unsatisfactory given that state agencies such as the NHS or the police will always have extensive legal representation at an inquest.

However, in some instances and subject to means testing, legal aid can be provided to an individual for inquests into the death of a member of the individual's family - see Legal Aid, Sentencing and Punishment of Offenders Act 2012 Schedule 1 Part 1 para 41.  In some instances, exceptional funding may apply.  A lawyer experienced in inquest work should always be consulted about legal aid.

Did the 2009 Act go far enough with reform?

For some, the reform process in the 2009 Act did not go far enough.  A very good article on this point was published in the Law Society Gazette (Polly Botsford 18th June 2009) - Does the Coroners and Justice Bill go far enough - and is there enough money?

The role of the Chief Coroner:

The Ministry of Justice announcement of the appointment of a Chief Coroner sets out the principal responsibilities:
  • Provide support, leadership and guidance for coroners in England and Wales;
  • Set national standards for all coroners, including new inquest rules;
  • Oversee the implementation of the new provisions of the Coroners and Justice Act 2009;
  • Put in place suitable training arrangements for coroners and their staff;
  • Approve coroner appointments;
  • Keep a register of coroner investigations lasting more than 12 months and take steps to reduce unnecessary delays;
  • Monitor investigations into the deaths of service personnel;
  • Oversee transfers of cases between coroners and direct coroners to conduct investigations;
  • Provide an annual report on the coroner system to the Lord Chancellor, to be laid before Parliament;
  • Monitor the system where recommendations from inquests are reported to the appropriate authorities in order to prevent further deaths.
The team at the Ministry of Justice has now been reformed / reshuffled.  The Minister with responsibility for Coroners is Helen Grant MP.  The Chief Coroner has to oversee the implementation of the new provisions of the Coroners and Justice Act 2009.  Perhaps over the coming months we will see some progress toward modernisation even if the reforms do not go anywhere near far enough!

See also Coroner reform: update and implications for local authorities - Dominic Smales - Ministry of Justice March 2012.


  1. I entirely agree. The local variation which one finds with Coroners must be brought to an end. They must be trained, inspected and appealed where necessary. I recently appeared before an Assistant Deputy Coroner who did not have a clue about how to conduct an inquest, confessed as much and asked the Bar for help - the ADC had never had any proper training. One chink of good news is that the LCJ has allocated all Coronial JRs and fiats to the Chief Coroner - a route of appeal by the back door?

  2. I also agree - I have a letter in my posession, from 2008, in which the Coroner for Bournemouth misquoted S.19 of Coroner's Rules - omitting the two sentences that were added post-Shipman, which gave me the right to see the evidence on which he had based his decision NOT to hold an inquest into my late father's 'involuntary euthenasia' in an NHS hospital. It is signed by him, and written in the first person.
    In addition to failing to answer my telephone call for 5 days, I was told:
    If I did not apply for a S.19 (post mortem without Inquest), I wouldn't get one, as the Coroner was short of money, and that my father was 'old anyway';
    I counted some 18 breaches of NICE and NPSA guidance in the 'care' he received - the Coroner's chosen 'expert' was a GP who was in the employment of the same PHCT, had no relevant training in Pathology, did not hold a valid HTA licence, who conducted the post mortem 10 days later in a Home Office Lab serving 3 Police Forces, despite holding an invalid CPA licence, and who lost a vitreous humor sample relevant to the Toxicology report.
    I was unable to find a solicitor or independent pathologist, whereupon the coroner threatened to charge me for storing his corpse, despite the Council telling me there was no shortage of space in their mortuary, and that no additional costs were incurred if the units were full or empty.
    I attempted a JRA application after being telephoned and told he had deep frozen my father, tried, to acquaint myself with Public Law on the internet, was not supplied with any medical records by the hospital, and I'm afraid had to withdraw in a state of exhaustion after blacking out, 'disappearing ' for 3 days and coming to in a completely strange town with no idea how I got there. The Coroner (despite being a legal appointee) was represented by two QCs from Temple and indemnified from local Council Taxes - in effect, I was paying CT to shaft myself.

    I am staggered that the evidence was never secured - when I finally received the medical records, they were all written on 'continuation sheets' - when I asked the Coroner for the copies he'd kept so I could compare and look for evidence of alterations, he wrote his 'misrepresentation letter' , and when I queried this using statutes database, he was forced to admit he'd never asked for the medical records in the first place.

    I would like to think there was SOMETHING that could be done about a Judge who deliberately cuts two sentences out of a UK Statute to obscure his own shortcomings in investigation....but hey, I've met Anne Reeves - her mother was one of the 200+ murder victims of Jane Barton in the Gosport War Memorial Hospital - 10 years on, she's still fighting for inquests on behalf of 90 other familes, and Jane Barton was permitted to carry on practicing! A woman died under the care of the same surgeons, operating outside their area of specialty within a year of his death - I think that was avoidable too.

    Lots of 'Cowboy Coroners' out there - they make every other serving Judge look like complete tossers - and if they're happy with that, so be it.....

  3. Assistant Deputy Coroner North East Lincs presiding in Scunthorpe on 5th October 2005, would not allow the daughters of the deceased who were present for the last 6 days and nights of their father's life give evidence.

    This Coroner never gave the blood family any information whatsoever and refused to speak to them.

    This Coroner and the Doncaster Coroner who "recused" himself a year after the death, never contacted either of the two Consultants for information which would have proved my father was not dying when terminal drugs were prescribed by an on call doctor without seeing the patient. for a health condition the Pathology Report proves my father did not have.

    This Coroner was obviously covering up what happened since the NHS had been used or he was totally ignorant of what his job was.

    We need a new inquest into Ralph Winstanley's death now please.

  4. Was initially searching for information for medical law solicitors, but have found this blog really interesting. Would be good to see you write about medical negligence.