A Short Historical Tour...

Coroners have played a vital role in society since 1194 and have been subject to very little reform since 1887.  In 2003, publication of the Shipman Inquiry and a Fundamental Review of Death Certification and Investigation identified serious weaknesses in the coronial system.  There was very little consistency in the way that Coroners, their Deputies and Assistants acted.  In some cases Coroners were efficient and Inquests were held fairly quickly, whilst in other cases, bereaved families were expected to wait for well over a year or more.  There was a distinct lack of national supervision, leadership and an absence of rights entitling bereaved families to participate in the process. 

A number of reviews formed the building blocks of what was to become the Coroners and Justice Act 2009 ("the Act").  It cherry picked the best of what used to work at that time and introduced a number of structural changes to the coronial system.  The new Act was designed to offer a user focused, transparent, effective and responsive coronial system for victims, bereaved families and the general public. 

The balance lay in improving the services Coroners offer, but also ultimately allowing families more opportunities to participate.

…a Whistle-Stop Tour of the Key Changes…

In brief, the Act provides the following structural changes which take effect from June 2013:

  • Only lawyers will be able to become Coroners.  Medics wishing to qualify will now need an obligatory legal qualification as well as 5 years of practical experience.  Medics currently in post will not be prevented from continuing in post, although those who are Deputies or Assistant Deputies will not be promoted to Area or Senior Coroner. All Coroners must retire aged 70.
  • The current 111 coroner areas will be reduced initially to 97, through the amalgamation of several smaller areas, thereby ensuring that all coroner areas are roughly the same size.
  • Currently each coronial jurisdiction usually has one full time Coroner who will appoint Deputies and Assistant Deputies. The change will mean that the full time Coroner will be known as 'Senior Coroner' and he or she may be assisted by 'Area Coroners' and 'Assistant Coroners'.
  • “Verdicts” will now be known as “determinations”. In accordance with their no-fault concept, determinations may not be worded to appear to determine questions of criminal liability or civil liability.
  • Where “determinations” relate to more detailed Article 2 (European Convention of Human Rights) cases, Coroners must not only include a simple ‘determination’, but also a ‘determination’ as to the ‘circumstances of the death’.
  • It will no longer be mandatory for all prison or custody deaths to be jury inquests by virtue of the Deceased having died in custody.  Going forward, a jury inquest will only be mandatory if the death was violent, unnatural or was of any unknown cause or caused by the act/omission of a police officer in the execution of their duty or where the death was caused by accident, poisoning or disease.  The Coroner will retain their discretion to empanel a jury if there is sufficient reason for doing so.
  • Coroners will have wider powers to compel witnesses to attend Court and to admit written evidence.
  • Coroners are to notify Interested Persons of the date of the inquest at least one month in advance of its commencement, although this can be reduced where appropriate. The date, time and venue will also be made public through the Coroner’s website.
  • Disclosure of information at any stage of an investigation, on an application by an Interested Person, will be “encouraged.” The Coroner can determine what information is relevant and is able to redact it where necessary.
  • If an inquest is not completed within 1 year from the day that the Coroner became aware of the death, the Chief Coroner must be notified and he will keep a register of such cases, which will be reported to the Lord Chancellor.  This is designed to ensure faster access to justice.  Even in cases were multiple agencies are involved, delays in filing statements, even if caused by internal investigations, will be unacceptable and the Chief Coroner must be notified with reasons. The aim is to ensure quicker access to Coroners and speedier internal investigations.

It has been suggested that there may be specialist groups / specialist Coroners who deal with certain types of death, such as deaths in custody, service deaths or deaths in a healthcare setting.  Further consultation on this proposal is expected to follow in due course.

...and finally: The Future of Rule 43 Recommendations

The power for a Coroner to make a Rule 43 recommendation is already well established, allowing Coroners to make a report to a person or organisation where he or she believes that action should be taken to prevent future deaths, requiring a response within 56 Days.

Going forward, Rule 43 recommendations and their responses (which will be required within one month) will not only be shared between the Interested Persons, but also copied to the Chief Coroner, and summarised in the Chief Coroner's annual report to the Lord Chancellor. A copy will be laid before the Houses of Parliament.  Therefore, what used to be a rather private “telling off” will now become a public naming and shaming exercise and Rule 43 Recommendations should not be ignored.

Therefore, going forward, more emphasis needs to be paid at the Inquest preparation stage to ensure that organisations can demonstrate what actions they have taken to prevent future deaths from occurring. Only in cases where the Coroner is fully satisfied that the organisation has taken reasonable steps to prevent future deaths from occurring will the Coroner refrain from making such a public recommendation.

Effect of these Changes

These changes are due to take effect at some stage this month.

It is likely that organisations will need to review their internal investigation procedures to ensure that investigations are completed promptly without compromising on the detail required.

It is hoped that the changes will result in a more consistent approach which in turn should enable healthcare professionals and organisations to gain a better understanding of what will be expected of them, and what challenges they may encounter.

The recent years have seen an increase in the number of inquests, including increased analysis of deaths in healthcare settings. It is anticipated that this growth will continue. It is hoped that the 2013 changes will go some way to ensuring that our Coronial service is better equipped to handle such an influx in a user friendly manner.

Undoubtedly, the enhanced importance of Rule 43 Recommendations will be a focus for all organisations, and ensuring responsibility internally for the implementation of recommendations will be of key importance. Thorough preparation before the inquest will continue to play a vital role.

For more information please contact Debbie Rookes or Will Pickles.

Our use of cookies

We use necessary cookies to make our site work. We'd also like to set optional analytics cookies to help us improve it. We won't set optional cookies unless you enable them. Using this tool will set a cookie on your device to remember your preferences. For more detailed information about the cookies we use, see our Cookies page.

Necessary cookies

Necessary cookies enable core functionality such as security, network management, and accessibility. You may disable these by changing your browser settings, but this may affect how the website functions.

Analytics cookies

We'd like to set Google Analytics cookies to help us to improve our website by collection and reporting information on how you use it. The cookies collect information in a way that does not directly identify anyone.
For more information on how these cookies work, please see our Cookies page.