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Call for ‘equality of arms’ and other major reforms in Coroners Courts

26 May 2021

The House of Commons Justice Committee has called, in a report published today, for fundamental reforms of Coroners Courts to, in the Committee’s words, bring bereaved people into the heart of the system.

A principal recommendation is that in large, complex inquests - such as that following the 1989 Hillsborough disaster where many people were killed in a football crowd crush – there should be a legal ‘equality of arms’, with bereaved people having an automatic right to public funding for legal representation. 

The Committee also called for the creation of a national coronial service for England and Wales, for an inspectorate for that service to ensure consistent standards, and for a charter of rights for bereaved people.  

These and other recommendations are contained in a major new report by the Justice Committee, The Coroner Service in England and Wales. The full, embargoed report is attached to this press release. The Committee - a cross party group of MPs that scrutinizes the judicial system and how the government runs it - published the report after taking extensive written and oral evidence.

Legal representation needed for bereaved families

Many of the complex and tragic cases like Hillsborough involve public authorities – such as the police and medical services – being legally represented in inquests at public expense. The Committee said it was unfair that bereaved people should not have similar representation. Bereaved people, the report said, should not be put through the difficult process of meeting complex legal requirements – and be means-tested for legal aid – when the public authorities they sometimes have to face up to in court are legally represented at tax-payers’ expense. 

The Committee therefore said the Ministry of Justice should, by October 1, 2021, for all inquests where public authorities are represented, make sure that non-means tested legal aid or other public funding for legal representation is also made available for the bereaved.  

The coronial system in England and Wales – which registers deaths and, in some circumstances, mounts inquests into them – is widely believed to have an unacceptably wide variation in standards across the two nations. This is largely because local authorities are responsible for funding it.  

An 'ad-hoc' coronial service

Witnesses repeatedly told the Committee that the coronial service was fragmented and under-resourced. One expert described it as ‘ad hoc’ and ‘largely dependent on a grace and favour relationship’ with other public agencies.  

It was not until 2013 that one small element of a nascent national coronial service began, with the appointment of the first Chief Coroner for England and Wales.  

The Justice Committee report said some bereaved people are not treated with the respect and consideration that they and their deceased loved ones deserve. The Committee heard from a bereaved parent, Andrew McCulloch, who said: 

“The Coroner arrived late and brusquely stated that he wanted no shouting in the court. He looked at [my wife] Amanda and I and aggressively said only one of us would be allowed to speak and only for two minutes. No mention of sorrow for our bereavement or concern for how we might be feeling.”  

The Coroners Courts Support Service – volunteers who give emotional and other support to bereaved families – said, however, that the picture varied:  

“There are Coroners who will truly enable bereaved families to participate in the proceedings, and, whilst maintaining authority in the court, will address the families with empathy […] However, some Coroners may make bereaved families feel unheard, frustrated and angry that the Coroner seems to be dismissing their concerns.” 

Unite coroner services

After hearing evidence about the variation in service across the coronial system, the Committee recommended that the Ministry of Justice should unite coroner services into a single, properly funded national organisation for England and Wales. 

The Committee heard that the overwhelming desire of many bereaved people, especially where loved ones die because of accident or error, was that others would not go through the same pain as them - that the death was not in vain. 

The Committee therefore called for much more consistent follow up to what Coroners call their ‘prevention of future death reports.’ These reports are, in essence, a description of lessons that could be learnt.

The Committee called on the Ministry of Justice to consider setting up an independent office to report on issues raised by coroners and juries. The information collated by such a service, the report said, should be made freely available online for the purposes of transparency and efficiency. 

Chair's comment

The Chair of the Justice Committee, Sir Bob Neill, said:   

“It is the mark of a civilized society to show respect and sympathy for the deceased and their bereaved families. That respect and sympathy must be followed through with a robust way for us all to learn from tragic, sometimes unnecessary premature deaths.  

“For many years, there has been clear evidence that such support is not consistently available across the country. The refusal by successive governments to establish a National Coroner Service to rectify this is hard to understand. We conclude that such a service is necessary to ensure that those who have lost loved ones – sometimes in dramatic and terrible circumstances – can receive the level of help and advice that they need, wherever they may live.

“The first two Chief Coroners, in office since 2013, have done a great deal to improve the quality of the Service through leadership, guidance and training. It is vital we now support the Chief Coroner further through the creation of a properly funded, empathetic and efficient National Coroner Service.”

Further information

Image: Christine Matthews, Geograph, CC BY-SA 2.0