Written evidence from Kevin McLoughlin, Senior Coroner, for West Yorkshire (East)



1.The case for a National Coroners Service


There is a strong case for a national service to replace the current mosaic of Coroners, currently organised by reference to local authority areas.


The decisive factor when considering the case for reorganisation is: whether the service provided to the public would be improved sufficiently as a result to merit the change. 


My perspective is based upon my experience as:

(a)   A current Senior Coroner

(b)   An Assistant Coroner who sat in four separate coronial areas

(c)   An advocate who has appeared in 35 different Coroner’s courts in England & Wales over a 30 year career.



The Coroners Statistics for 2019 (Table 12) reveal outcomes from Inquests which show there are marked inconsistencies between different Coronial areas. Some examples illustrate the variations:

Cases where post mortem required: Staffordshire 18%; N Yorkshire 65%

Natural Cause conclusions:  Liverpool – 302;     North London-13

Suicide conclusions: W Yorkshire (E ) – 140;     Newcastle -24

These examples are put forward not to criticise the Coroners involved in any way.  Rather, they demonstrate material differences in interpretation and practice.  Greater uniformity could be achieved with the oversight which should be inherent in an organisation with a national structure.


My reasoning is that if the Coronial Service is to be lifted to the next stage of professionalism, it is essential to develop comparable standards in each aspect of the service provided: accommodation, resources, operating practices and most importantly, equivalence of outcome for bereaved families.


In relation to the accommodation provided under the current arrangements the spectrum ranges from areas with modern purpose built courts, to those who must hire rooms in public buildings in order to conduct an Inquest.


One facet of this unevenness relates to the security arrangements available. These vary from the non-existent (as in my building) to the stringent systems in place where a Coroners court is co-located with other courts. In contrast to Crown Courts, County Courts and Magistrates Courts which have specified security standards, security is left entirely to the discretion of the local area.   Inquests often arouse strong emotions.  If an incident were to occur in a court which had no (or lax) standards, the reputation of the coronial service as a whole would suffer. 


The absence of a unified system has led to inconsistent standards in many aspects of the coronial service; for example, there is no acknowledged ‘industry standard’ computer system. Neighbouring coronial areas may opt for different software systems, which in turn hampers analytical comparisons or possible mergers. 


An insight into the current divergence is provided by the fact that some use the term ‘HM Coroner’ whilst others use the statutory term ‘Senior Coroner.’  In itself this may seem insignificant.  But it betrays a lack of coherence and may serve to confuse the public.


2. The capacity to handle public disasters


The Manchester Arena bomb incident was well handled by the Coroner involved with the support of neighbouring colleagues.


3. Strengthening the Coroner’s role in the Prevention of Future Deaths.


At present a Coroner can only report circumstances which give rise to concern. I understand that in New Zealand, Coroners can make recommendations.  It would help to strengthen this important aspect of the Coroner’s role, if such a power was available to us, in suitable cases.


4. Covid 19


In the West Yorkshire (East) area we have the benefit of a building exclusively for the use of the Coroner’s Court.  Our staff have co-operated by working remotely in shifts in the early morning and evening (so as to overcome the problems encountered with the resilience of the Local Authority computer system). This has enabled us to maintain the administrative service.


In this area we have heard over 300 Inquests thus far during the ‘lockdown’ period.  These are cases which can be heard on the basis of documents alone or with only a few people in court (in accordance with the limits imposed on the court for social distancing purposes).


The restrictions on attendance in the court has prevented any Inquests being heard which require a Coroner to sit with a jury.  In consequence, in this area alone, we now have over 20 jury Inquests outstanding with a combined time estimate of three months of court time.  Despite searching, we have not been able to identify any alternative venue where a jury Inquest could be held.  This will inevitably cause long delays before the backlog can be cleared.  This is clearly not in the interests of bereaved families or witnesses.


I contend that legislation is required to permit a Coroner to sit without a jury in suitable cases, if the family agree.  An example drawn from a current case demonstrates the point:  a man choked on a piece of toast whilst eating his breakfast.  He died despite the prompt intervention of staff who witnessed the incident.  This man had been detained in a psychiatric unit for several decades under the Mental Health Act. The Coroners & Justice Act 2009 currently requires an Article 2 compliant Inquest, conducted by a Coroner sitting with a jury.   Given the prevailing Covid crisis, it would be appropriate for the need for a jury to be dispensed with in this case, in my judgment.


5. Training & Guidance to Coroners


The training courses arranged for Coroners are excellent.


In relation to scrutiny by others in the coronial service (whether in the form of an appraisal or site visit) I have had none in the 2 years I have been in post as a Senior Coroner.  One could infer this is because our statistics have not given cause for concern. But President Eisenhower once said “the uninspected inevitably deteriorates.” The divergence in suicide conclusions mentioned above, indicates my area has returned more suicide conclusions than almost any other. Surely, this requires an audit to examine why this is the case? 


6. Improvements in services for the bereaved.


Consistency of approach throughout England and Wales is the goal.   This requires benchmarked standards, ideally managed by a full time Chief Coroner.


7. Fairness in the Coroners system


Coroners (whether full time or sitting occasionally) are a dedicated group who strive hard to deliver a valuable and fair service for bereaved families.


‘Fairness’ should, however, also extend to the way in which Coroners are treated.  Their status is currently somewhat uncertain.  This is reflected in the expressions used by senior members of the judiciary, for example “you are members of the judicial family.”  It is time to end the uncertainty and declare that Coroners are unequivocally ‘judges.’ This should also trigger an amendment to the present statutory requirement for the Chief Coroner to be someone other than a Coroner (see Schedule 8, paragraph 1 of the 2009 Act). The transition to a national coronial service would symbolise this recalibration. 

25 August 2020