Written evidence from Bristol City Council on behalf of North Somerset, Bath and North-East Somerset and South Gloucestershire councils.

  1. The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service

Coroners and Justice Act 2009 does not include centralisation and nationalisation of the coronial system and support services for coroners. Coroners continue to be appointed and funded by their local authorities and served by coroners’ officers drawn from the local police or local authority.


Bristol City Council leads on behalf of three other unitary authorities (North Somerset, Bath and North-East Somerset and South Gloucestershire – formally the County of Avon) in providing resources to the Coroner, including buildings, staff and access to council specialist teams. The financial burden on local authorities in relation to supporting the coroner is increasing and significant and consequently unevenly resourced nationally. We believe that the service should be a national one, under the remit of HM Courts and Tribunal Service.


The Avon Coroner’s Service is functioning well, due to the heavy input of financial and staff resources. This is in the context of increasing financial pressure on local authorities, leading to competing and sometimes conflicting priorities. There is a good working relationship between the local authority and the Senior Coroner for Avon, where resources are discussed and allocated as efficiently as possible, according to legal requirements and Chief Coroner guidelines.


The issues raised by the original enquiry, the Home Office and Parliament prior to the Coroners and Justice Act 2009 in relation to resources and local authorities remain unaddressed.


The Shipman Inquiry, 2004

‘The death certification and coronial systems are isolated from each other, from the mainstream healthcare and justice systems, and from other public health and safety agencies…. There is a general lack of resources and support.’


The inquiry …..proposed a radical overhaul both of the coroners’ system and of the arrangements for death certification, in which a new national coroners’ service under a Chief Coroner would be established at arm’s length from national government, replacing the current system of local coroners appointed and funded by local authorities. ….


Reforming the Coroner and Death Certification Service (Home Office, 2004) “The present system operates on a very limited budget, often dependent on hidden subsidies from local authorities which, for example, may provide premises free of charge or from police authorities, some of which do not charge for the time of police officers acting as coroners’ officers…. Even the most moderate changes are likely to need a substantial increase in resources.



House of Commons Constitutional Affairs Committee, Reform of the coroners’ system and death certification (2006)

‘.....Moreover, the Government has failed to nationalise the coronial system, leaving local authorities as the main source of funding. It is, therefore, likely that the current inequalities of resourcing and variable levels of service to the bereaved in particular and society in general will continue…..’


  1. The Coroners Service’s capacity to deal properly with multiple deaths in public disasters


We are confident that the necessary plans and resources are in place to allow the Avon Coroner to fulfil this responsibility. The Avon Coroner has fully engaged with Local Resilience Forum planning and multi-agency exercising. Although a certain level of resilience could be provided by neighbouring Coronial areas, there would be significant time pressures on the Coroner in terms of incident response verses business as usual work.


  1. Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths

No comment.

  1. How the Coroners Service has dealt with COVID 19

The Avon and Somerset Police force and Local Resilience Forum covers two coronial areas, which resulted in two coroners’ involvement in all COVID-19 related meetings and two, sometimes differing opinions. However, on the whole, the Coroner’s Service contributed extremely positively to overall planning and explaining clearly to other agencies the impacts on Coroner’s Service provision.

The Coroner’s Service proved itself to be adaptable, flexible and wholly engaged in the response – for instance, moving to home-working and effectively using IT resources to allow remote participation in inquests. The Avon Coroner committed to and developed improved, ongoing partnership working, which will continue and is currently addressing general winter pressures.

  1. Progress with training and guidance for Coroners

In addition to the training provided by the Chief Coroner and Ministry of Justice, the Avon Coroner engages and participates in local authority training such as data protection, equalities, and recruitment and selection.

Nationally-issued guidance is essential, however, it has often been provided very late.

  1. Improvements in services for the bereaved


  1. Fairness in the Coroners system

A 24/7 out-of-hours services for faith needs is not in place due to the limited number of coroners in the Avon area, however the Senior Coroner is keen to understand and provide appropriate services and she does, for example, attend multi-faith events.

Modern, high-quality AV provision has been installed within the Avon Coroner’s Court, which positively impacts on people with disabilities and/or language difficulties. This is invaluable during the ongoing COVID-19 pandemic.


September 2020