Written evidence from Evidence by Tom Luce C B, Chair of Fundamental Review of Death Certification in England, Wales and Northern Ireland 2001-2003.
This evidence has been seen by Dame Janet Smith of the Shipman Inquiry who approves its general thrust and recommendations.
Introduction and Summary
1. Since 2003 when the Fundamental Review and the Shipman Inquiry reports on death certification and investigation recommended major reforms and 2004 when the then Government outlined a prompt and comprehensive reform programme some important reform has occurred but with delay, compromise and significant gaps. This is characteristic of historic governmental lack of interest in and delay over modernising the socially, medically and judicially important regulatory systems concerned with deaths. Contemporary examples of this historic tendency include the serious breach of the Ministry of Justice’s undertaking to Parliament to report the outcome of the 2015 consultation on the reformed Coroner service, the lengthy delay in making regulations standardising the categories of deaths to be referred to coroners, and the repeated failure fully to introduce on promised dates the Medical Examiner system to oversee the death certification system.
2. My observations on the Committee’s key questions are, in summary:
(1)Service unevenness and case for a national service. The 2013 coroner reforms preserved local authority financing but introduced important innovations- judicial leadership and guidance, legal qualification requirements for and central oversight of appointments, improved and compulsory training, and provision for exceptionally complex cases to be handled at higher levels. These have undoubtedly improved the service’s standards and consistency. There remains plausible evidence of some unevenness in case timing and handling and the conduct of relations with bereaved families. The issue is whether the reformed service in its present structure still has further potential to provide a national service even though it is not financed through a centralised national system. Regular studies should assess unevenness in resourcing and service delivery so that the need for further improvement can be kept under review and after a reasonable period the case for central financing and accountability can be further and finally reviewed.
(2)Capacity to deal with multiple deaths in public disasters. Dramatic single disasters involving multiple deaths such as fires, transport crashes and other catastrophes are usually investigated by Government-appointed ad hoc Inquiries under the 2005 Act sometimes after delay. The reformed coroner service is more able to deal properly with some dramatic cases of the kind previously referred to Public Inquiries. The Justice Working Party’s well worked-up proposal for Special Procedure Inquests would deal satisfactorily with series of individual death cases suggesting local or national systemic mistreatment or public health failings and might also enable the Coroner service to deal more promptly and less expensively than Public Inquiries with some dramatic catastrophes.
(3) Strengthening Coroners’ role in prevention of avoidable deaths. The Special Procedure Inquest proposal under (2) above is relevant here because it would enable the Coroner Service to identify and publicise mistreatment or public health failings more promptly than is now the case and so probably save lives. The reforms have significantly increased the number of Prevention of Future Deaths Reports and their availability on the Chief Coroner’s Website is helpful. There may be a case for more public analysis of trends emerging from these reports, and some interaction between the Coroner Service and Public Health England and its successor body.
(4) Handling of COVID. I have no comments to offer on this.
(5) Progress with Training & Guidance for Coroners. The Chief Coroner’s Guidance Notes now number 40 and cover very wide subjects. That and the new training arrangements provided through the Judicial College which are compulsory on first appointment and for continuing professional development are significant changes and should progressively contribute to improvement and standardisation of the service.
(6) Improvement in services for the Bereaved. The Justice Working Party’s recent report contains evidence of continued dissatisfaction on the part of some bereaved and makes valuable recommendations for improvement including the creation of a small coroner inspectorate. The Chief Coroners’ development programmes have bereavement service as a central objective and will no doubt continue to do so.
(7) Fairness in the Coroner System Required legal qualifications and experience in coroner appointments and the service’s judicial leadership and guidance should continue to instil into the service the standards of consistency, fairness and impartiality generally attributable to the British judicial system. However, access to coronial death investigation is an important aspect of fairness still of some concern. The very large gap created by the absence of statutory definition of death categories requiring coroner referral was largely filled when the Ministry of Justice in October 2019 first exercised its statutory power provided in the 2009 Act, though the guidance still does not specifically cover child deaths. However an important triage process for coroner referral is the death certification system. The promisingly evolving but still seriously incomplete Medical Examiner system is designed to ensure consistency and correctness in death certification and coroner referral. Until it is fully implemented there will continue to be cases that should have expert coroner investigation but are not referred for it, and others referred unnecessarily at a cost of delay and families’ distress.
3. I also raise an issue about the long-term arrangements for appointing Chief Coroners.
4 There is a long history of Governmental slowness or failure to implement proposed improvements to and modernisation of the systems for regulating deaths. Over the last 140 years there have been various Committee and Inquiry exercises. None was followed by reasonably prompt and full Governmental action:-
-Special Report from the Select Committee on the Coroners Bill, 1879, recommended that Coroners should be legally qualified and supported in their work by one doctor to advise on medical issues and another to do post mortems. Coroner appointments have required legal qualification since 2013, 134 years after it was first recommended. The recommended medical involvement will be implemented if and when the Medical Examiner system is fully introduced.
-1910 Report chaired by Sir Mackenzie Chalmers: various recommendations, some introduced in 1926.
-Lord Justice Wright’s Committee, 1936: various recommendations including that coroners should be legally qualified, that a “whole-time service” should be a goal, and that the number of coroners should be reduced. Implementation of similar proposals started in 2013.
- Judge Brodrick’s Committee in 1971: various recommendations including that coroners should be legally qualified and appointed by the Lord Chancellor, and the service be financed by central government though perhaps provided by local authorities on an agency basis. Legal qualification introduced in 2013. Central financing not implemented.
5. This background and especially the more recent delays and failures prompt me respectfully to suggest that following up on its present very important and timely inquiry, the Select Committee might consider each year reviewing the Chief Coroner’s annual report, seek comments thereon from the Ministry of Justice and other key participants and publicly summarise its view of the service’s situation and development without necessarily extending the annual review into a full Inquiry.
Service Unevenness & Case for a National Service.
6. It is beyond question that the coroner service, however structured and financed, should provide consistent services to clear national standards. The most important judgement is whether the service in its present structure meets or has the potential to meet that requirement. If that is doubtful the next step is to assess whether and how a centralising reform would be a solution.
7. The Chief Coroners’ annual reports (summarised in the latest of September 2019), the Justice Working Party Report and no doubt the Coroners Society and other sources will provide important evidence on the consistency and acceptability of standards.
8. Standards and consistency of the coroner service are determined by four factors – a suitable structure and leadership, professional qualification training and assessment, local authority resourcing, and central government support and oversight.
9. On structure, leadership and professional standards, the 2013 reform introduced judicial leadership with strong powers of guidance, and influence over appointments. It requires all newly appointed coroners to have legal qualifications and experience. The Chief Coroner is represented on appointment committees and in consultation with the Lord Chief Justice must approve all key local appointments. There is also a strong trend to whole-time appointment of Senior Coroners. Training is much expanded and now provided through the Judicial College. Initial and continuing professional development training is compulsory for coroner and coroners’ officers. An appraisal system is being introduced.
10. The 2013 innovations led not to an instant overnight total reform of the service but a process of improvement and evolution which has made a strong start and is still continuing. I have no direct experience of or involvement in the service in its present form. But based on careful study of Chief Coroners’ guidance, the evolution of training and some opportunities for contact with coroners I sum up my impression of the change in the service and its personnel in a single statement: When in 2001-3 my Fundamental Review colleagues and I reviewed the service it was customary to refer to it as “quasi-judicial”; I am now confident that the “quasi-“ qualification should be dropped. It is developing into a properly judicial service and continues to deepen that essential characteristic of its work to an impressive extent worth public recognition.
11. Relevant to the resourcing of each of the 85 coroner areas by local authorities the Chief Coroners have outlined the necessary characteristics of a model area, including features influential on costs and resources. The latest version (Annex B to the Chief Coroner’s 2019 Report) recommends a minimum of one full-time Coroner’s Officer for each 350-450 referred deaths with more in districts with facilities likely to generate complex deaths such as prisons, and a 3:1 ratio of Coroners’ Officers to administrative support staff. With around 220,000 deaths being referred to coroners each year these recommendations imply that there should be at least 600-650 whole-time equivalent coroners’ officers in England and Wales and more than 200 administrative support staff. A sufficiency of Coroner’s Officers is crucial to the proper support of bereaved families. Two other resource issues are important to that support: -the prompt availability of suitable accommodation for inquests with provision for families to be separate from other participants, and prompt pathology services to avoid delays in investigations and the release of bodies to families for funerals.
12. There seem to be no publically accessible figures available to enable a judgement to be made of how many authorities are satisfactorily providing the necessary staff and inquest facilities. My impression is that a majority come close to doing so but a significant minority are failing. The Ministry of Justice’s important annual publication of coroner activity statistics would helpfully also include resource summaries so that the situation could be assessed. The small coroner service inspectorate suggested by the Justice Working party would also be of value in both reporting and helping to correct deficiencies.
13. It is already clear from successive Chief Coroners’ annual reports that there are serious
problems in the provision of pathology services. Apparently neither the Ministry of Justice nor Department of Health and Social Care will accept responsibility in this area. There is a great deal to be said for the Chief Coroner’s proposal in paras 140-160 of his 2019 annual report for special and well equipped regional pathology services jointly financed by local authorities and the NHS to support coroners.
14. The central government support functions relevant to coroner service consistency include providing information and analysis, guidance, legislative oversight and inter-service support. On this successive Chief Coroner Reports raise an important agenda. His 2019 report summarises a number of guidance or other central contributions considered necessary for service improvement, consistency and efficiency defined for the most part in previous years but still awaiting delivery:
(a) Para 23: Government’s review following 2015 consultation still awaited
(b) para 78 on Medical Examiners: “…the Chief Coroner remains of the view that the interlocking system of oversight for community, hospital deaths by the ME, with the coroner performing a more specialist role in relation to their legal jurisdiction, as envisaged in the 2009 Act, should be the ultimate objective. Until then the issues the ME was designed to address, as highlighted in Dame Janet Smith’s third Shipman Report and elsewhere, will not be fully dealt with”
(c) Paras 131-139: failure to introduce systems to ensure consistency and thoroughness in referral of deaths to coroners, in particular the absence of such guidance specifically provided for in the 2009 Act
(d) Paras 140-160: shortages and weaknesses in pathology services supporting coroners. Proposal defined to deliver better services though regional structures providing prompter and more suitable services.
- (f) Paras 173-192 recommended law changes to facilitate coroner area mergers, in suitable cases to enable coroners to settle investigations without post mortems or inquests, and the High Court to adjust inquest outcomes without requiring repeat inquests.
15. On (a) it is remarkable that in spite of an undertaking that the consultation would be reported in 2016 and Cabinet Office Guidance that such consultations should be reported on within 12 weeks there has still been no such report. This may be because the outcome report would raise issues, for example about resourcing, which Ministry of Justice Ministers have not wished to confront. It would be normal for such consultation outcome reports to identify issues which if constructively addressed would lead to improvement in service standards and consistency. But if the outcome is now so belatedly reported it must be doubtful how much 2015 consultation evidence reliably represents or is relevant to the evolving coroner service half a decade later.
16. Medical Examiners (b above), and regulations with associated guidance on categories of deaths for coroner referral (c above), are both very relevant to service consistency. The medical examiners situation is referred to in paragraphs 44-46 below. On the death referral guidance, the Ministry of Justice consulted on details in 2007, powers to issue such regulations were created in 2009 but not used until 2019, 12 years after the consultation, 10 years after they became available and 6 years after the coroner reforms. In the meantime there was no national consistency in death referrals and coroners in each locality were left to give their own informal guidance to doctors and others. The guidance issued last October still contains no specific material on child deaths. (The 2003 Fundamental Review report recommended coroner referral of “Any death of a child by or on behalf of a social services authority, or on the “At Risk” register, or in a family in which another child is or has been looked after or on the “At Risk register; or of a child being privately fostered”).
17. It is notable that the issue referred to in (f) above – investigations without post mortems or inquests- along with the pathology issues already referred to would improve services to bereaved families and that the shorter investigations like the easier area merger provisions would also save costs.
18, The Justice Working Party reports evidence that consistent standards are not being achieved (or perceived as being achieved) in the coroner service and draws attention to and makes recommendations on some particular service areas relevant to the coroner service particularly related to bereaved family support and covered in paras 41-43 below.
Case for a National Service
19. A key issue in considering whether coroners should be encased within the same centrally financed type of jurisdiction as other judges is whether in the specific coroner context a centralised national system is necessary to deliver a standardised and consistent national service.
20. It is not clear that the service inadequacies reported by the Justice Committee or from other sources are necessarily and directly connected to the role of local authorities in financing the service or their involvement in coroner appointments. Most of these issues can be addressed by the present guidance powers and training procedures though some may require additional resources which could possibly be provided through pressure and persuasion on the relevant authorities.
21. If so they do not of themselves constitute a case for replacing the present structure with a fully centralised one and the Justice Working Party stops short of recommending that though it recommends that the issue should remain on the agenda.
22. It is not absolutely clear that restructuring the service as a centralised national jurisdiction would have swiftly and automatically ensured that the service weaknesses identified by the Justice Working Party would never have arisen or would have been swiftly resolved. Two key provisions are necessary to ensure consistency of practice within a jurisdiction – all practitioners’ observance of practice standards and equivalence of resourcing between different areas.
23. I am not aware of any study or material assessing inconsistencies of practice in centralised national jurisdictions overall. However it is interesting to note in the Family Division allegations of failure consistently to implement the provisions in Practice Direction 12 J which covers difficult issues in child care cases where there is evidence or allegation of domestic abuse. A special report in 2014 by Mr Justice Cobb recorded complaints that the “Practice Direction is not effectively or consistently implemented by the Judges (including the Magistrates) of the Family Division.” The report recommends that “in order to focus sustained attention on the implementation of the Practice Directive it would be helpful if more consistent monitoring and oversight of the use of PD12J including the collection of relevant statistics could be obtained”. So it seems that a centralised judicial and provision structure is not an absolute guarantee against inconsistencies of practice.
24. Nor is it clear that a fully centralised system would provide the judicial head of the Coroner service with greater legal influence than is presently available. The Chief Coroner’s guidance on legal matters starts by asserting that “As independent judicial officer holders, coroners remain responsible for their own judicial decisions and the Chief Coroner cannot direct them to make a particular kind of decision in an individual case or group of cases, neither can he intervene in any other way in individual cases”. My understanding is that this is true also of judges in centralised national jurisdictions.
25. As things stand the main accountability for the resourcing of the service lies with individual local authorities. But the Ministry of Justice is responsible for providing extra resources for changes imposed through national legislation or centrally determined policy change, and for ensuring that overall the service is being resourced to meet the service standards centrally recommended by the Chief Coroner.
26. It may be of interest that between 2012-13 and 2018-19, the first half dozen years of coroner reform, local authorities in England increased their average real terms spend on coroner services by 19% while the Ministry of Justice reduced real terms spend on the Courts and Tribunal Services during the first four critical coroner reform years by 35%. (I have sent detailed figures to the Secretariat). It is notable that though local authorities increased coroner resources their spend on other services fell by roughly as much as the Ministry of Justice’s on its judicial services. This may mean that if from 2013 the coroner service had been centrally financed its resources would have been considerably less than they actually were. It does not, however, necessarily mean that the service has been or is now adequately financed to meet the improvements initiated in 2013 and other pressures. Nor does it necessarily mean that local authorities would be more reliable than central government in properly resourcing the coroner service in the medium and longer term future.
27. Structural centralisation could only be beneficial if part of a high priority strategy for the continued reform, renovation and consistent support of the death regulation services.
28. There are general structural issues in favour of centralisation:
-the coroner service is judicial (since 2013 in its appointment requirements as well as its functions) so would be best placed alongside other judicial jurisdictions
-its public standing and recruitment attraction would probably be enhanced by national status
-Local authorities are providers of services in which investigated deaths occur (children’s and adult social care, roads and highways) so it would be better for the investigation service to be and be perceived as completely independent of local government.
29. Other aspects of the service need also to be considered. It has closer links with local services than is characteristic of other judicial services – reliance on local provision of e g pathology, mortuaries and police. It has links with the registration service (itself a service largely financed and provided through local authorities though statutorily independent and nationally led) and local public health and safety systems (for example membership of Local Resilience Forums).
30. The transition into centralisation would involve considerable change and uncertainty which could divert attention from service standards for a while. The early years of the Crown Prosecution Service the Children and Family Court Advisory and Support Service (CAFCASS) after centralisation were not easy however successful the services have been subsequently.
31. Centralisation now or in the near future could interrupt the service development strategies designed and initiated by the Chief Coroners after the 2013 reforms. These include major improvements in coroner and coroners’ officer training and a strong emphasis on improving the service’s interactions with bereaved families. Another interesting feature is the increasing tendency of coroners to become part of “the judicial family”.
32. The present structure can be seen as hybrid – local resourcing but national leadership which sets and increasingly monitors national standards and has powers to call in exceptionally difficult cases for judgement at a higher level.
33. Taking an overall view of these issues there seems advantage in a strategic approach to the development of the Coroner services along the following lines:
a. the strategic aim would be to continue the Service’s development of independence, public standing, consistency, resourcing of skills, and support that should be characteristic of a main national judicial jurisdiction
b. the timing of moving to a national system and structure would need to ensure that the change would lead to proper resourcing and the transitional risks of the change process would be justified by definite longer term benefits
c. the position and performance of the service should be reviewed annually as suggested in paragraph 4 above and should in the medium term once again be fundamentally assessed with the possibility of recommending the creation of a national jurisdiction establishing the service permanently with the status that ideally it should have; or alternatively concluding that it has achieved the necessary standards and status within the present structure.
34. Such a review should consider the Brodrick Committee recommendation that the service should be centrally run and resourced but with local support from local authorities on an agency basis. This would enable the local service relations to continue but create a definite central government responsibility for the service’s resourcing and standards.
Capacity to Deal with Multiple Deaths in Public Disasters
35. Most major public catastrophes involving multiple violent deaths are investigated by public inquiries established by the Government under powers in the Inquiries Act 2005.
36. Given the improved skills and structure of the coroner service there may well now be a case that some disasters of a kind previously investigated by ad hoc Public Inquiries should be referred with special funding to the Coroner system for investigation either by the relevant Senior Coroner or by the Chief Coroner or a Judge appointed by him after consolation with the Lord Chief Justice. All handling decisions would thus be made within the independent justice system. The main characteristic of cases beyond the reasonable capacity of the relevant senior coroner would be that the likely scope and timescale of the investigation would be so great that it could not reasonably be handled alongside the regular daily caseload of reported deaths.
37. The important proposal by the Justice Working Party for “Special Procedure Inquests” within the coroner service also deserves sympathetic consideration. Dramatic single disasters involving multiple deaths such as fires and transport crashes are usually inquired into by ad hoc Inquiries as described above. Less satisfactorily handled are series of individual deaths with shared features suggesting local or national systemic mistreatment or public health failings. The coroner service, particularly when supported by the Medical Examiner system overseeing death certification, should be aware of such situations through individual referrals and investigations but currently lacks power formally to investigate them together as a series. The Justice Working Party’s well worked- up proposal for Special Procedure Inquests would fill that gap. It would enable the Chief Coroner, after consultation with the Lord Chief Justice and considering any comment by the relevant Government Department, to set up a special investigation of serial deaths over a period of time and perhaps in different places and so identify any shared treatment, public health or other common factors and thus encourage changes to remove or reduce the risk of further deaths.
38. There have in recent years been several examples of multiple serial deaths which should thus have been identified, independently examined and prevented more quickly – the C Diff Outbreaks in Maidstone (2007, 90 deaths), Mid-Staffs NHS Foundation Trust Inquiry (2013), Morecambe Bay Investigation (2015, 3 mother & 20 baby deaths), Gosport Independent Panel 2018, 450+ deaths 1987-2001).
Strengthening the Coroner’s Role in the Prevention of Future Deaths
39. The Special Procedure Inquest as described above would provide the coroner service with a new procedure very relevant to the prevention of future deaths. The procedure in paragraph 7 of Schedule 5 of the 2009 Act requiring coroners in suitable cases to identify features likely to prevent future deaths and report them to the institutions concerned who are required to respond within 6 months has generated a considerable volume of such reports. They are also reported to the Chief Coroner who arranges their publication on his website and summarises them by category. This is a valuable addition to the output of the coroner service.
40. Possibilities for strengthening it further might include (a) more monitoring of coroner areas which make such reports significantly below the average (b) involving the regulatory and inspectorial services of the institutions concerned in the follow-up to the reports, and (c) possibly, more liaison with Public Health England and its successor body, relevant staff associations and professional bodies in analysing and publishing the overall patterns of preventable deaths which emerge from the reports.
Training and Guidance for Coroners.
41. See para 2 (4) of the Summary above. Most of the issues identified in the following paragraphs as needing improvement in bereaved peoples’ experience should be addressed within the existing training and guidance frameworks.
Improved Services for the Bereaved
42. The Justice Working Party’s recent report makes recommendations reflecting some bereaved peoples’ experience of the service:
(a) Bereaved people and survivors in investigations into contested deaths should be afforded the relevant entitlements outlined under the Victims Code (para 3.35).
(b) Where an inquest, inquiry or other form of investigation follows a concluded criminal trial, investigators should consider whether the witness statement (including the victim impact statement) of a bereaved person used at the trial might be sufficient to serve as that person’s evidence for the purpose of the investigation (3.24).
(c) The Chief Coroner should issue guidance defining “next of kin”, and the term should be explained in communications from the coroner’s office to bereaved family members.(para 3.30).
(d) where a coroner decides that an investigation should be discontinued, the coroner’s office should ensure that the next of kin are always informed of the reasons for the decision (para 3.34)
(e) Fuller and more timely communication with bereaved people over investigations’ procedures and progress e g providing them with a full explanation of the process at the very beginning, and progress reports every 3 weeks or such interval as they would prefer (3.44) and informing all family members of intended post mortems and their results with careful provision of warnings where the result might cause distress (34. 8&9)
(f) Local authorities…. should ensure that venues for hearings are chosen and designed in order to prioritise the needs of bereaved people and survivors (4.25). This would avoid situations where family survivors find themselves uncomfortably close to other participants including those they consider responsible for the death.
(g) Fuller and prompter disclosure of documentary evidence (4.30)
(h) Introduction of a Statutory Duty of Candour on the part of public body participants. (4.44).
(i) Various training, professional development and procedural changes for coroners and all concerned in investigations to promote their understanding of and give priority to the emotional vulnerability and support needs of bereaved family survivors, including the avoidance of aggressive and hostile cross-examination. (5.4, 5& 10).
(j) The Lord Chancellor should…provide non-means tested public funding for legal representation for families where the state has agreed to provide separate representation for one or more interested persons.
43. All these issues seem well worth considering sympathetically. The majority could be dealt with through the existing powers and procedures for coroner guidance and training. The duty of candour and provision of non-means-tested funding for families’ representation in inquests require Government policy action.
Fairness in the Coroner System
44. See Para 2 (7) above. The need for proper oversight and support of the death certification system has been acknowledged by Governments since the 2009 Act but there has been great delay in implementing the relevant provisions for the Medical Examiner scheme. There has been a good deal of research showing significant failure on the part of death certifying doctors to comply with coroner reporting obligations, and so denying surviving families the benefit of fair access to the investigative service.
45. There were government announcements of the full implementation of the scheme in 2012, then 2014 then 2018 and then 2019. The present non-statutory version of the scheme is worthwhile but currently does not extend beyond deaths in acute hospital trusts, even though many of the more questionable deaths may occur in other settings (as did all of Shipman’s murders). Legislation to re-establish NHS organisations as the responsible medical examiner employers and to re-engage the Examiners’ statutory independence as provided in the 2009 Act was introduced last December before the election but no public commitment to its re-introduction has yet been made.
46. The full and effective implementation of this statutory scheme is essential for the overall reform of the death regulation processes that successive governments have committed themselves to over nearly two decades during which some 10 million deaths in England and Wales have been handled through regulatory systems known to be unreliable.
Chief Coroner Post
47. The Justice Working Party recommends that the post of Chief Coroner for England and Wales should be full-time. The first two appointments have been part-time but it is remarkable how much has been achieved during their tenures and the incumbents’ continuing links with the established judiciary may have been of value in the initial phases of coroner reform. Given the scale of the jurisdiction and the complexity of its functions there may well be a case for full-time leadership in the future.
48. There may also be a case in the medium-long term for reviewing the appointment procedure for the post. Under present legislation the appointment is made by the Lord Chief Justice in consultation with the Lord Chancellor and needs to be of a High Court or Circuit Court Judge. Is there any good reason why, as the coroner service further develops and increasingly reflects the attributes and qualities of the wider justice system, the Judicial Appointments Commission should not have the selection and advisory role in the appointment of its leader that it has for other judicial appointments? This would somewhat widen the range of opinions involved in the selection process and also enable other suitably qualified people including experienced coroners to apply for consideration.
 Ministry of Justice. Post Implementation review of coroner reforms in the Coroners and Justice Act 2009: “A response to this call for evidence will be published in early 2016 as part of a post-implementation review.”
 Cabinet Office 2012: Consultation Principles guidance: Section J.
 “Statutory Duty for Doctors and Other Public Service Personnel to Report Deaths to the Coroner”, TSO July 2007.
 Review of Practice Direction 12J FPR 2010- Child Arrangement and Contact Orders: Domestic Violence and Harm: Report to the President of the Family Division by the Hon. Mr Justice Cobb 20 January 2017.