Written evidence from Christopher Taylor and Nicole Taylor


We would like the Justice Committee to consider the following written evidence for your inquiry into the coroner service.
















We responded in 2011 to the draft charter for the coroner service. The guide produced following that consultation and the appointment of a Chief Coroner have delivered some major improvements to the coroner service.






As a result, the coroner service is now very different to the one we experienced in late July 2009, following our daughter’s death in a car crash in September 2008.


Our experience was not as severe as others experienced before the Guide to Coroner Services for Bereaved People was first published in 2014. Unlike some families we have met, we were at least allowed to speak and ask questions at the Inquest. We had 14 days to prepare for our daughter’s Inquest. There was no pre-inquest meeting for us to discuss what would happen at the Inquest. We had to pay for copies of the witness statements and police report. We quickly became concerned by what we read, there were factual inaccuracies in the investigator’s report (e.g. cars recorded in the wrong sequence) and the drainage had not been properly investigated. Our request for an adjournment was declined. The coroner had allowed for 30 minutes for the Inquest, it lasted about 90 minutes. At the end of the Inquest we were left with many unanswered questions. It was only through commissioning reports and monitoring flooding on the road we got those answers.


We share this to illustrate the changes made to the coroner service since 2014. However, whilst “a journey of a thousand miles begins with a single step", the coroner service still has many steps to take to deliver a modern, fit for purpose service that is empathetic and compassionate to the needs of the bereaved.


One of those steps is changing the language we use and to stop referring to road deaths as “accidents”.




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


We strongly support the creation of a National Coroner Service. In our experience local services are far too uneven. Whilst there are a few coroners who provide an excellent service, there are too many who are simply not good enough.


One issue we highlighted in 2011, that remains an issue today, is the number of cases that take too long to come to Inquest. West London has been a specific cause of concern, as highlighted in the Chief Coroner’s most recent annual report.




The time taken to understand our daughter’s death was an issue we encountered in 2009. After waiting nearly a year, we were extremely disappointed by the quality of the police investigation and coroner’s inquiry. Our daughter’s death was caused by a blocked drain that flooded the road. It was only because of our diligence that we eventually persuaded NCC to take action to stop this road from flooding.


In April 2020 we performed a detailed analysis of PFD reports since 2013.






Vulnerable road victims accounted for 58% of PFDs with a category of Road (Highways Safety). 83% of them had environmental contributory factors with road design or maintenance being a factor in all but 2 of them. This means the coroner is often directing their requests to prevent future road deaths to local authorities.


Because of this potential conflict of interest, we believe it is inappropriate for local authorities to be responsible for coroner services. We provide the following to illustrate how this conflict of interest can arise. In 2015 the ICO decided it was unlikely the HM Coroner for Northamptonshire had complied with the DPA, when she allowed an NCC lawyer access to our daughter’s Inquest file, including private and confidential correspondence between us, the coroner and the police. Anyone else (including us) would never have been given such unrestricted access.


Whilst our analysis focused on road deaths, the total number of PFDs reported varied widely by coroner area. Manchester South, Inner North London, Milton Keynes, South Central Wales, Isle of Wight, Brighton and Hove, Manchester North and City of London all stand out for reporting an above average number of PFDs. Coroners in these areas deliver the standard of service all bereaved people should expect to receive and highlight the deficiencies in coroner services elsewhere.


We highlight the following in relation to road deaths:







75% of coroner areas, in the top 20 for road deaths, report below average PFDs. These are clustered around the East of England and East Midlands (Kent, Essex, Suffolk, Norfolk, Cambridgeshire and Peterborough, Northamptonshire, Leicestershire, Nottinghamshire and Derbyshire), South and South West of England (Gloucestershire, Hampshire, Somerset and Devon) and North of England (Lancashire with Blackburn and Darwen and North Yorkshire).


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


Manchester Arena and Grenfell Tower deserve special care and attention that may go beyond the capability of local coroners. The same is true for many other deaths covered by local coroners. 5 people are killed on our roads every day. However, the scale of loss, 1,870 people in 2019, does not get the attention it warrants.




A National Coroner Service would allow coroners to specialise and bring specific expertise and focus to road deaths, suicides, hospital deaths, deaths in care etc.


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


Coroners often decide not to hold an Inquest following a criminal trial for death by careless or dangerous driving. While they may have many good reasons for not holding an Inquest, it weakens their role in preventing future deaths. A National Coroner Service would be able to develop the guidance and codification needed to ensure reasonableness, fairness and consistency in this decision making.


To strengthen their role in prevention of future deaths the coroner service needs to be more inquisitorial and investigative in preparing for and presiding at Inquests. To answer the question “why could this death not have been prevented? coroners need to be better supported in gathering the evidence needed for Inquests.


PFDs for highways safety are low compared to railways and accidents at work, 2.6% compared to 19.6% and 8.7%. Our analysis of PFD reports supports the argument that highways should be subject to the same governance framework as railways, including a Road Collision Investigation Board to support investigations.


The DfT is currently funding a pilot of new ways to investigate road collisions.




A Road Collision Investigation Board combined with a National Coroner Service, with a cadre of coroners who specialise in road deaths, would bring a much-needed focus to reducing KSIs on our roads. Road collisions cost the UK £36 billion a year, that is enough to fund every Primary School and GP Practice.




Coroners can raise a PFD report to request actions be taken before the Inquest (this is something that rarely happens), the responses received could aid the investigation and future deaths could start to be prevented sooner.


Many of the people who have lost a loved one in a car crash are passionate about lessons being learned and action taken. By preventing road deaths, we can also reduce the people who suffer serious injuries every year (27,455 in England and Wales in 2019). To deliver Vision Zero coroners should perhaps request actions to be taken to prevent future deaths and serious injuries.




4. How the Coroners Service has dealt with COVID 19


We have not directly experienced the coroner service’s response to covid-19. However, the systemic approach taken to tackling covid-19 has lessons for both the coroner service and most of the categories of deaths investigated by coroners.




Like multiple deaths in public disasters, covid-19 deaths would probably be better handled by a National Coroner Service, which would be better placed to quickly build expertise and promote good practice. In contrast local initiatives are more likely to be uneven, variable and result in a postcode lottery for the bereaved.


5. Progress with training and guidance for Coroners


The creation of the post of Chief Coroner was a welcome change. However, they cannot direct coroners and the role is restricted to providing training and guidance. This limits the leadership that His Honour Judge Mark Lucraft QC (and his predecessor Sir Peter Thornton QC) can provide to the coroner service.


Road deaths illustrate this issue. Whilst most experts, involved in reducing road danger, share our concern about the low number of PFD reports for road deaths. They have also expressed concern that some PFD reports are the result of misinformed conclusions, that can be counterproductive in reducing future deaths.


Road collisions are often the result of multiple factors. Coroners need to be trained in Vision Zero. It is neither inevitable nor acceptable that anyone should be killed or seriously injured when travelling on our roads. The Safe Systems approach considers people’s vulnerability to serious injuries in road traffic collisions and recognises the system should be designed to be forgiving of human error.




However, guidance and training on its own will not fill the capability gap. As highlighted earlier we need better investigations and we also need better coroners. Bereaved people deserve a much better coroner service and a National Coroner Service would be an opportunity to recruit the people who can deliver that service.


6. Improvements in services for the bereaved


We received very little support when our daughter died. We contacted our Police and Crime Commissioner, who responded to this gap in service for the bereaved.




Irrespective of whether a crime has been committed, bereaved people should be supported and covered by the Victim’s Code. The role of coroners is not covered in the code, yet they identify who died and seek to understand how, when, and where they died. And whilst the coroner does not seek to apportion blame, they can request actions be taken to prevent future deaths and they deliver a verdict.


Once an Inquest has been held, the only way to challenge the coroner's verdict is by judicial review. Similarly, complaints about coroners' personal conduct must go to the Judicial Conduct Investigations Office (JCIO). Two major improvements in services for the bereaved would be: an appeal process for Inquests and for the Chief Coroner to be responsible for the performance management of all coroners.


Whilst the Guide to Coroner Services for Bereaved People has helped, the service remains uneven and highly variable. A National Coroner Service would deliver a more comprehensive and consistent service that developed good practice and pursued continuous improvement. To deliver continuous improvement the service needs to be monitored and the bereaved surveyed to understand what they have experienced (whether it be poor, good or excellent) and how it can be improved.


7. Fairness in the Coroners system


Most road deaths do not result in a prosecution for death by careless or dangerous driving.




For other road victim fatalities, the Inquest is the only opportunity to investigate their death and identify how to prevent future deaths.


For the coroner system to be fair the bereaved need to have the right to a quality investigation supported by a modern, fit for purpose, inquisitorial coroner service.


The focus for our evidence has been on road deaths. Similar issues are likely to exist for most of the other categories of death investigated by coroners. Some of these categories are probably also underrepresented in the number of PFDs reported by coroners. And the bereaved people impacted by these deaths may have also encountered issues with the support that is available to them.


We trust you find this information of assistance to your inquiry. If you require any further information (including our analysis on PFD reports), please do not hesitate to contact us.


29 August 2020