Written evidence from Ashley Chaplin


Death: Gerhard Venter (1 September 2018)

My relationship: Husband




The introduction into my experience with the coroner and the coronial process is an overwhelming conclusion of betrayal, prevention of truth and a denial of justice. It has left me with a feeling of bitterness.


One’s faith in God is already challenged through the loss of the one you love. The coronial process only served to break an already weakened faith. But it is through the rebuilding and re-evaluation of it that, despite the horrible experience of the coroner and the coronial process, I have been able to sustain a measure of spiritual survival.


The coronial process is a draconian autocracy leaving it exposed to bias, prejudice, political interference and corruption. It controls the process of investigation as well as inquisition and is the sole ruler in giving a finding without justification of it. It hides from challenge and accountability behind a wall of financial privilege inaccessible to the ordinary person.


I remain firmly of the opinion that the Inquest into Gerhard’s death had many of the hallmarks of a kangaroo court. It has taken many months subsequent to understand why this would be but as the evidence unravelled and the facts have begun to surface, so to the importance of accountability is laid bare.


Autocracy is the ability to act without accountability and for so long as the coronial process and the power granted to coroners to act without accountability exists, so the chances of bias, prejudice and corruption increases exponentially.


The deadline for submission to this committee is 2 September 2020. Two years to the day that I found Gerhard deceased in Regents Park, London. His body remains in Westminster mortuary unable to be laid to rest while a process of investigations and appeals are followed to uncover his Truth and ensure his Justice, all denied by the betrayal granted by the coronial process.


But Gerhard’s Truth is his Power and his Denial of Justice must come to an end.


The ultimate cynicism lies in the autocracy of the coroner having free reign in undoing the commitment inscribed in the web page of the Ministry of Justice committing the coroner’s office to “treat you with fairness, respect and sensitivity” and “act with compassion and without judgement about the deceased and the cause of death”.


It appears that same commitment does not extend to the coroner itself, making it therefore, a ruse, a farce!


My only sad solace in all of this is the discovery that I am not alone in my bitterness. The pain reverberates and is heard repeatedly through social media channels. Often, the pain of others, I can only imagine to be substantially greater than my own.


To be certain, the coroner’s services has denied Gerhard his Rest in Peace, and no matter the Everest I have to climb, I must work to release him his eternal peace.


It is not listed as a point of reform contribution, but I would ask that the commission, because of its importance to the wider public interest, consider adding as a separate point to this list:


Accountability of the Coroner and access to Remedy and Accountability for the bereaved.


Without it, your reform will be shallow and incomplete.



As evidence I would like to contribute on points:


  1. The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service
  1. Improvement of services for the bereaved
  2. Fairness in the Coroners system



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


My first experience with this point was a punch in the stomach in learning of the despairingly unevenness of the coroner’s services to the extent that the legal firm I approached advised against their legal representation on my behalf because of their belief that the coronial system was too inconsistently applied to assure me of reasonable success and declined as they said, in good conscience to not expose me to the absorbency of cost.


If there is no consistency in the way coronial processes are applied and followed, if there are no consistencies in standards of investigation or inquisition then how can any legal firm in good conscience offer their services, especially to the working class where financial resources are scant?


Consistency is surely as important to the coronial system and to the bereaved as consistency of the rule of parliament is to the electorate. Without consistency in standards and rules, the coronial process is exposed to the whims of bias, prejudice, political interference, influence of organised crime and corruption. All are masterminds at exploiting the weaknesses that exist in institutions and the fissures and chasms between the different institutions that bring together the finding of the coroner.


The need for a National Coroners System should form the basis of ensuring the rights of the bereaved at the highest standards possible at a time of greatest pain for them, while protecting from the infiltration of the forces that lay waste to fairness, truth and the right to justice.


Every member of public is touched by death during their lifetime and in the end, death too comes for them. It is the one institution that must surely be held to the highest level of accountability and the guarantees that can give the assurance of trust.


Put your ear to the wind, and you will hear the cries of the souls denied their peace, you will hear the sobs of the bereaved denied truth and justice, and you will hear the whispers in the walls amongst the victors enjoying the spoils of the failures of the coronial processes.


  1. Improvement of services for the bereaved and
  2. Fairness in the Coroners system


These are so closely related that I have treated them together as each point would possibly fit into both.


  1. The right to due process


The bereaved will never reach a point of satisfaction while aspects of the investigation or requests to investigate further are denied without explanation or justification.


If the bereaved feels that something is amiss or substantially important for contribution into the “where, when and how” then it should be obligatory for the coroner to pursue the request or give proper accountability for not doing so.


If it is a matter of cost or budget constraints, then the bereaved must be told so and be given the opportunity to contribute or pay for the costs.


In Gerhard’s case, the coroner refused forensic testing of certain evidence despite repeated pleas. The response was a rebuttal without explanation or justification therefore. Subsequent forensic testing provided material evidence not previously presented by Met Police, not presented at the Inquest and which interpretation of it contributes to a body of evidence that points to a materially different finding.


  1. A higher weighting of opinion and input from family and close friends


Spouses, close family and friends have greater insight into the life and mental state of the deceased. The coroner should be obliged to hear their input and opinion and to give full and proper justification for any actions, decisions or opinions that are contrary to that of the bereaved.


This is especially relevant in a finding of suicide when there are often substantial contributions to be made in determining the circumstances which may lie behind the cause of death. Any rebuttal or contrary finding should be fully disclosed and justified by the coroner.


  1. The right to transparency


There should be no material considered secret nor able to be seen or observed. In the event that identities or events need to be protected for purposes of confidentiality, the paragraphs, words or names can be redacted.


In Gerhard’s case, evidence was withheld from being viewed by me without justification despite repeated pleas to view in order to self-assess the evidence. This relates to his life signs on his apple watch that can have no reason to deny viewing. The only explanation given was “because it’s mine” (the coroner’s).


Subsequent evidence now obtained makes the interpretation of this evidence critical in evaluating the events that led to his death.


It should be obligatory for the family members registered as “interested parties” to have sight of all evidence presented.


  1. Access to quality and sufficient time to consider and draft evidence


Whilst I understand the need for the coroner to take steps to prevent information being leaked to social media it needs to be balanced against the right of the bereaved registered as interested parties, to view and consider evidence in their own time without time pressure and to use the tools available to them to properly assess and record their opinion and argument.


There are measures similar to the statements made on release of the autopsy report that hold the recipient of such sensitive images or information accountable. Unless the images are of such a nature so as being against the public interest to release (such as with minors, sexual organs or abuse or of imagery so grotesque as to cause public distress) then it should be released with the appropriate guarantees and protections in place for confidentiality.


In Gerhard’s case, there were none of the reasons mentioned above but I was reduced to having to attend the coroners office to draw diagrams of his wounds, position of his body and material evidence at the scene. I was under time restrictions to listen to recorded evidence which would understandably not be able to be released to me. While time was given to me, it was always under time pressure.


This placed an unbearable level of emotional stress on me and prevented proper and full assessment of evidence for discussion at the Inquest.


  1. Justification of any finding by the coroner


At Gerhard’s Inquest, the coroner read out all that was heard and ruled a finding giving no justification or accountability for such ruling. It left the bereaved angry, suspicious and bitter.


This should be taken in context too that the coronial process is different to that of a legal process in which there is substantial separation between investigation, presentation and argument with a final assessment being made by a judge and it’s justification for such finding.


By not having to give accountability or justification it provides the basis for the infiltration of bias, prejudice, influence and corruption into the finding.


By controlling the entire process from investigation, through inquisition and finding, the coroner appears to rule with the power similar to that of the divine right of the Pope!


It is an autocratic power and runs contrary to the principle of separation of duties, powers and of democracy.


Unaccountable power can surely never be in the public interest.


  1. Forum to Challenge, Complain and Request Accountability


On submission of a complaint of bias from the coroner, the JCIO goes on to explain “This means they are entitled to make decisions and manage cases free from outside interference by officials (including this office), government ministers or other judges”


One may understand this partly only if there were a forum to hold the coroner properly to account in their case management.


The argument would be no different to that of Met Police, DPS or IOPC where it is essential that they are also not exposed to undue influence or interference by anyone. However, the crucial difference is that the Police Force has substantial measures in place to ensure a greater level of accountability and provide a forum for the public to recognise mismanagement or corruption, report it and for it to be investigated. In other words, there is a full multi-level range of institutions to better ensure accountability and instil public trust.


The JCIO refers to the coroner as being a “Judge”. But they are not equal to a judge in a law court as one may expect; they yield far more influence and power; the coroner’s range of control is substantially more involved and controlling of the processes that leads to a finding.


In Gerhard’s instance, the investigating officer frequently interacted with and referred to taking instruction only from the coroner, creating an environment in which the coroner maintains control over the investigation and conversely provides the platform for any bias, prejudice or criminal influence exerted over the investigating team to pass directly onto and over the coroner and infiltrating the coronial process. Similarly, it facilitates an environment, especially in poor case management, where investigating officers can deny proper investigation by hiding behind this chinese wall of challenge. This surely substantially increases the need for oversight, and equally importantly, a process to raise the alarm and obtain remedy in the case management of the coroner – I refer back again to the JCIO statement of the unchallengeable case management of the coroner by anyone, including themselves or any judge.


Without a forum to challenge coroner case management, the coronial services will always be treated with suspicion and will never secure public trust. Without oversight and the right to more easily obtain remedy, in instances of case mismanagement, the coroner becomes the enabler of those who wish to ensure an outcome favourable to themselves to the detriment of the bereaved and ultimately to the wider public interest.


Oversight bodies similar to the DPS and IOPC needs to be put in place to facilitate this trust and root out mismanagement or corruption.


This would go a long way in reducing the need for Judicial Reviews and S13 Applications which are substantially more formal and complex in contesting Inquest findings. Both are mostly beyond the financial reach of the wider public.  Both too, are after finding at the Inquest rather than facilitating resolution before conclusion.


  1. A more appropriate, engaging and less intimidating setting for Inquests and especially PIRs


In a court of civil or criminal law, one would understand the need for the setting and the judge being presented in the manner that it is. It entrenches the rule of separation of powers and due process. The judge forms the role of final arbitrator based on evidence presented. If either the prosecuting or defending teams present poorly or incompletely, then it is to their own detriment and the judge rules on evidence presented.


Surely, the role of the coroner, regardless under which ministerial division it may fall is materially different and has a highly weighted responsibility towards the bereaved to account for the “who, where, when and how”. The deceased is dead, and it is the bereaved that are left needing Truth and Justice for themselves and on behalf of the deceased.


Why then is there a need for a setting that appears to pit the coroner against the bereaved rather than an environment that no only encourages commitment to the bereaved in ensuring the truth is laid bare in their loved one’s death but one that also instils a sense of co-operation with the bereaved in hearing their concerns and their opinions. The environment further causes a chasm of mistrust between witnesses and the bereaved and serves to increase a feeling of hostility.


I would recommend and ask the commission to consider the current settings of Inquests and especially PIR’s to be inappropriate and insensitive to the bereaved. Furthermore, it creates a destructive environment rather than one that is constructive in co-operation to finding the truth.


A setting more corporate in nature which encourages a spirit of co-operation, wellbeing, respect and sensitivity would be substantially more appropriate. The grandstanding entrance of the coroner is both insensitive and disrespectful to the bereaved and entrenches the feeling of the “them versus us”.


Wherever the coronial process may fit, referring to the coroner as a “judge” is not only misleading, it is inappropriate. I would ask that this committee consider defining the role differently as it is materially different to a judge in the sense the public identifies with in a civil or criminal proceeding.


In those proceedings, a judge finds for guilt or innocence, a coroner does not. It defines circumstances, that is all, and specifically avoids the findings of a judge.


The term of “judge” should be removed and replaced with a term more similar to an arbitrator or investigator. This in line too, with a setting more appropriate to the role the coroner performs; that of Inquisition and Finding.


People presenting evidence to substantiate aspects of the investigation and death are referred to as witnesses. This term too, creates hostility and defensiveness of those presenting the evidence. It creates the environment of the need to withhold rather than the encouragement of transparency and full disclosure.


Surely, they are contributors of information rather than witnesses. Their information and presentations need to be scrutinised and challenged in order for everyone to make sound and balanced opinions of the circumstances of death.


If the opinion leads to a civil or criminal proceeding, it is then that the role of judges, witnesses and separation of powers become relevant and important.


In a coronial process, they are negative influences and break down the effectiveness of transparent and effective Inquisition that overwhelmingly respects the bereaved and their need for truth.


Concluding Remarks


The anger and resentment of the public that feel disenfranchised and betrayed by it, towards coroners and the coronial process is surely an alarm that the coronial process in its current form is not fit for purpose.


It requires an overhaul of its image and the manner in which it presents itself. It requires oversight and accountability, and it requires standards and processes consistent no matter where it is applied.


Only then will it have public trust and respect. Only then can it serve the bereaved and be the last bastion of truth for the dead and assure them of their rest in eternal peace.


In its current form, it is exposed to bias, prejudice and corruption. It denies trust and it has the elevated potential to deny truth and to deny justice.