Written evidence from Ms Joanne Kearsley, HM Senior Coroner at Greater Manchester North

In submitting this evidence, I deal specifically with the North Manchester Coroners Service (Rochdale, Oldham and Bury).  In doing so it should be noted I have had the benefit of contributing to and reading the response submitted by the Coroners Society of England and Wales.

Examples from some of the feedback received 

The elderly mother and father of the deceased wished me to express their gratitude to all those “in the Coroners service” as they described it, for the care and sympathy that they had been shown in respect of their sons case.”

Thank you so much from the family. For you to deal with this on Christmas Eve the way you have done is highly appreciated and commendable. I honestly did not think you would still be in the office and honestly never seen anything like it. Will let it be known how much out of the way the staff went to make this happen.”

“I would like to thank you and your team for the very professional and thorough investigation of my cousin’s death.  I am now content that all my questions have been answered, after what has been a very long road due to all the issues surrounding his death.  From the outset of this process, I have been impressed with the efficiency of the Coroner’s office in keeping me up to date with events as they unfolded and the speed with which legal challenges and other issues arising were resolved. I found each person I spoke to from the Coroner’s office whether by phone or in person to be very helpful and informative and I was always treated in a very kind and sensitive manner.”

Question 1

As the CSEW highlights there is unevenness in the coroners service. When all things are considered, much of the unevenness is, in essence, due to lack of resources, lack of funding and importantly lack of understanding of the functions and purpose of the coroners’ service. Too often those in senior positions within a local authority do not understand the service, moreover they do not appreciate the risks associated with an inadequately resourced service and ultimately the impact this can have on those who have been bereaved and the community which the coroners’ area serves. 

In my opinion the North Manchester Coroner’s area is a good example of a well-resourced and well-supported service which in turn provides a high quality service in timely and efficient manner.  To provide the full context, consideration should be given to the following:

The number of deaths reported to North Manchester in 2019 was 2181

The number of Inquests held was 507.

Manchester North is well supported by the lead local authority, Rochdale and the other areas Oldham and Bury.


The service has the benefit of a Senior Coroner, a full time Area Coroner and 8 Assistant Coroners.  Use of the Assistant Coroners is entirely at the discretion of the Senior Coroner in order to address the needs of the service.

The service is staffed by both local authority staff and Greater Manchester Police Coroners officers. It should also be noted that Greater Manchester Police are extremely supportive of all coroner areas in Manchester and provides coroners officers in each area.

North Manchester Coroner’s Area has the following staff structure:-

First Officer

Second Officer

4 Administrative staff

10 Local Authority Coroners Officers

A number of casual staff who work as Court ushers.

Senior Police Coroners Officer (provided by Greater Manchester Police)

6 Police Coroners officers (provided by Greater Manchester Police)


In addition to adequate staffing, the North Manchester Coroner’s Service is currently in the process of relocating into new office and court premises.  This move is in response to the recognition by the lead local authority and other areas of the need for suitable premises which are fit for purpose for both Court hearings and in order to allow staff to carry out their duties most effectively.

There will now be three Courts, fully supported with remote hearing technology.  Court 1 will be able to facilitate a jury and there is a separate jury room including a kitchen area and bathroom for the sole use of the jurors.

The Court (public) floor has access to 6 meeting rooms for advocates and families and a multi faith room.

The office floor has adequate space to accommodate all Local Authority and GMP staff which will enhance efficiencies.  In recognition of the challenging nature of the work undertaken, a suitable breakout area has been provided in order to protect and promote staff welfare.

The reason the above matters are important is that they directly correlate with the ability of the local service to work efficiently through the cases.  This may be in providing timely updates to all Interested persons, providing disclosure ensuring the same is properly redacted, or progressing cases to hearings.   The inability to do these things in an efficient way leads directly to complaints and concerns being raised especially from bereaved families.

All of the above does not address the other issue of the unfunded burdens which have been placed on local authorities following the implementation of the Coroners and Justice Act 2009. This issue is dealt with in more detail in the response from the CSEW.

Question 2

In respect of this question I would defer to the CSEW response. However I would add my experience as Chair of the Mass Fatality Co-ordinating Group (MFCG) following the Manchester Arena Attack confirmed and reiterate my belief that coroners are best placed, highly trained, skilled and informed to respond to such incidents.  

Question 3

I would defer to the CSEW response. On behalf of North Manchester I would also add that there are also some specific programmes of work carried out in this area which are aimed at the reduction of potentially avoidable deaths.  These are as follows:

Suicide Prevention Work

As in many coroners’ areas the increasing numbers of deaths as a result of self-harm remains a matter of significant concern. North Manchester coroner’s area works proactively with the three local authority suicide prevention leads.  At the conclusion of every inquest involving a death from self-harm, the presiding coroner populates a detailed spreadsheet which includes demographic information and the potential issues affecting the Deceased at the time of death such as debt, illness, relationship issues, employment and bereavement.  This information is shared with the three local authority leads each month in order that key themes and issues highlighted at the inquests inform future local suicide prevention plans.  This work also informs the discussions at the suicide prevention meetings which take place in each of the areas.

In addition to providing information to assist suicide prevention planning, the close working relationship which our office has developed with the suicide prevention leads for each local authority area means that there is effective communication of new modes and trends in deaths through self-harm (such as the use of a new drug or an app) at the time that they emerge.  This provides the suicide prevention leads with prompt intelligence of new trends at the time that they arise.

In order to build on the suicide prevention work undertaken by our office, we are currently in discussion with the Inquest team at the Ministry of Defence as to how we may assist them in learning more about veteran deaths within the area and to inform their mental health and suicide prevention planning.

Recognising local issues

As a well-resourced area, the Senior Coroner has the capacity to oversee local demographics and to identify trends and issues arising from inquest cases which are specific to the local area.  As an example earlier in 2020, the Senior Coroner wrote to the Directors of Adult Social Care in each area highlighting a number of deaths relating to the support of complex individuals with multiple problems who were difficult to engage with.  As a result of this intervention, the three areas sought to share and maximise learning from each of their respective cases and put in place additional training for their staff around the provision of care to those perceived to ‘self-neglect’. A joint learning event was held across the three boroughs.  

This demonstrates the benefit of having coroners with local knowledge of their areas and is in my view, a critical feature of ensuring an effective and robust coroners’ service.  It underlines the benefits of the local nature of the service.

Question 4

As with all coroner areas, North Manchester adjourned a substantial number of inquest hearings in response to the COVID-19 Lockdown.   On a local level, North Manchester is in an excellent position being a well-resourced area with positive proactive support from the three local authorities.   Business continuity plans had been tested in 2019 with the result that as soon as Lockdown was announced, remote working was effected seamlessly.  We were classed as a high priority service within the local authority and IT support was immediately put in place to facilitate the resumption of remote hearings.   Extra cover from Assistant Coroners is never an issue, if the service requires it.  In addition the new court and office building, as mentioned above, will allow us to safely facilitate jury Inquests which will resume in January 2021.

Question 5

I would defer to the CSEW response. The only point to add would be the amount of training provided by coroners within their own localities.  Each year, both I and coroners in this area deliver training at events organised by the Local Medical Committees for all GPs.  In addition, I deliver bespoke training on coronial matters to the local NHS Trusts and Greater Manchester Police Force.  Delivering lectures and training events is a fundamental feature of the Coroner’s role in order to assist the education and working practices of key partner agencies and enable the effective running of the Coroner’s service.

Question 6

Improving the service for bereaved families is at the heart of how North Manchester coroner’s area looks to progress and improve.

Coronial Bereavement Nurse Project

One key example is the introduction of the first coronial Bereavement Nurse to work within the coroner’s office.  SWAN Bereavement nurses have been available for some years within the local NHS Trust (Northern Care Alliance) for all families whose loved one died in hospital. In 2018 a collaborative piece of work between the coroner’s service and the NHS Trust placed a bereavement nurse in the North Manchester coroner’s office to deal solely with families whose loved one had died in the community.   Such deaths are, in general, some of the most traumatic deaths such as suicides, murders, accidents etc.

This service enables us to offer immediate bereavement support to anyone who has been impacted by the death whether this be family, a witness to an incident or someone who has found someone deceased. 

This service is welcomed by other agencies such as the police who now have the benefit of being able to provide positive proactive information on support services at the outset.   The coroner’s staff have also reported on the benefit of being able to offer the bereavement nurse service as onward support to those individuals with whom they often have difficult and distressing conversations.

This service does not differentiate by the type of death ie it is not solely for those who have been bereaved by suicide. It is open to anyone at any time.  A copy of the first annual report is attached to this response for consideration.

Out of Hours Service

The religious and cultural needs of some of the local communities in the Rochdale, Oldham and Bury areas mean great importance is placed on burial at the earliest opportunity; often within 24 hours of the death.  Faith may be one of many reasons why escalation of a death is requested.  This has been recognised by the coroner’s service in this area (and indeed across the whole of Greater Manchester) and funding was made available to ensure coroners are properly funded and supported to provide this service out of hours and at weekends. This service greatly assists the bereaved in our communities.  However it is important to note that the service in North Manchester is properly funded and is not reliant solely on the Senior Coroner being on call continuously.

Design of the new Court facilities

The needs of the bereaved were very much at the forefront of the design for the new court facilities.  Adequate meeting rooms with rooms and facilities allocated specifically for the use of families will now be available which allows them necessary space and privacy. This was regarded as important in view of how traumatic it can be for some families attending court to wait in small waiting areas with other witnesses. We also recognise the needs of vulnerable or traumatised witnesses who may also find the experience of attending Court to be difficult such as the drivers of a car or train which was involved in a death linked to self-harm.

Question 7

I would defer to the CSEW response on this issue.

Concluding Comments

It is important to understand the role and context of coronial work.  There is no questioning the importance of ensuring families are at the heart of the Inquest process and that they are treated with dignity and respect. However there must be recognition of the fact that the coroners service deals with a wide range of investigations and inquests and the high profile state detention deaths are, thankfully a very small proportion, albeit extremely important, part of the coroners function.  Whilst the Coroners service should strive for national standards and the Chief Coroners guidance and training go a long way to addressing some of those issues, such as the provision of disclosure, pre-inquest reviews, summing up and directions to juries, conclusions etc the importance of local knowledge should not be underestimated.


September 2020