Written evidence from the Birmingham and Solihull Coroners



The Coroner is tasked with investigating all violent and unnatural deaths, deaths where the cause is unknown and deaths in custody or state detention.

Birmingham and Solihull is one of the busiest jurisdictions in the country with around 5200 death referrals each year, 1700 post mortems and 800 inquests. It is a complex jurisdiction with a busy multicultural city having a Major Trauma centre, Prison, Airport and significant redevelopment. Our average time to conclude inquest is 12 weeks which is one of the best in the country.

The purpose of an inquest is to determine how someone has come by their death and is not there to tribute civil or criminal liability.

I turn now to the specific questions posed by the Justice Committee:

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

Inevitably the mechanism to fund coronial services though their Local authorities does create a post code lottery. Those Councils with financial challenges will be less able to support their Coronial services and the families involved in those cases.

To ensure a consistent service for all it is important that coroner areas are appropriately financed with similar resourcing for each area based on a criteria such as the number of referrals and complex features of the jurisdiction e.g. a prison. The right number of staff for the volume of work coupled with suitable court buildings will provide a higher quality service: there is currently a huge variation that has no correlation to the size or complexity of the jurisdiction. Coroners are Judges doing a legally challenging job. They are often preparing complex Article 2 cases with limited support putting considerable pressure on the coroner. Low staffing numbers in some coroner areas results in considerable pressure being put on the Coroner to prepare those complex cases. Coroners would be better supported with paralegals and other staff for those types of cases.

The Senior Coroner has to develop a relationship with their Local Authority for the purposes of planning, managing and running the Coroners service, yet they may have the same Local Authority as an interested person in their court. There is no other judicial office expected to undertake this balancing exercise which is caused by the Coroners service being funded by Local Authorities and not being part of a nationally funded service.

Management provided by the Local Authority for the Coroners service changes regularly and this can create difficulties as new staff do not understand the requirements of the service. This creates an additional burden on the Coroner having to educate new staff. A national service would avoid this pressure.

Our experience is that Councillors frequently struggle to understand that they cannot lobby or interfere with the judicial function of the Coroner and Council Officers do not have the authority or control over Councillors to stop inappropriate behaviour. Consequently, time is lost explaining why Councillors cannot attempt to interfere and influence the Coroner’s decision making. Nationally there is a real risk that, consciously or unconsciously, such pressure will have an influence.  Taking Coroner’s services away from local authorities would remove this risk.

A national funded service would also provide better resilience and support to the Coroners service. The Assistant Coroner (AC’s) appointments are part time which creates difficulty arranging cover for the Coroners service as AC’s have another job. AC's being unable to attend regularly makes them less effective and creates a lack of consistency in the office. Regional AC appointments managed centrally would vastly improve the cover available and the quality of service.

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

Recent events have forced Coroners to gain the necessary skills to manage a mass fatality incident. All coroners have been trained through the Judicial College. The Senior Coroner co chairs a strategic Mass Fatalities Group with the West Midlands Police lead to ensure the area is suitably prepared for any future incident. The Birmingham Senior Coroner and Area Coroner are both trained Senior Identification Managers (SIM's) having undertaken the College of Policing course. We recently attended and supported a 2 day live exercise at Cosford Training centre where a counter termism unit incident was played out. This provided valuable learning for all agencies who worked together to manage the initial incident.

During the COVID19 pandemic the Senior Coroner chaired the Mortality Working Group (MWG), a sub group of the LRF SCG, which was responsible for setting up a regional mortuary and PMART service for community deaths.

We have also had to deal with several mass fatality incidents in the area including an industrial incident killing 5 workmen and a two vehicle RTC killing 6 persons.

We sit on our local LRF strategic group and provide advice and support regarding mass fatalities and the excess death process.

We are confident that the necessary relationships are in place with relevant agencies and we are equipped and prepared for any mass fatality incident.

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

We take a proactive approach to preventing future deaths with the coroners working alongside other agencies to attempt to make a real difference. The current projects we are involved in are:

In addition we send Reg 28 reports when required. One aspect of this work which is frustrating is that once the Reg 28 report has been sent, as the Coroner is functus officio when the inquest is concluded, we cannot follow up any points in the response. This means we cannot follow up an inadequate response which is frustrating for families.

How the Coroners Service has dealt with COVID 19

The pandemic was a challenge. Overnight we had to change our processes to allow staff to work from home and cancel court cases. We had to urgently find laptops for staff and set up their work stations so they could work effectively. Our current case management system worked less effectively from home due to the amount of broadband it used. 

We had to deal with a significant change to the way doctors provide MCCD's (Medical certificates of cause of death). During the first wave we received double the amount of referrals we would normally expect - over 200 a week for approximately 6 weeks. The dedication of the staff and leadership from the Coroners allowed us to continue to provide a high level of service to bereaved families. Chairing the MWG allowed us to influence how deaths were investigated to try to improve the death process to allow early release of bodies. Working in partnership with key stakeholders, building on existing relationships, allowed us to provide adequate mortuary places through a purpose built regional mortuary along with a PMART service to support community deaths.

We are prepared for a second wave however our staffing levels are limited such that any sickness would result in considerable pressures for the team.

Lockdown created a backlog of inquest cases due to adjournments which we have been working through. We currently do not have a venue to undertake jury cases so we have the prospect of 4 months worth of jury cases to be heard in the new year when we are due to move into a new court building with adequate space to accommodate social distancing.

Progress with training and guidance for Coroners

Compulsory guidance for Coroners has been a welcome addition from the CJA 2009. Keeping up to date and learning new, or revisiting old, skills is important. We also provide in house training for our staff and Assistant Coroners inc: Article 2, Toxicology, GDPR to name a few.

Guidance from the Chief Corner is a very welcome addition. This helps consistency in court and drives good practice nationally.

Improvements in services for the bereaved

One of the most important things we do is to keep the bereaved at the heart of the service. In Birmingham we invite pen portraits/photos from each family to use at the start of the hearing. We speak to key stakeholders about the importance of providing evidence in plain English so that families can properly understand what happened. For medical cases we encourage use of diagrams and props to help families. We ensure we manage expectations of the inquest process so that families understand what we can, an importantly, what we cannot do.

It is a source of frustration that lawyers attending court often do not manage their clients expectations which encourages a more adversarial hearing which can be difficult to manage and result in disappointment.

We strongly believe that the evidence will speak for itself and our role is to ensure the correct evidence is provided in court to allow the Coroner, or a jury, to deliver the correct conclusion based on that evidence.

Fairness in the Coroners system

The process is fundamentally a fair one. Adequate case management in combination with the right evidence will achieve a fair result. State agencies, professionals and companies are often "over" represented where families are rarely represented creating a perception of inequality. Yet in our experience these agencies do not influence the outcome, they just make the process prolonged and more adversarial. Further work is invited on this topic to ensure that those attending inquests have the right expectations and skill.


The role of the Coroner is a unique and important one. Being Senior Coroner for Birmingham and Solihull is a role I am extremely proud to do. We provide a service and answers to those recently bereaved such that they can understand how their loved ones died and allow them to grieve and move on from their loss. Many families are hugely grateful for the information they get from the inquest process, however we continually strive to improve our service. I have no doubt that the CJA has vastly improved the coroners service, providing disclosure and making the process open and transparent.

September 2020