Written evidence from Mr. Nigel Meadows, Her Majesty's Senior Coroner, Manchester City Area


My background and introduction


I qualified as a solicitor in 1985 specialising initially in criminal work but then also dealt with personal injury and medical negligence cases plus representing patients before the mental health review tribunal (MHRT) as well as interested persons before Coroners in inquest proceedings. This involved a lot of advocacy experience. I was appointed an Assistant Deputy Coroner in 1995 for the Plymouth and South West Devon area. In 1998 I was appointed the Coroner for the same area. Initially this was a part-time position but then became a full-time one. In 2000 I was appointed a part time Judge of the MHRT. In 2006 I was appointed the full-time Coroner for the City of Manchester. I have worked under the previous statutory regime of the Coroners Act 1988 of the Coroners rules 1984 in addition the last seven years in accordance with the Coroners and Justice Act 2009 which was implemented in 2013.


Over my coroner career of over 25 years I have investigated over 60,000 deaths and personally completed over 10,000 inquests and would consider myself a very experienced Coroner who has worked and in an urban and rural area as well as one of the major Cities in the country on a part-time and full-time basis. I have dealt with virtually every type of investigation and inquest that there can be including three police shooting cases; innumerable healthcare related; many prison and mental health related suicide cases; deaths abroad as well as over 250 jury cases. I have also dealt with the country’s second worst ever terrorist incident. Consequently, I believe I am able to contribute to the inquiries work.


I understand that "the committee’s inquiry will examine the effectiveness and capacity of the coroner’s service and whether enough progress has been made since the 2009 improving bereaved people's experience the coroner’s service."


I am submitting this evidence in a personal capacity but am aware of the response submitted by the Coroners Society of England and Wales (CSEW).


Preliminary and fundamental issues and context:


The Coroner death investigation system one of the most sophisticated in the world working for the benefit of society as a whole. It is far more advanced than the overwhelming majority of European countries. It is said that the test of a civilised society is not necessarily how we deal with the living but how we treat the dead.


I am very proud of the service I lead in Manchester and the job I do for the public and the bereaved. I have copied below some examples of the responses I have received from families:


“Just a quick note to you for your kindness and understanding when dealing with my evidence in the ……inquest. It was so much easier”.


“ Forgive me for contacting you directly but as  a family we wished to express our thanks  for the meticulous yet sensitive way in which the inquest into the death of……..was conducted. Naturally it was a very traumatic experience for us but the care an consideration shown by all concerned helped us through this very difficult and was very much appreciated. On behalf of all the………Family, thank you once again”


“ I write to you after the inquest held on……..for my brother’s death. I want personally to from my family and myself for all your help with regard to his death in………We did not get a chance to personally thank you for everything on the day, so I felt I should write on behalf of…….friends, family and myself and say a big thank you for helping us to understand in more detail the facts surrounding his death.


“The family and I would like to thank you for all your help in finding and proving the cause of……death. We admire you very much for your compassion, politeness and dignity. Thank you once again.”


Finally, from two of the families of victims of the Manchester Arena bombing:


We would like to say thank you to the Coroner’s office for all you have done for us from both the ………….and ……….families. Thank you at this horrendous time”.


The inquiries terms of reference


In order for the inquiry to have relevance and value it is vital that aspects of the terms of reference are properly defined and understood. Exactly what the terms "effectiveness and capacity" mean in this context. The use of the phrase “enough progress" has to start with precisely what the position at the outset and how progress is going to be measured and what it involves. Likewise what is meant by "improving bereaved people's experience?" In respect of the specific questions posed in general I would say the following. Every person is experience of bereavement is different. Bereaved people will have contact with them coroners service at a point when a loved one has been lost and often at the point of their greatest grief. The provision of honest and accurate information to them is vital but there is enormous variability of their capacity to understand the law and the process. It is extremely common the bereaved have expectations that the Coroner can investigate every possible issue and make findings and draw conclusions which the law simply does not permit. It is inevitable in any judicial process that some participants will not agree with the process or outcome but that does not mean the task was completed incorrectly or inadequately and indeed it is invariably conducted in accordance with compliance with the law.


We are working in a time of a nationally recognised shortage of pathologists are particularly in very specialised areas of practice such as paediatrics.

What specific "failures" are being referred to? The role of the Coroner is defined by statute and uniquely it is inquisitorial in nature and not adversarial. However, to be effective it has to be thorough and properly focused. Difficult an challenging questions have to be asked and addressed. It is a judicial process and not some alternative form of complaints procedure and is vital in establishing how and why people die understanding trends and features of death and improving society and public health. In practical terms we already have a national service but delivered locally by Coroners who develop specialist local knowledge of their communities and how best to serve them within the ambit of what the law permits. I ask what does a “National Coroners service” actually means? What difference would it make apart from adding additional bureaucracy? Any identified areas for improvement can be achieved under the current system.

In all the years I have been a Coroner on no occasion as an MP made direct contact with me asking to visit my court and offices to see first-hand what we do and the challenges faced and also to observe first-hand the conduct of inquests in a variety of cases. I would suggest that practically this must be the starting point to begin to fully understand the practicalities which are not apparent from other sources of information and better inform our MPs.


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

There has been a huge change the diversity of coroners now being appointed from largely being a white male cohort to almost equal numbers of men and women and many more from the BAME community. The selection and appointment process of coroners has also significantly improved and the role of the Chief Coroner has been vital in this.

Once again it is vital to understand what is meant by the phrase unevenness in this context. Does it mean the provision of appropriate premises and resources to the coroner?

Such unevenness that does exist is very largely due to the lack of resources required to produce a 21st century service. This includes premises and staffing. Local authorities very often do not understand the fundamentals of the system despite it being a vital public service for the benefit of the public at large but also the bereaved.

My premises

I am very fortunate in having a supportive and committed local authority who wish to actively engage with me to and recognise the benefit to all and have invested significantly in the service. We moved into purpose designed and fitted out premises in November 2018 with the facilities the bereaved, my staff and all other court users have deserved for a long time and is now fit for purpose. This comprises a large jury court with technology for partially remote hearings, a second large court and a very small third court that doubles as a meeting room. Two family rooms and five for families, witnesses and advocates conference/meeting rooms of different sizes. Importantly there is modern internal office accommodation for all the staff and the Coroners. This has long been required and was a substantial financial investment in the service. These are the sort of the facilities that would be likely to be appropriate and I anticipate desired by colleagues in other coroner areas.

I always strive to give the best possible service in every way. I have a very busy City jurisdiction which by its very nature deals with a large number of lengthy and complex cases. In 2019 I have 3380 deaths reported and concluded 743 inquests.


I now have one part-time and one full time Area Coroner together with a total of 9 Assistant Coroners who are only required to sit by me when the demands of the service cannot be accommodated by myself and my Area Coroners.

My office staffing is very similar to the other three Greater Manchester Coroner Areas.

With the correct level of support and facilities the service can deal with cases more efficiently. I cannot praise my staff highly enough. They are immensely dedicated to the work and deliver a service which is second to none. We work as one team.

This without the legal and practical implications and burdens of the Human Rights Act 1998 and the raft of European Court of Human Rights and domestic courts case law which is forever refining the scope, remit and conclusions that can be reached in investigations and inquests. This significantly effects the length and complexity of inquests

There has been significant but slow improvement in the provision of court accommodation, office facilities and staffing needs of the public in the 21st-century. This is an ongoing process but it is very much better than it was 10 years ago but it is not uniform or of an appropriate standard.

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

It has to be recognised that Coroners are the specialists in dealing with deaths of any nature and we can and have adapted to dealing with larger incidents.

I am one of the few Coroners and the country who have experience of what could be described as public disasters because I was the coroner who led the coronial response to the Manchester Arena terrorist bombing atrocity because the incident occurred in my area. I had already developed extremely close working relationships with all my stakeholders including my funding local authority; the police and other blue light services; the major local NHS trusts as well as faith groups and funeral directors as well as the Registrars of Deaths. Importantly also very limited numbers of forensic pathologists were essential. Under my leadership with the invaluable voluntary assistance of two other local senior Coroner colleagues I believe I delivered the best overall response to the situation that could possibly be achieved. This involved several visits to the scene the incident; arranging for the recovery of the bodies of the deceased in a forensic way the preservation of evidence for any ongoing investigation and future criminal trial. This was done in a wholly dignified manner as fast as possible enabling the process of identification to beginning and establishing causes of death. It also involved recovering the remains of the perpetrator and arranging for their forensic examination and subsequent release for funeral purposes. The process involved setting up a temporary mortuary facility by expanding an existing one and securing the staffing of the facility and obtaining all equipment that was not already in place.

I met all the families of the deceased with within days to explain to them the process and procedures involved and when they were likely to get the loved ones back the funerals. For the first time we used a specialist team of bereavement Nurses from the outset who supported the bereaved and took a vital role in arranging for them to see the bodies of their loved ones in a manner which was as natural and normal as possible. I know this was enormously appreciated by them.

This involved if an honest, accurate and timely information to the bereaved in accordance with the MacPherson recommendations as the investigation progressed by whatever means which was updated whenever necessary. Personally, I believe that the response could not have been improved and I am sure Greater Manchester police could contribute their views in this respect.

It will be inevitable that in some cases subsequent major public inquiries will have to be held after the Coroner’s initial involvement has finished under usually the Inquiries Act 2005. I advised the Manchester Arena bombing families at the outset that this would almost certainly be the case and it would take a long time as would any criminal investigation.

Tragically since this incident in other major terrorist attacks and the Grenfell Tower fire tragedy have occurred which involved the Coroner on each occasion successfully dealing with their responsibilities in a similar manner. I only have praise and admiration for them.

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

There is still a misunderstanding the Coroners make "recommendations". The law is very specific unless and this is set out in paragraph 7 of schedule 5 to the 2009 Act. Namely, a concern that circumstances creating a risk of other deaths will occur. However, for the first time the power to make reports identifying risks of future death has statutory force. The PFD reports no more focused and consistent in drafting. I would value being able to require recipients to respond in meaningful ways and be able to challenge them publicly when they do not and require them to come to court to explain their position. At present they cannot be compelled to respond at all. In my view the current position of being unable to insist and compel a proper and full response to a PFD report is a weakness. Recipients are not required to respond at all.

Since we know our local areas very well we can identify local issues and trends quickly and take action to try and prevent specific avoidable deaths so far as is possible in our role. Examples of this include Drug deaths, Waterways incidents, deaths of Homeless persons, Suicides, failures in the provision of mental health care and improving prison regimes.

4. How the Coroners Service has dealt with COVID 19

The role and involvement of the Coroner was essential emergency planning generally but also in working with all partner agencies in formulating practical responses to this public health emergency which is very far from over. I have been involved in two previous similar pandemic planning initiatives. Identifying and improving methods for ensuring ongoing death investigation for non-Covid cases continues during the pandemic itself. Liaising with all stakeholders to ensure that the proper death certification process was complied with even taking into account the emergency time-limited changes. Ensuring appropriate management of the potential for a considerable number of additional bodies can be safely, stored and then buried or cremated. Plus having a major role in setting up the Nightingale hospitals with regard to the inevitable deaths that would occur within them.

It was inevitable that many ceases which required the physical attendance of witnesses, advocates and other interested persons had to be adjourned. I personally was coming to the end of a 4 week jury case with 10 advocates that could not be completed because of the lock down. However, since then with the benefit of having modern court facilities we have managed to complete a significant number of cases by Audio link and have a new Video link system installed in court. My court building has been closed to the public for some months but the essential work has carried on.


5. Progress with training and guidance for Coroners

The role of the Chief Coroner has been invaluable in promulgating and delivering ever improving focused training which in practical terms has to be designed and delivered by Coroners themselves who are the complete specialists but with input from other resources. I carry out local training initiatives with, for example, NHS Trusts, Lawyers, Faith Groups and others.


The legal guidance documents issued by the Chief Coroner from time to time have also been extremely valuable in establishing better consistency of practice.


6. Improvements in services for the bereaved

There has been a tremendous development in the recognition and response of the service to our varied faith communities and their needs in a timely manner. I have operated for several years an out of hours service. Avoiding where ever possible invasive post-mortem examinations within the scope of the law has improved immeasurably. The ability to use, when appropriate and possible non-invasive CT/MRI scans This development originated in Manchester over 20 years ago but is now accepted practice in the rest of the country where the facilities and expertise is available. Over the last 14 years I have developed extremely practical and close working relationships with the large Jewish and Muslim population. I would encourage the committee to contact local faith leaders who I feel sure would verify this.The availability of the Voluntary Coroners court support service for families attending inquest hearings could have direct central government funding and would be of general benefit.

7. Fairness in the current system


It is not clear to me exactly what is meant by the term “Fairness” in this context.

There is now a much more structured approach to pre-inquest disclosure of relevant evidence and information prior to hearings as a result of the Inquests Rules 2013. There is national guidance from the Chief Coroner on making findings of fact and conclusions that can be reached.

The provision of public funding for representation families inquests where other state agencies are involved is a matter for Parliament. There is a perception of inequality of representation. The cost to the public purse would be relatively little and would in some considerable way achieve a greater balance. The current tests for exceptional public funding are over bureaucratic and militate against it being granted. The requirement for means testing seems incompatible with the way the state arranges its representation.




I am sure my colleague Coroners who have also made submissions will make deal with additional issues that I will not have covered. If asked I would be happy to help the inquiry further.



1st September 2020