Written evidence from the Coroners’ Courts Support Service


The Coroners’ Courts Support Service (CCSS) is a charity whose trained volunteers offer emotional support and practical help to bereaved families, witnesses and others when they attend an Inquest at the Coroner’s Court immediately before, during and after the Inquest process.


Set up in 2003 by our Founder Trustee, Roey Burden OBE, who attended an Inquest in to the tragic death of a family member but received no support. The charity strives to make the inquest process transparent and accessible, and we aim to meet the emotional and practical needs of all those attending.  Owing to no financial support from central government, the support of our 400 volunteers is currently only available in half of the coronial areas.


We are submitting evidence to this inquiry as we strongly believe that the Government’s improvements to the coronial service do not go far enough particularly in putting bereaved families at the heart of the inquest process.  If the Government is ‘determined to ensure that bereaved families are properly supported and able to fully participate in the Inquest process’, receiving support should not be a ‘postcode lottery’ but should be offered to anyone who might need it wherever they attend an Inquest through a national service.  Although our focus is on responding to question 6 – improvements in services for the bereaved, we do briefly address the other questions.


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


In our experience there are Coroners who will truly enable bereaved families to participate fully in the proceedings and, whilst maintaining their authority within the court, will address the families with empathy and an understanding of the impact the death may have had on them. However, some Coroners may make bereaved families feel unheard, frustrated and angry that the Coroner seems to be dismissing their concerns.


The CCSS has long believed that each Coroner should be held accountable to the same standards. There are many positive examples of high standards that some Coroners achieve and maintain. This needs to be more consistent across England and Wales. It does not necessarily require a national service, what might work for one area does not always work for another, and there is merit in delivering a local service to local people whilst maintaining control of the local costs. However, we do believe that the same standard of Service should be delivered. The CCSS has achieved ISO:9001 standard. This ensures we meet the criteria set and we must achieve certain standards. This is audited by an external assessor annually to ensure we continue to meet these standards. The Coroners Service could develop something similar to ensure that not only operating standards are developed but they are met and maintained.


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


Our involvement with the London PMART (Pandemic Multi-Agency Response Team) Operation demonstrated how the Senior Coroner for Westminster was able to pull together a number of agencies to rapidly respond in a very short space of time to the COVID-19 deaths in London. The CCSS were proud to be part of this multi-agency approach and took an integral part in supporting bereaved families soon after the death occurred.


However, the attention given to multiple deaths in public disasters is that bereaved family members of people who have not died due to a mass fatality may feel that the death can be on a sliding scale where someone who dies in a very public or mass situation holds greater importance than those who die when only the family are aware of the death. It is important to recognise and acknowledge these deaths for the individual family as much as the multiple deaths.


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


This has been strengthened in the recent Coroners and Justice Act 2009. The onus is now on the Coroner who must order a prevention of future deaths report if they feel future deaths can be avoided. However, there is no independent agency or individual who takes responsibility for this report being put into action other than the organisation the report refers to. Therefore, many mistakes can be made within the same hospital trust for example, which the Coroner may be aware of but is limited in how these can be addressed or actioned. Preventing Future Deaths reports must be followed up to ensure actions are taken and addressed in a timely manner. This will assist the bereaved families who will then believe that they have been able to help prevent any future deaths occurring in similar circumstances. Therefore, the death of their family member was not in vain and something positive could come out of it.


  1. How the Coroners Service has dealt with COVID-19


Many Coroners were quick to respond and converted smaller Inquests into virtual hearings. Whilst this did enable bereaved families to get some form of conclusion, it may have put pressure on them to accept the virtual hearing when there was little or no alternative. It may also have had the negative impact that they had no access to the CCSS support that would usually be available to them. The CCSS would have welcomed the opportunity to have bereaved families referred to them for virtual or telephone support via our National Helpline and via our Court volunteer teams. There are continuing capacity issues now that most Coroners have begun to hear Inquests with people attending in person and therefore, the CCSS volunteers have not always been able to resume their duties at some of the Courts. There continues to be inconsistency in how Inquests are being heard while the socially distanced measures are in place. People who attend Inquests should receive consistent standards of Service across the coronial areas of England and Wales.


  1. Progress with training and guidance for Coroners


The CCSS believes the Chief Coroners guidance documents ensures individual Coroners are aware of the latest advice, guidance and examples of good practice. The concern the CCSS has is that these documents are guidance only and, as such, can be disregarded and not acted upon. We believe that certain guidance should be mandatory to ensure each coronial area is working to the same standard of service. This enables bereaved families and witnesses to better understand the level of service they should expect when they attend an Inquest at the Coroner’s Court wherever that may be within England and Wales. A Guide to Coroner Services outlines what families can expect but as these are not mandatory standards it is difficult for families to know what their rights are as opposed to what they might expect.


  1. Improvements in services for the bereaved


The Coroners’ Courts Support Service was the concept of Roey Burden, OBE who attend the Inquest of her cousin’s son, David, who had died the year before whilst in Tasmania. As David’s body was brought back to this country an Inquest had to be held. Roey attended the Inquest at a busy London Coroner’s Court with her cousin, Elizabeth and the rest of Elizabeth’s family. There were three other Inquests due to be heard that day. As it was so busy, the Coroner’s Officer called the families and witnesses from all four Inquests into Court at the same time. Therefore, the family had to sit through harrowing details of other deaths. When David’s Inquest had concluded the family came out of the courtroom and collapsed with grief as it had been so traumatic for them all.


Roey had assumed there would be some form of support available at the Court and was shocked to find there was nothing, no water, no tissues and nowhere private for the family to sit and compose themselves.  She decided there and then that this needed addressing and, along with her friend Annie, they set about developing some form of support service and that is how the CCSS came into being. Since launching the Service in January 2003, the CCSS has now supported 105,000 people and has almost 400 trained volunteers supporting people attending Inquests at half of the Coroners’ Areas across England. The volunteer teams are supported by just 7 dedicated CCSS staff. 


We strongly believe that bereaved families should be able to fully participate in the proceedings and as Simon Hughes (when he was the Parliamentary Under Secretary of State) stated, that bereaved families should be at the heart of the Inquest process.  Current and previous Chief Coroners also believe this and are supportive of the CCSS being extended to ensure bereaved families, witnesses and others attending an Inquest at any Coroner’s Court within England and Wales would have access to the Service and the support they should be entitled to.


People attending courts in other parts of the justice system are able to access support and the fact that support within the Coroners’ Courts is left to chance is not acceptable and we feel must be addressed. 


Some Coroners believe the Coroners’ Courts Support Service is an integral part of the Inquest process and benefits bereaved families and witnesses a great deal, adding value to the coronial service as a whole and they feel they could not do without the Service being there. Other Coroners are frustrated at not being able to access the CCSS as they can see what a positive difference the Service can make and how it would improve the experience for those attending.


Bereaved families and witnesses attending an Inquest at a Coroner’s Court should have the same level of care, attention, understanding and empathy no matter where they are attending and it should not be left to chance as to what level of Service they receive or what information they are given. Families attending inquests are often ill-prepared for the experience and can find it deeply distressing and can have a negative impact on their grieving process. 


In the year to March 2019 there were 31,284 Inquests concluded in the 88 coronial areas. The CCSS volunteers attended 8,850 Inquests, supporting 58,427 people of which 23,875 were family members.


This means there are over half of the Coroner areas where the CCSS does not have a Service and therefore the support is not available at more than 22,000 Inquests. Bereaved families are going unsupported. The coronial staff do not have the capacity to give people the time and emotional attention they might need. To help with this, we officially launched our National Helpline in 2018 with a team of experienced volunteers who also support people in Court.  We recognised that for some, support would be extremely helpful at a much earlier stage of the Inquest process and soon after the death has been referred to the CoronerThe Helpline has enabled us to reach many more people even when we do not have a support service in the Court. Since officially setting up the Helpline we have had 1,063 calls with an average time taken to respond of 11.6 seconds.


The support we provide includes:





Despite overwhelming evidence that demonstrates the value our Service brings to the coronial system and how our support relieves the pressures off the coronial staff therefore making inquests more effective and timelier, we do not receive any central government funding. We rely on contributions from local authorities which cover a fraction of the cost of the Service and from grant makers who also contribute towards the costs.  Although we have been in talks with the Ministry of Justice since 2014 regarding funding for a national expansion, we are no further forward with this. As far as we are aware there are no plans by the MoJ or central government to establish a national Service or financially contribute towards its costs. Our financial situation is not sustainable and could result in bereaved families going unsupported in the future.


The Ministry of Justice in its Final report: Review of legal aid for inquests which was published in February 2019 stated as follows:


The Coroners’ Courts Support Service (CCSS), provides support to bereaved families at inquests. Its volunteers provide emotional and practical support, demystifying the inquest process and potentially making a huge difference to a family’s experience. At the moment the CCSS covers 44 of the 88 coroner areas and it has made clear to the Ministry of Justice that it would welcome the opportunity to expand to the remaining 44 areas. In its response to Dame Elish’s report the Government said it would consider the case for extending support services to all coroner’s courts. National coverage has been a ministerial ambition for some time, but it needs to be affordable and there must be a fair and open competition that allows other providers to bid for the work.


This year, subject to affordability, the Ministry of Justice will run a competition through which providers will bid for funding to extend support services so that they cover all 88 coroner areas. Our aim would be to complete implementation within two years of concluding the competition.


Despite our best efforts, meetings and correspondence with MoJ ministers and officials and fully preparing a competitive bid which, after the initial development funding, had the Government contributing approximately 40 percent of the total costs we were later extremely disappointed to be informed that the process would not be going ahead at that time due to the election


In 2014 the CCSS commissioned an external evaluation of its Service in which Coroners and their staff said that CCSS volunteers provided both practical and emotional support to bereaved families and witnesses attending inquests at their courts. Many of them described the practical support that CCSS volunteers provide; for example, they talked about how CCSS volunteers’ welcome families and witnesses when they first arrive and familiarise them with the court layout.


The CCSS volunteers clearly also provide invaluable emotional support to those attending court. Inquests can be upsetting for families and witnesses. Coroners and their staff valued the care and support that CCSS volunteers are able to offer to families and witnesses:


I find them providing emotional support when people are nervous and worried. They reassure them and that's not just families, any professional witnesses.

They assist in supporting family members - during the inquest, they are sitting in court and they let the family know that if they want to leave the court, they can signal to them. Also, if people do leave the court, you see the support service leave with them. 


Feedback from coroners and their staff about the support that CCSS volunteers provide for families and witnesses was extremely positive with many commenting generally on the support provided by the volunteers: 


They provide superb support to the families. 

They are there for anybody who needs support. That might sound obvious… so families who don’t have anyone with them. They are particularly good for witnesses.....witnesses don’t often have support. 

They engage with people, they're not in the background at all, anyone who needs their help they provide it. They're always here, right to the end.


Most of the families and witnesses who had completed the survey said they had found the support very helpful. Some had particularly appreciated the way in which CCSS volunteers helped them understand what was happening:


It's a strange and scary experience, being at an inquest for your own relative, and you're at a very vulnerable and anxious stage. So, it was very, very nice indeed to have someone to greet us and take care of us and explain the process and answer any questions we had. 


This was echoed by many of those who had written to the CCSS:


The volunteer was so helpful in explaining the procedure and looking after us throughout and afterwards. We couldn’t have got through it without her.

The volunteer spent a good deal of time discussing forthcoming arrangements and answering any questions leading up to the event. She even arranged for my sister and I to visit the coroner’s court ahead of the inquest date so my sister could familiarise herself with the setting. Her support and guidance helped keep my sister focussed whilst her kind manner kept things steady.


In conclusion, the government is determined to ensure that bereaved families are properly supported and able to fully participate in the Inquest process. In practice we know that this is not happening, there are still so many bereaved families, witnesses and others not receiving the support and are not able to fully participate in the Inquest process. The CCSS believes receiving support should not be a ‘postcode lottery’ but should be offered to anyone who might need it wherever they attend an Inquest.


  1. Fairness in the Coroners system


Bereaved families and witnesses may receive a very high standard of service when they attend a Coroner’s Court, but this should not be dependent on individual areas maintaining that high standard or not. The CCSS believes those attending should receive a certain level of service wherever they attend. This would make it easier for people to understand what service they are entitled to and what they can do if it doesn’t meet these standards. This will help to manage the expectations of bereaved families. All Coroners’ Courts should have a range of faith books. However, there is inconsistency with some areas having one holy book available leaving the witness little or no choice and often will have to affirm as an unsatisfactory alternative.



September 2020