Written evidence from RoadPeace


RoadPeace is that national charity for road crash victims. We support families bereaved by road crashes, and campaign to reduce road danger. We have campaigned for all families who have had experience with a coroner to be asked for feedback. Only then will we be able to know for sure if reforms are working and bereaved families truly are at the heart of the process.

This evidence is submitted in conjunction with our members who have been bereaved by road crashes. We are grateful to all of our members who have written to us on the issue. And thank the Justice Committee for looking into the effectiveness of the Coroner Service.

RoadPeace has answered your questions based on the many phone calls we receive from bereaved families on our helpline, and the experiences shared in support groups. Members have kindly submitted responses, which we have included in Appendices at the end of our evidence. We have included them verbatim as feel that coming from bereaved families, they encapsulate the problems crash victims face. 

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

RoadPeace and our members support a National Coroner Service. Like the Chief Coroner, RoadPeace wants a national coroner system so road death inquests are consistent and bereaved families receive the same good standard of service nationwide.

One of our bereaved members, who is a nurse, described the Coroner Service like cancer treatment in Britain “there is such a big variation - it’s like a postcode lottery”.

And she is not alone in that interpretation. The victims who call us up frequently complain of the treatment by Coroners. Experiences vary wildly across the country. Please refer to appendices to read examples. Of particular note is a campaign carried out by two bereaved members, on the issue of second post-mortems. The inconsistency in approaches by coroners across the country, details in appendix F showcases the unevenness of the coroner service.

RoadPeace holds that it is unjust that a body set up to deal with people in their greatest time of need is not publicly regulated to the extent other agencies are. In particular, the fact that the Coroner Service does not subscribe to the Victims Code of Practice is unacceptable. Read our response to the recent VCoP consultation here.

***please consult appendices for specific examples of local failures**

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

As a crash victims charity, RoadPeace cannot answer this question.

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

RoadPeace thanks two members - Chris and Nicole Taylor, for their analysis of Preventing Future Death reports.

They have submitted their full response to the committee - which we urge you to consider.

RoadPeace backs their findings, and calls out the following as areas and issues to deal with:

       For every forty deaths on roads in England and Wales only one is reported by a coroner as being preventable. This is not right. All road deaths are avoidable - and it beggars belief that so few receive a preventing future death report.

       Over 50% of coroners raised less than 3 Preventing Future Death (PFD) reports related to highways safety over a 7-year period

       30% of coroner areas issued over 50% of the PFD reports with a category of Road (Highways Safety)

       There should be a Road safety inspectorate to monitor whether the work promised and carried out by the transport authority is adequate to Prevent Future Deaths.

       An example of the Transport Authority not following up on the PFD: at Euston, Simon Wickenden filed a report showing that the intervention by Camden following the PFD request had no significant reduction in speed; TfL had no idea of the whereabouts of the follow up report. There needs to be systematic follow up and monitoring of the recommendations made in a PFD.

       Recommendation for how to improve the Judiciary.uk site where the PFDs are published would be to include a map functionality and also tag reports so it's easier to search e.g. 'pelican crossing', 'london'. It is currently impossible to search for PFDs which include certain types of recommendations.

       The responder of the PFD request should include:

       the contact details of the person responsible for the execution of the recommendations

       a timetable for the planned schedule of works

       Court lists - The quality is variable because the Chief Coroner does not inspect and does not bring to account the Courts who do not follow the guidelines. Moreover, the Category of death should be included in the lists, to simplify the work of the media and those organisations that have an interest in the hearings.

       The majority of Preventing Future Death reports in road traffic collision cases are directed at the local authority with regards to road layout. However many collisions are due to driver behaviour or other factors, which are not within the local authority’s jurisdiction. Training and guidance should be given to Coroners on this subject.

       Every road death should receive a Preventing Future Death report.


4.     How the Coroners Service has dealt with COVID 19

As a crash victims charity, RoadPeace cannot answer this question.

5.     Progress with training and guidance for Coroners

RoadPeace has not recently been approached by the Coroner Service regarding training and guidance for Coroners. However we feel very strongly from our work with victims that further training is required in terms of how victims are treated and spoken to (see appendices).

We are also aware that a national coroner’s conference is held every year. We would like to recommend and put forward bereaved families to attend the conference and speak at it.

We welcome the guidelines that were issued last year by the Chief Coroner, clarifying whether and when second post mortems should be allowed.

However guidance is ultimately just guidance, and as it’s not a requirement for Coroners to abide by the guidelines.

It is paramount that a national coroner service is introduced to address this.

Any basic training must stress the importance of speaking up and making eye contact with the bereaved family. Too often families are left isolated with poor acoustics, coroner mumblings and the focus on paperwork rather than the bereaved.


6.     Improvements in services for the bereaved

There are many things that could be done to improve the services for the bereaved. Including:

-         As a priority - the coroner service should be subject to the Victims Code

-         Access to evidence prior to the inquest, so that families have time to prepare to ask meaningful questions

-         Up to date information leaflets. Victims have reported that in one court, the leaflets were so out of date they had gone brown.

-         Consideration given to the environment of the court. It has been reported that one court was “ten times worse than a GP surgery reception”.

-         Consideration given to the religion of the bereaved family. We have heard of instances where the body has not been relinquished in time to uphold religious practices.

-         Leaflets for support services should be available in all courts. RoadPeace leaflets should be made available to all families bereaved by road crashes.

-         Bereaved families should be at the heart of the service that Coroners are delivering. Coroners should have key performance indicators.


Suggested Coroner KPI


-         Website with inquest dates and findings, including PFDs

-         Pro disclosure policy publicised

Bereaved at the heart

-         Encouraged to attend opening and another inquest

-         Allowed to give opening statement

-         Encouraged to give feedback with standard survey used

-         Respect request for verdict, unless not possible

-         Respect request for PFD, unless not possible

-         Stakeholder working group


7.     Fairness in the Coroners system

Fairness is a broad word. The above and the appendices address the issues that crash victims have faced. However RoadPeace feels that beyond addressing these issues, fairness is something that needs to be monitored through surveys with bereaved families that experience the Coroner Service. We are calling for:


-         a stakeholder working group. This should be established to help develop coroner performance indicators, in order to ensure bereaved families are at the heart of the coroner system. Equally, issues within the community should be held at this working group. The community should be encouraged to give feedback, and given that Preventing Future Death reports affect the whole community - coroners should be more open to hearing their concerns.

-         regular surveys of families experiencing the coroner service.

-         an appeals process. Once an Inquest has been held, the only way to challenge the coroner's verdict is by judicial review. Similarly, complaints about coroners' personal conduct must go to the Judicial Conduct Investigations Office (JCIO). Two major improvements in services for the bereaved would be: an appeal process for Inquests and for the Chief Coroner to be responsible for the performance management of all coroners.


It must be remembered that the majority of road deaths do not result in a criminal prosecution.

Inquests are the only chance for many to find out what happened to their loved one, and they deserve a system that is transparent and treats them with compassion.


All appendices are verbatim from bereaved families. Some have chosen to remain anonymous.



The Justice Committee call for evidence

To improve how bereaved families are treated by The Coroner Service

On behalf of my daughter, MELANIE LAKIN, age 29, victim of a fatal RTC on 1 June 2014, Welshpool, Powys.

My response below is for questions 1, 6 and 7 and potentially question 5.

The entire experience of my daughter’s inquest, held on 26 June 2015 in Welshpool by Mr Andrew Barkley (at that time HM Senior Coroner Powys, Bridgend and Glamorgan Valleys) and the two pre-inquest hearings was one of immense and disturbing disappointment, from the confused, incomplete and inconsistent information from the coroner’s office/officer prior to the inquest to the flawed inquest itself, all of which fell far below the standard I was expecting as a bereaved parent.

I have numerous criticisms of the coroner service I experienced but one of the main issues is with the response by the coroner and coroner’s officer to the non-attendance of two key witnesses at the inquest. The implications of the failure of the two witnesses to attend the inquest was not explained to us, the bereaved parents, before or during the inquest. Mr Barkley asked one question; if we objected to the evidence being read for the record. We were “put on the spot” forced to make a quick decision to a question, the significance of which we did not understand. We were not offered a short break to seek advice in order to reach an informed decision as to our response. We were denied the opportunity of a fair inquest, denied the opportunity of questioning two key witnesses. After the inquest I raised the issue of the non-attendance of the two key witnesses in an email to the coroner’s officer and after a lengthy delay of FOUR months I was eventually informed in a brief email from the coroner’s officer that the two witnesses had moved address and had not received their summonses. I replied expressing my firm belief that serious failures had occurred in the coroner’s office’s procedures for ensuring the attendance of witnesses at an inquest including the fact that we were deprived of the opportunity to question the two key witnesses. Mr. Barkley eventually acknowledged that his coroner’s officer failed to check whether the witnesses had received their summonses and apologised for the “error.” We remain disillusioned, disappointed and frustrated by an experience that has intensified the pain of the loss of our daughter.

I wrote twice to the Chief Coroner, HHJ Mark Lucraft QC stating my concerns, and a section of his subsequent reply by an assistant private secretary, stated that “All coroners and

coroner officers attend annual training to ensure that relevant practice and legislation is being shared.”

I sent an email query to the Coroners’ Society, Hon Secretary Andre Rebello, requesting clarification of any national standard administrative procedures in all Coroners’ offices in England, and his reply included the statement … “The Senior Coroner is responsible for the administration of the coroner’s service … “

I have discovered that there are no formal qualifications required for the role of a coroner’s officer. They may be serving police officers or civilian police staff or local authority employees, so the terms and conditions for the role are not standard, nor are the job descriptions or roles and responsibilities, resulting in a large variation in the role across England and Wales. This is not acceptable.

I therefore submit that the coroner service is desperately in need of an overhaul. Whatever changes were implemented in 2013 my experience has exposed serious weaknesses in the conduct of an inquest by the coroner and office practices currently adopted by some, if not all, coroners’ offices in England and Wales. The apathetic responses I have received in my pursuit of answers clearly demonstrates that a more efficient and empathetic inquest system which, unfortunately, from my experience, I did not receive, is long overdue.

Pam Lakin

27 August 2020





In May 2019 my Mum biked back from the Co-op. As she passed a Give Way junction, Mum having right of way, a lorry overshot the junction knocking Mum off her bike. She died instantly when her head hit the road. I saw my Mum lying on the road under a blanket, her possessions strewn across the road, her boot in the gutter, her prosthetic breast on the floor, her blood trailing across the tarmac. Mum was 74. I’ve always been a ‘glass half empty’ sort of person. But on this day, someone kicked my glass over, spilled all the water and stabbed me with a shard of glass.

14 months have passed- to date we only know scant details about the driver or what happened, which we were told mostly on the day. We declined to know the driver’s name, in case we somehow affected any prosecution – yet his family, friends, employers, people local to him, all know what he has done. My first issue with the system has been the length of time everything is taking - we don’t even yet know if the driver is to be charged and this lapse of time adds to the distress of the family. It feels like Mum doesn’t matter. It also means that it’s always on your mind, no hope of beginning some sort of closure. We are suing the lorry company for our loss of Mum. Some people are surprised at this, thinking this somehow reduces the level of our grief. However, at this point in time this is the only redress we have against the person who did this. His life has carried on- he is even allowed to carry on driving. Further, I was staggered to find that although we can claim on behalf of the estate, that other than this there is no automatic payout to close relatives. You have to prove each person needs to claim- the loss itself isn’t enough, causing additional stress. I was put in the position of having to tell my sisters that, in law, their loss didn’t matter- I was only able to make a case of PTSD because I attended the scene. And we are going to try to make a case for my brother, who was dependent on Mum – but we have to somehow prove that he deserves a payout. There are limits written down as to what can be awarded as well. This all seems wrong and seems to have been designed to protect businesses and insurance companies from massive payouts, neglecting the victims. I do not feel that because Mum was a 74 year old single woman, that a pay-out should be less than anyone else. It again feels like Mum doesn’t count as much as anyone else.

Losing Mum was bad enough, but losing her like this multiplied our grief. Mum had to have a post mortem and because the Coroner held Mum’s body we had to travel 15 miles to do the formal ID. We were not either allowed to touch Mum, no goodbye kiss or stroke of the hand. This also meant a delay in Mum being released to the funeral parlour, so by the time they had organised the coffin, it was 3 weeks on. My sister saw Mum then had to advise my other sister and her daughter not to see Mum, it was too late. So my sister who lives away never saw Mum again. Further was the stress of the driver’s legal team being allowed to consider a second P.M.- no-one knows how awful it feels for the person who killed your loved one to have power over their body. There will be a trial or inquest, another ordeal.

Mum’s death rocked the little town where we live and the public nature of it was sometimes comforting, but brought bad moments too – the girl who taunted my son that his Nanny ‘flew up in the air’; the person in the shop queue who was heard to say that the accident involved ‘some old woman who shouldn’t have been on the road’(not true); some people thought it was my daughter who had died; a relative heard that Mum had literally been run over and had been waking in the night in horror; seeing her photo on the front of the local paper; my children breaking down at school. All because of the way in which Mum died.

The impact on our family will be felt for generations. Mum had 4 children and 5 grandchildren – she should have died in her bed, with us around her, holding her hand, not lying on the cold hard road, her last thoughts of panic and of the sensation of people pounding on her chest. She did not deserve to die so early, let alone in that way. She had everything to live for. She was still incredibly active. She ran and supported her house herself, kept my brother, still had a job and took sewing work in at home. She loved gardening, baking, knitting, crafts. She sold plants and knitted items for charity. She had two dogs, a cat and an aviary of birds. And most of all, she lived for her family. She was my daily companion for shopping trips, car boot sales and visiting others; my sister’s holiday companion; my other sister’s reference point for the sewing business she is setting up; her grandchildren’s beloved Nanny. All this was taken away from us in an instant and losing her so suddenly has devastated us all. For myself, I feel that the light has gone out of my life. Not having Mum is painful enough, but knowing that someone killed her, I would go so far as to say murdered her, has not only increased the pain of her loss, but has made it so I can’t accept it, as I would have accepted the death she should have had from old age. I have agonised with guilt for not being there in time, indeed for not preventing it, by perhaps taking her on the holiday she had hinted at. I have been over and over what I think happened, still trying to make sense of why, why, he didn’t stop. I have worried about whether I said ‘goodbye’ properly the last time I saw her. I have had nightmares about Mum and death and flashbacks to the scene, images of how she fell in such a way as to hit her head so badly. I can’t visit the places we used to go to; a lifelong reader, I can’t read books at night anymore as they don’t absorb me enough to stop bad memories popping up; I get angry sometimes, because I feel robbed of the many more years Mum should have had (her parents and many aunts and uncles all lived well into their 80s or even 90s) - I get angry for Mum too, at all she had taken away from her; I sometimes struggle with driving, shying away from lorries so much I worry I will have an accident myself and hurt someone- this isn’t helped by the fact that unless I go out of my way, I literally have to drive daily over the actual spot where Mum died, which regularly makes me burst into tears- nor is it helped by the fact that the lorries from the same company appear regularly locally, when I slow my car and stare at the driver and wonder, was it you?? Good memories only bring forth the bad ones, so I try not to think about Mum at all. I have taken down all photos of her. I have been on sleeping/anti-depressant pills for the last year and am now undergoing CBT therapy for the PTSD I suffered from seeing Mum at the scene. Losing Mum in this way has completely altered the way I think about life. Someone can go to the Co-op and not come back. I’m literally waiting for the next bad thing to happen. My Mum worked hard all her life, she was still incredibly active and yet she had this happen to her. What’s the point of trying to live a good fulfilling life or working hard or looking after your health, when you can just be wiped out? My relationships are damaged. My partner and children now live with someone who bursts into tears at all sort of things, who is scared to let the children go far, who is depressed a lot of the time, little interest in doing anything and scared of going anywhere. I can’t see how to be upbeat anymore, so I think eventually these relationships will suffer. I’ve spent my adult life thinking about how to help Mum day to day- why wasn’t I there to help her? I let her down- I didn’t get to say how much I loved

her or say goodbye or be there to hold her hand. I cry almost daily still, sometimes multiple times. People are now expecting me to be ‘over it’, but though I have to keep breathing and therefore alive, I do not feel that I shall ever recover from this loss. I don’t just ‘miss’ Mum, I feel like a part of me has been amputated.




6. Improvements in services for the bereaved

i) Make the coroners decision not based on that of a single person.

ii) Provide the option for the families to have access to the evidence to be presented at the inquest prior to the inquest so that they have time to ask meaningful questions on the day. For me, the inquest was the first time I found out what actually happened / how my partner was killed and as such I was in no emotional state to ask any intelligent questions. After reading the full version of the forensic investigators report obtained from the coroner a few days later I realised that the coroner had omitted some information from his statement which indicated to me that the police investigation was biased in favour of the driver. Had I known about this information prior to the inquest I would have challenged it.

7. Fairness in the Coroners system

Once the coroners decision is made it cannot be challenged. How is this a fair system. All the coroner (and every other authority concerned) were intent on doing was closing the my partners inquest and moving onto the next one knowing full well that the decision cannot be challenged. Like a conveyor belt production line.




1.  Coroners have such enormous power over inquests, there is no scrutiny whatsoever of how they handle inquests or what decisions they make and why they make them which in turn affect so many lives. There does not appear to be any regulation or accountability and varies from coroner to coroner.


From our own perspective gleaned from experience in our ongoing inquest regarding our daughters death, we have no where to turn to (Judicial Review is not a realistic proposition for the majority) in order to question (in our view) the Coroners bias and the Coroners seemingly dogged determination to hold the inquest by her own individual rules and not the Coroners rules.


The fact a Coroner is not accountable to anyone but themselves is absolutely absurd, it cannot possibly be seen as appropriate open and fair justice as the majority of the public would assume it to be so. A National Coroners Service would benefit all inquests to be effectively and fairly monitored with regulated guidelines to follow which in turn would be available for public scrutiny.


As far as we aware costs for inquests are funded by local authorities and  therefore creating an ‘uneven playing field’ The whole system needs to be restructured, financially and systematically to enable fairness and impartiality for all parties. An effective National Coroners Service would effectively be the ‘kingpin’


2. No comment.


3. Appropriate training is absolutely necessary, again this reverts back to the need for a National Coroners Service to be implemented.


Funding must be also addressed as extra time has to be allocated in order to compile PFD reports. 


4. No comment.


5. Absolutely vital. This needs to be implemented with immediate effect with appropriate interim reports made available to the public.


6. There do not appear to be any special services for the bereaved? We were told we would be (as the family) at the centre of the inquest but the reality has been the complete opposite. We have and still are (in our view) at the bottom of the pecking order in the Coroners eyes. We have been treated with disrespect and other IP’s have been given preference which should never be the case.


Coroners need to accept and understand the fact families are IP’s but not solicitors or more importantly barristers. It can be very overwhelming overpowering and unnerving when trying to make oneself heard fairly in a courtroom. If families cannot afford representation then the system itself is at fault. It becomes almost impossible to interact at the same level and in turn completely unbalances the scales of open justice.


7. The points made in the above answers also cover this last question but again, from our ongoing experience we have seen first hand unacceptable unfairness shown towards the family and outright bias shown towards other IP’S who are or who have the weight and might of the law and/or intimidating barristers behind them.


Again, Coroners can decide what to address, whether they want to divulge relevant answers or not for whatever reason, whether they are willing to send documents which have been requested for valid reasons, all on their own terms without any recourse.


We have never ever been subject to such unfairness in anything we have encountered in any other walk of life. To experience this in a Coroners court is simply incomprehensible. We have respectfully tried to find answers but feel we have become ‘thorns in the Coroners side’ The more we push for answers it seems the more disrespect is shown to us. Whilst we are fully aware of the seriousness of the court, the lack of respect and fairness is and has been to date.....nothing short of breathtaking. We genuinely pity anyone who has to endure the system which in our wildest dreams we never anticipated to be enduring at present.


To endure this alongside still trying to come to terms with the traumatic death of our beautiful daughter is without question the worst and most distasteful legal experience of our lives which will never leave us. How can this possibly be allowed to happen and continue to happen in the name of open justice and fairness???





Thank you for giving me the opportunity to have a say,I had to attend my son's inquest into is death ,he was hit by a lorry on Xmas eve 2016 and died instantly.Alex Postolowsky my son's fiancé and myself had to go Nottingham . As you may realise this in its self was horrible .The coroner did not display much emotion for the bereaved.The worst part for me was when she read the postmortem out every little detail was read out which upset me .She was most instant about the amount of alcohol my son had drank and more or less it was his fault.There was nowhere to speak privately we was put in a corridor where the lorry driver and his solicitors where which was not appropriate,some of the evidence was not all read out and when leaving we had to pass the opposition where they where congratulating him for not being prosecuted.There was also a mix up and delay in the paper work for releasing my son's body.I felt the system was all one sided and it needs to be changed so other families do not have to go through the trauma of coroners court.Than you for giving me the opportunity you helped Alex and myself to go through a part of our lives that would not wish anyone else.




There is huge variation in approach, attitude and interpretation of the law from coroner to coroner. When Elaine and I wrote to the coroners – there were essentially three types of response:

· No response at all – is it reasonable for a coroner to point blank ignore a letter from the public?

· A response which defended the right to a second post mortem, often believing the right to one was law (incorrect), and of the belief that not allowing one would cause a court case to be damaged (the Chief Coroner confirmed to us saying no to a second PM would not damage a case)

A very sympathetic response, stating that they did their best to not allow them, or limit the time, and agreeing that second PM’s were of no value in road death cases – we could find no example of a second PM actually changing the cause of death or outcome of a case after a RTC

It took the two of us months, and a meeting with Prof Rutty to actually establish that there wasn’t a law saying the defendant has an automatic right to a second PM (the police had told us there was, as had Philip Lee MP who was Under Secretary of State for Justice). Why was this so hard? Why were the coroners not all clear and in agreement on what the process was, how it should be carried out, and what the grounds for allowing or not allowing a second PM was? It was utter chaos - I have never known anything so ridiculous. These things should be clear and have clarity – how on earth are families meant to understand coronial decisions when there is such discrepancy and disagreement amongst the coroners themselves? The coroner Mark Bricknell wrote that he knew of no second post-mortems that had taken place against the wish of the family – how incredibly out of touch he was.

When we met Prof Rutty, and as per his letter – it was made clear, if Peter and Gina had been killed in Leicester or Northampton – the delays in releasing their bodies would have never occurred. This is an excellent reflection on the coroners in those areas, but left us feeling sickened that Peter and Gina basically became victims of a postcode lottery – their dignity was taken from them because the coroners in the areas in which they were killed were offering/allowing consideration of second PM’s as though this should be standard practice.

The PM report carried out on my brother was abundantly clear – he was a fit and healthy man with absolutely zero underlying health conditions or problems discovered. He was killed because of the most horrific injuries clearly caused by being hit at considerable speed – there was no ambiguity or grey area – why would the coroner therefore retain his body for as long as 6/7 weeks – despite being aware of the family’s distress. Disgraceful.

There was no way to appeal or challenge this decision – as a family we were left helpless, and actually told that pushing for the release of Peter’s body would do more damage than good. Is there any other system in the country, where there is no way to challenge a decision? The coroners are untouchable and all powerful, and this is fundamentally wrong. I believe, that we perhaps could have pushed to go to the high court (not one hundred percent certain), but in reality what normal grieving family will have both the financial means and the emotional strength to do this in the aftermath of a bereavement? When we met the Chief Coroner, he did say if families felt unfair decisions were being made, they could contact him – but again, why should the onus always be on a bereaved family to do this? Surely the system should just be clear, and information be provided to the family in an upfront manner, in order to remove as much additional upset for them as possible.

Elaine and I tried several times to meet with the Birmingham coroner Louise Hunt. Our letters and emails were of a very polite manner. We always received responses saying she was too busy, and did not meet with members of the public, and that the matters we raised were for the Chief Coroner. I would go as far as to say her secretary, who responded to us, was borderline terse and rude.

When we first wrote to the Chief Coroner, which I believe was in the September, we received a quick reply to say he was considering our letter and would work on a full response to us, to be received by the November. This never came. We chased and received no response. We sent email after email after email, always polite. No answer. We wrote a letter and posted it recorded delivery, it was received and signed for – no answer.

When we spoke to Baroness Newlove, one of her first questions to us was have you contacted the Chief Coroner, when we told her we were being ignored she asked for us to send her the email chain, which we did. She was very upset by this, intervened and secured us a meeting with the Chief Coroner. We are thankful for Baroness Newlove, but why was she answered so quickly, when we were ignored for months? During the meeting we told the Chief Coroner that the Birmingham Coroner was refusing to see us – his first response was that this was Louise Hunt’s choice and he could not in any way enforce a meeting. Again, Baroness Newlove intervened and was angry at this – she asked why not, why is a coroner refusing to see two polite and well-mannered victims, who simply want to understand why there was such a delay in being able to have funerals for their siblings? The Chief Coroner did look slightly taken aback but quickly changed his tack saying he would speak to Louise Hunt, and after this meeting we did finally see Louise Hunt face to face.

Again, why was this all so difficult? I believe that the coroners are a very weird mismatch of being appointed by the crown, and yet funded by local authorities, and basically public money. There is no other public service in which no checks or balances would be made, in which there would be no accountability or clear appeals process. There should be no reason why people cannot talk direct to the coroner/coroner’s office about their loved one, and no reason why the decisions a coroner makes should not be challenged? At the end of the day, if a coroner can clearly justify their decision-making process – what is the problem with being open and transparent?

Professor Rutty explained to us how no audit on coronial decisions took place – an audit or some kind of annual random review of cases would be a clear way to improve the service. The coroners, like everyone else, must become open to scrutiny, evaluation and feedback – how else will this service ever improve or become fit for a modern world? Moreover, the coroners do not keep any records or statistics on second post-mortems, or the length of time for bodies to be released. Due to this, Elaine and I had a real issue in proving there was a problem. The coroners would simply come back saying that second pms and delays were very rare – but this was purely their opinion. We knew, there were many families in RoadPeace terribly affected, and Brake told us it was one of the most frequent reasons for calls to their helpline – but we simply were not believed. Statistics and proper records should be kept and made public – and this should be done as a matter of urgency. Many MPs including Preet Gill, Rachel Maclean and Richard Burden tried hard to challenge the coroners – but the reality is even MPs have no power against them. This must not be allowed to continue. Indeed, even the Chief Coroner can only provide guidance and recommendations – and cannot enforce anything.

Then we come to the method of using scanning – so many coroners seem to have an entrenched view against this – when it is being used in many areas successfully. We can accept scanning is not appropriate for all deaths, but it is for road traffic collisions. In Birmingham, they now have an agreement with IGENE who own the scanner in Sandwell – a CT post-mortem including transportation of the body costs £238, as opposed to thousands for a traditional invasive forensic one. Surely not utilising the CT method, where it is available and appropriate, becomes a waste of public money. We have had some difficulty getting the coroner and the council to accept that grieving families do not automatically know that CT scanning exists – so the council and the coroner should advertise this service, and make sure they present it to families as an option (where appropriate) – they seem unwilling to accept that they need to make this info available, rather than wait for a family to think to ask for it. If the service was advertised more, I am sure more people would choose this over an invasive PM, where possible, even if it had to be at the expense of the family – I would imagine it would be hugely popular with faith groups particularly against the cutting up of the body. When a person is seriously injured and rush to hospital – they will inevitably be sent for a scan to pinpoint what the injuries are. If this is good enough for the living, why not good enough for the dead?

Finally, in Birmingham, the coroner has made a huge fuss about the state of her court and viewing room etc. Elaine and I were actually shown the viewing room as a part of our meeting with her. There is no doubt the building is in disrepair, crumbling and in an undesirable area of the city, with no immediate access to parking. With this in mind, we support her calls for a new facility. However, some of the things she complained about were ridiculous – old dusty plastic flowers and an uncomfortable viewing room – I could never understand why not just throw the flowers away, and give the room a paint, to at least make it slightly better.

Finally, in Shabana Mahmood’s report, she calls for a citizen’s bereavement group to provide impartial oversight of coronial decisions – this is an excellent idea, it ought to be taken up across the county.




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

The time allowed at the inquest is very short. Presumably this is due to volume of cases. This may lead to inaccuracies and certainly I felt it did in our case. I felt that facts presented by the police and possibly others were not 100% accurate and that the coroner did not have sufficient time to assess this evidence or query facts. He took the information presented to him as gospel and possibly it should be, but in our case I don’t feel the information was accurate. This was extremely stressful as we are allowed little interaction, even through a representative such as a solicitor. The coroner’s role could be strengthened by a better support system and more liaison between all parties prior to the inquest. Most probably time and money will be the decider and probably have been to date, ultimately leading to a poor system which is inadequate and unjust. Until an accurate reporting system is in place, the Coroner is in a weak place as this appears to be what he relies on. Future deaths will only be avoided if mistakes are accurately reported and accurately acted upon.

4. How the Coroners Service has dealt with COVID 19

5. Progress with training and guidance for Coroners

6. Improvements in services for the bereaved

I would suggest there is vast room for improvement for the bereaved at inquests. It is an austere, cold, unpleasant environment in which to place someone suffering from grief. It is stressful not only to hear the whole series of events again, but possibly to hear inadequacies and inaccuracies. However polite or apparently sympathetic the coroner may appear to be, the need for professionalism and the ‘distance’ that this requires must lead to an atmosphere which is not altogether helpful for those who are grieving and possibly suffering from post-traumatic stress. There is no system that I know of where the bereaved are automatically cared for. It is always up to the bereaved to go out and seek help and guidance from charities and counsellors. This is appalling given that ultimately, we are all likely to be bereaved during our lifetimes, possibly multiple times.

7. Fairness in the Coroners system

See 3. From my experience, I don’t believe the Coroner can be completely fair as I don’t believe the information he receives is always accurate or completely inclusive. In our case I felt the whole process was designed to ensure that the least possible effort and money could be spent. The process was about apportioning guilt rather than improving the situation. Because out of the two separate car drivers involved one was deceased, it made it easier to make the situation for the surviving party more favourable and give less blame to that party.




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

I did find that the process was quite laborious, my Husband died in a RTC and the communication between the Police and the Coroner was quite disjointed. I felt that the Coroner could have put more pressure on the Police to conclude their investigation a lot sooner and should have addressed this. My case was opened in Liverpool, then it was transferred to Southport. When the Southport Coroner Office called me they asked me questions that I had already told Liverpool Coroner Court. They asked me whether I had made arrangements for my husband’s body to be taken from the hospital when at that point he had been dead for a year, we had had the funeral and were deep into the grieving process. I found this distressing there was clearly a miscommunication between the two regional offices.

I was lucky I had a solicitor at that point because she arranged for it to go back to Liverpool we request that they keep it in Liverpool because this is where it had began. It added to a stressful situation. The case opened in December 2018 and concluded at the end of February 2020 when I eventually was issued with a full death certificate.

It is distressing enough having to go through this and I understand that Coroners only have capacity that is given to them, the Liverpool and Southport Coroner Courts are relatively small.

The Coroner’s Officer who I dealt with in Liverpool was very, very helpful. When it did get to an inquest and we went to the Court, they were very helpful and sympathetic, it is overwhelming.

Overseeing this nationally I think would be a good idea, there should be some more timeframes, frameworks and guidelines in place when cases are running with a criminal case element, I was left in limbo for such a long time. It was a year before the criminal investigation concluded, there were so many delays, RTC death investigations are not given any degree of priority. Had this been a murder or something else it would have been dealt with.

Insurance and Pension companies will not deal with anything until they have had the Coroner’s inquest completed as well so I was for a time in financial hardship. They told me that they needed to be sure that I wasn’t involved in his death so they needed the Coroner’s Certificate before they could pay me the pension my Husband had saved for 28 years.

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

I cannot comment on this, my experience was from a single death

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

This is a difficult question to answer in my circumstance, I could have done with the Coroner making a recommendation to the Local Authority to look at the speed limit in that area and road safety measures. The stretch of road my husband was killed on has had a number of incidents and the Coroner should/could be able to make recommendations to the Local Authority about these which should have been investigated and reported. There should be some degree of weight behind their recommendations.

4. How the Coroners Service has dealt with COVID 19

I cannot comment on this my experience was from another form of death

5. Progress with training and guidance for Coroners

I feel like the Coroner’s hands are quite tied with their decision making processes and what they can put on death certificates.

I did find that the Coroner who dealt with our case was sympathetic, she did make me feel at ease so I think she would be a good example to use as someone who has got it right.

I suppose it is an underfunded system and not given the support that it probably needs to have. It is important to families to get some truth, some answers that they may not find or have justice anywhere else in the civil or criminal system.

The delays, were unacceptable this should have been dealt with quicker, the Police and the Coroner Court did not work well together I felt, they need to marry up much better and quicker in tragic and traumatic cases. So I would recommend some partnership training and working together to deal with cases. There should be guidelines in place and a timeframe to make sure cases don’t drift. Criminal and Civil Courts have strict protocols that are followed I don’t find that the Coroner Courts have that level of adherence sometimes when they are especially dealing with very delicate matters.

There should be more ready access to support not just from the Coroner Assistant, in the end I had to get a solicitor.

6. Improvements in services for the bereaved

As above, I think that there should be more explanation, a support call from someone who understands the system and can explain. I think the Coroner assistant has that many cases it is unfair just to rely on them to manage the case and support.

Perhaps more information can be given to the Police and a referral service in place, victim support I think may assist but I just wasn’t sure. I was lucky I had solicitor, friends and family support but not everyone is lucky to have that.

7. Fairness in the Coroners system

It was a difficult case, the witness evidence that was available wasn’t great. I did find it difficult that we couldn’t ask some of the questions of the Driver that we wanted. We were stopped because the Coroner pointed out that it was a fact finding inquest and not a trial.

Its on balance of probabilities so they are as fair as they can be. I didn’t feel that it was fair that the Driver got away scot free, no points on his licence, no retake of his test, no fine, nothing and he killed my husband, he was speeding on balance, he was speeding and he has just been left to get

on with his life. In any other circumstance he would have points and a fine, yet he has killed someone and no consequence. So this to me is unfair and someone in the system should be allowed to make a finding.

Admissions made by any party should hold weight in civil or criminal cases as well.


September 2020