Written evidence from Professor Catherine Mason Senior Coroner for Leicester City and South Leicestershire

The extent of unevenness of Coroner's Services, including local failures and the case for a National Coroner's Service

Underfunding of a national service would reverse all the great work already done.

The coroner’s service’s capacity to deal properly with multiple deaths in public disasters.

Coroners have always been at the centre of mass fatality public disasters.  Every coroner has undergone a specialist training course as part of their mandatory annual residential training.  Coroners officers have also had very similar training.  Annual in-house training is given and local exercises attended. Two Coroner’s officers are nominated DVI Coroner’s Officers and at least one is always available to provide immediate assistance. I have produced and maintained a Mass fatalities Guide for Coroners which is available locally but also shared with all coroners via the Coroners Society of England and Wales Website. The coroners service is better prepared than ever to work with emergency responders. 

How the coroners service has dealt with COVID 19.

Coroners have always been involved in excess death management.  Although it is not a statutory duty for coroners it is a particular area where emergency planners have looked to coroners for guidance, advice and support.  COVID 19 is a naturally occurring disease and although a natural cause of death, other stakeholders would look to the coroner for timely assistance.  Coroners have been extensively involved with deaths arising in the pandemic because it was the public health emergency and coroners had the necessary expertise.  A significant increase in the number of death referrals came about.  Coroners also had to adjourn any inquest listed for inquest as facilities did not permits social distancing.  That was predicted problematic.  Coroners work seven days a week over several months to maintain mortuary and funeral capacity in a collaborative way with all relevant stakeholders.  Although coroners’ services may now be at the recovery stage it is slow and the backlog of inquest hearings is considerable.  Coroners services are also wary about the prevailing infection rate on and the possibility that it may worsen.

Progress with training and guidance for coroners.

All coroners and coroners’ officers undertaken training by the judicial college with course directors from within coroners and officers under the direction of the Chief Coroner.  It is mandatory. The training is of high quality and covers a wide range of topics to promote consistency.

Improvements in services for the bereaved.

The Chief Coroner has brought a consistent guidance on a variety of topics.  This is very useful for coroners themselves but also for families and lawyers as the various documents can be referred to and are very clear.

More guidance and a bench book will promote further consistency.

About ½ Coroners’ Services have the excellent support for bereaved families and others from volunteers of the Coroners Court Support Service (CCSS). Further funding would extend CCSS to all coroner services.

Inquests are inquisitorial public hearings many of which have no lawyers involved. There is no place for an adversarial line of questioning although robust and difficult questions are often asked. Coroners like many other judges develop their court craft. It is for the lawyer to adapt to the needs of the witness not the other way around.

Local failures

I am unaware of any local failures in my Coroner Area that are of sufficient size to interest a Parliamentary Committee. However, the Committee may wish to be aware of the following successes generated at a local level with no national input:

  1. Post-mortem scanning

Since 2017 Leicester’s Hospitals in conjunction with Leicester City Council and Her Majesty’s Senior Coroner changed their approach to post mortem investigations.

Whenever possible, traditional post mortem examinations have been replaced with less intrusive alternatives, such as using a specialised x-ray technique known as Post Mortem Computed Tomography (PMCT). This pioneering approach was introduced in response to the wishes of the community and is free to families at the point of delivery 

The breakthrough was made possible after a long period of planning by HM Senior Coroner for Leicester City and south Leicestershire, Leicester City Council representatives and the radiology and pathology management teams. They managed to develop this service within the constraints of public funding and without impact on on-going clinical services.

The scan is reported by a Consultant Radiologist who gives their opinion on the cause of death to a pathologist who provides the cause of death to the Coroner. 

In conjunction with University of Leicester, the mortuary, radiology and pathology teams at Leicester’s Hospitals have developed techniques that have shown that PMCT can replace or enhance the traditional post mortem in many circumstances.

  1. Paperless system

In December 2019 a database was introduced into the coroner’s system which has meant that the information received on the initial death reports from the hospitals is transferred directly into the Coroner’s database without any additional input or data being involved.

Since the introduction of the database no new paper files have been created in the Coroner Area for Coroner's investigations and all information is held digitally on the system. Disclosure of large bundles of documentation is by secure download removing the need for copying and couriers. All storage of coroner files is held electronically. This system of course now has merit considering Covid 19.

  1. Local Stakeholder Partnerships

The Coroner's Service has actively engaged local stakeholders. Points of contact with the Coroner's Service, mortuary and Registrars have been established with the Muslim Burial Council of Leicester and Jewish faith group which has produced a more streamlined service.

  1. Service to the bereaved

A service with approximately 2,500 deaths each year and therefore touching the lives of many bereaved families will not always get it perfect and will receiving the odd complaint. However, if a complaint is received, I address each one with and explanation and / or apology. However, the letters of thanks hugely outweigh any complaints. Here are a few examples:


September 2020