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
- The coroners service is in the main a successful local service. This service under the leadership of the Chief Coroner continues to evolve and improve. Many local authorities have generously met the challenge and expense of reform. A minority of local authorities continue to neglect the funding of the coroner service and/or seek to micro mange the coroner service by failing to recognise the separation of powers.
- A national service would divest the local authorities with financial responsibility for the coroner service, but great caution is needed to ensure that any national service is properly funded and structured including:
- Expenses associated with investigations such as Post-Mortem examinations (including CT scanning)
- Counsel to the Inquest
- Witness and jury expenses etc.
- Liaison with a multitude of local stakeholders such as Registrars, funeral directors, crematoria, faith groups and many others
Underfunding of a national service would reverse all the great work already done.
- The delay with the implementation of the Medical Examiner (ME) system has considerably slowed down the overall reform project. It might be that when the ME is fully in place then a move to a National Coroner service could be progressed.
- The introduction of the Notification of Death Regulations in 2019 was a very welcome step because unusual reporting of deaths in a Coroner Area can markedly alter the statistics for the Coroner Area. For example, over-reporting requirements can dilute the post-mortem examination figures making them look lower than another Coroner Area. Local Authorities do not know the population size of other Coroner Areas and to simply look at the statistics means that they cannot truly benchmark themselves against other Coroner Areas. The answer would be to rebase the figures on a population basis thus allowing local authorities to benchmark the service on a level playing field. This would also assist with those local authorities that underfund their coroner's being able to increase funding and for those who squander the public purse to address budgetary issues on a fair, proportionate and reasoned basis. The Office for National Statistics has extensive figures on populations and would be able to assist in such an exercise.
- There is unfairness in the current system. This stems from lack of resources staffing infrastructure and accommodation and inconsistency in the provision of a number of services beyond the control of the coroner. For example, a family in one coroner area may be in a position to have access to a less invasive scan by way of a post mortem examination without cost. Equally there can be unacceptable delays with a post mortem examination because of the lack of availability of pathologists. The fees for pathologists are in urgent need of review as proper funding maybe the only way of reversing the decline in coronial pathology services the report of professor Hutton refers.
- Legal aid is not always available to some families who are involved in high profile complex hearings.
- The current Coroner annual return to the MOJ should be improved to provide for more meaningful data to enable a proper analysis of relevant information including the number of Prevention of Future Deaths (PFDs).
- By virtue of the Coroners and Justice Act 2009 coroners are now under a duty to write prevention of future deaths reports rather than to exercise their discretion to do so. Although the reports and replies are published on the Chief Coroner’s website some recurrent themes are not addressed appropriately by public authorities. It is important that the reports and replies are properly collated and analysed rather than simply being catalogued. To this end more staffing the Chief Coroner’s office would assist together with a specialist committee to make sure that the PFD is had very real outcomes. If not the specialist committee engagement of specialist research is from perhaps a university should be considered.
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.
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:
- 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.
- 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.
- 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.
- 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:
- “I spoke with you on Thursday 6th February regarding the death of my Grandmother XX. I wanted to say Thank You for being so helpful & resolving the issue so quickly. Myself and my family are truly grateful. Thank You.”
- “I wanted to thank you for all the arrangements you made to sort out Mum’s death certificate. You always call when you said you would. You did what you said you would do. You ensured everything went as smoothly and efficiently as it could. Thank you for all you did at a very difficult time for us.”
- “I would like to Thank you so very much, for all the support & kindness shown to me, leading up to X’s inquest, & the inquest. I always knew you was at the end of the phone, to answer my questions. Thanks again”
- “Thank you for the thoughtful and careful way in which you guided X and Y; my daughter and son-in-law, through their recent terrible and tragic experience.
- “We just wanted to say thank you following our mother’s inquest last week. We were always convinced that her care was inadequate and her discharge unsafe, so we are very pleased with the way the proceedings went on Friday. Please also thank your team, especially X and Y, who have answered questions, kept us informed and generally made the whole process a lot easier.”
- “I am writing to you to express my sincere thanks for the valuable advice and assistance given to me by one of your coroners, X, this week following the death of my mother. Owing to the fact that I live 200 miles from Leicester I am having to deal with the registration of her death and funeral in the “coronavirus way” of doing things. The death was reported to the coroner as she passed away following a fall at her care home and a subsequent hip operation at The Leicester Royal Infirmary. I was telephoned by X, who took the time to enquire how I was coping with my loss and advised me of the new procedures in registering the death at the registrar’s office. During our conversations on this occasion and on subsequent telephone call by him, keeping me up to date of what was happening, he treated me with the utmost dignity, efficiency, integrity and understanding. Nothing was too much trouble for him and his help and advice were invaluable. I would be grateful if you would forward a copy of this letter (enclosed) and my thanks to X. Without his help and advice at this time my sad task of dealing with my mother’s passing would have been so much more difficult.”