Written evidence from Miss Rebecca Smith


Submission for the Public Inquiry into the Coroner’s Service


I am Rebecca Smith Clerk/Inquest manager and work with and for Senior Coroner Mr Andrew Walker. I have worked as part of the Coroner’s Service for eleven years. I am employed by Haringey Council as part of the administrative support in North London Coroner’s Service. My role is as operations manager for the North London Coroner’s Service.


I make my submission at this time referring to two of the seven points of terms of reference. Terms of Reference

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

2.      Improvements in the services for the bereaved (see enclosed)



(2) I have provided a Coroners Service overview– providing the committee with evidence of the work undertaken over the last three years, to improve and reform the Coroner’s Service in line with the

Coroner’s and Justice Act 2009.


Case for a National Coroner’s Service


At present there is no recognised standard practice nationally or even within the same service. Local practice can differ from area to area. This by its very nature leads to inefficiencies, does not support professional standards, and does not provide families with consistency, continuity or place the family’s grief and management of their Coroner’s case at the centre of their contact with the service. I would recommend a national recognised service. This would begin a process to drive up professional standards, start governance and accountability locally and nationally. Key areas within each Coroner’s Service that could be scrutinized to improve Coroner’s Services, identifying failings and where a local authority/Police Service/Coroner requires additional support in all areas. National guidance for all staff working within the Coroner’s Service. This would see the Coroner’s Service regulated something that it lacks in its present form.


There is no accountability, review process or governing body to review decisions made by a local authority on the running of the Coroner’s Service, failures are often left unaccounted and undocumented. This leads to a lack of transparency and openness, with no service level agreements. For that reason, I would recommend a move into the HM Courts & Tribunals Service, which is accountable with rules and regulations, a government agency that can scrutinise and enforce compliance, as well as recognise Coroner’s Services that perform well.


I would also recommend – a National Code of conduct - Professional standards for Coroner’s Service staff. At the moment there is no standard practice. The professional standards would set the necessary elements for basic and effective practice staff must know, understand and be able to offer after completing a basic training program with a competency test. Improving standards. A national guidance framework setting out the minimum standard would set out and be intended to support Coroner’s Service staff understand the standards and to uphold them in their practice. A basic minimum standard. The professional standards for the Coroner’s Service would be mapped against key areas of practice and provide greater detail around the common themes for all Coroner’s Services. This guidance would make it clear to the public, to people with lived experience of Coroner’s Service, key stakeholders, local



authorities, Police, support services and to other professionals what is to be expected of all staff

working within the Coroner’s Service


For an improvement to better inquest case management - Coroner’s Officers in the old system and still do in some areas support the families with bereavement counselling from start to finish, investigating concerns on behalf of the family. This compromises the inquest and the role of the Coroner being independent. Bias towards the family starts before the Inquest begins and the case is prepared with officers already having a view and acting as quasi Coroners. This practice contributed to staff stress and well-being in the workplace.


In my view a way forward with reform would be to manage the Coroners Court - similar to proceedings in other courts - case papers are submitted to the court/judge. This would keep the inquest completely independent.

Medical Examiners would cover all reporting of deaths from the community and the hospital. The Coroner and the court are provided the case (death) only when the death is unnatural, or the circumstances make the death unnatural. Caseworkers collating court bundles – recognised court practice. This would improve training and professional standards across the whole of the Coroner’s Service, Police, NHS and Local authority when dealing with the reporting of death and the recording of information. Upskilling and providing an improved service to the bereaved families. The Coroner’s Service would be able to sit within the HM Courts & Tribunals Service as a court service – with no other function. It would no longer be involved in the investigation process of deaths; its focus would be on hearing cases avoiding conflict of interest.

The inquest caseworker model has been in place in North London Coroner’s Service for two years providing the bereaved families with a service that is kind compassionate and efficient. The reason for making this submission is to provide a summary of important issues where the Coroner’s Service could be improved and benefit from a move to the

HM Courts & Tribunals Service.              RS-01-09-2020



Submission for the Public Inquiry into the Coroner’s Service


Over the past three years the North London Coroner’s Service underwent a programme of reform and change, this was in direct response to the Coroner’s and Justice Act 2009. The key area was developing practice and processes that would benefit the family and all stakeholders providing an efficient and accountable service. Collaborative working was the focus of the success of the Coroner’s Service. The importance of how the Coroner’s Service interacts with a family when a death is reported to the Coroner’s Service is central in providing a professional, empathetic, compassionate, legal service.


Changes to service/key points – 2017 – to present day

    Three-year project, three teams, one service Reception team

Enquiries team (Coroner’s Officers) Coroner’s team

    Adopting a modern office environment, proactive and specialized roles within the teams.


    Reduce administration backlogs, increasing productivity and successful time management

      Sharing the workload and responsibility across the teams.


    Providing a standardised service to all service users.

    The reception step frees up Enquires Officer time. It makes more appropriate use of Enquires team skills.

    Benefits Service users; It is easier for service users to begin their contact with the service - and shortens the wait to get the right kind of help and assistance.

    Reduces issues of inequalities in service users experience of accessing information - standardised service for all callers.

    Use of digital, IT communication systems support systems already in use in the NHS, Police and the Local Authority

    The Reception team act as the service navigators ensuring the service user has correct clear information - email address, the first point of contact and provide clear information about contacting the service and the court’s duty to comply with GDPR, handling sensitive data and security identifiers.

     No advice, no case discussions, no messages/emails, no disturbing the Enquires team.

     First contact call - Enquires team (Coroner’s Officer)



     Template letters – written permanent record for families to read and digest at leisure. Consideration given to grief and emotional impact.

     Calm and considered approach to responding to families, stakeholder enquires, reduced complaints.

     Reduced stress for families.

     Reduced stress of Enquires Officers.

     Permanent record of every interaction the family, stakeholder have with the service.

     Creating a calm court, office environment.

                     Previously over 75% of all complaints from families and service users were about what was said on the telephone and the delivery of the information. Highly emotive telephone conversations, unrecorded calls and a stark difference in the service provided from officer to officer, no standard service.

     Immediate improvement in professional standards, consistent, lawful and correct advice. Staff became confident in the delivery of service, and the written responses praising the service became many. No repeat phone calls.

     6 Enquiries team staff (Coroner’s Officer), 1 Enquires team manager

     4 Key roles, 2 support roles

     Officer 1 Police reported deaths

     Officer 2 Hospital/GP reported deaths

     Officer 3 Post mortems

     Officer 4 Funeral Papers

     Team rota, continuity of the service, clear specialized roles. Management plan.

     Reduced stress – sick record fallen, fair work shares across the team.

     First contact call, template letters, guidance and court policy.

     No carrying stress from bereaved families.

     Developed with key advice from Registrars, leading psychiatrist, Met Police and the NHS legal departments.

     Service average 5 day turn around reporting of death to registration.

     Task and action based system, mirroring the Met Police Command.

     All requests emailed through the generic email address.



     Reviewed and allocated by the Coroner’s team.

     Benefits service early detection of issues, concerns.

     Provides a forecast of how the service is performing, identifying pinch points.

     Information is available at the fingertips of the Coroner’s team.

    Met with and took advice from CCG’s, GP working groups and Registrars.

    Presented at NHS GP/Hospital Seminars over two year period. CCGS including Coroner’s

Service on NHS bulletins. Registrars adding a Coroner’s Service page to their website.

    GP referral form uploaded on to every NHS Emis system

    Hospital referral form uploaded on to global net, intranet

    Collaborative working , assisting local trusts, and private hospitals writing policy in reporting deaths to the service.

    Collaborative working, assisting GP super practices writing local policy in reporting deaths to the Service.

    Starting the NHS partnership, encouraging development, training and skills for post mortem examinations with ULCH. Continuity – thinking of the future.

    Taking advice and guidance from the NHS legal teams about management and accountability.

    NHS workshops provided to Enquires team.

     Consultation with Senior Met Management, met with Borough Commanders, CCC Command. Approved system.

     Implemented a bespoke new reporting system CAD,EAB and Merlin system. The three mandatory documents produced by the Met when attending a sudden death. The CAD recording every action taken in relation to the scene, the EAB (Evidence and action book of the Police Officer) and the Merlin report (– nominal record)

     Audit done by Police Officer average wait time was 7 hours on the Borough – now reduced to 2 hours. Releasing Police Officers to attend crime.

     Three documents sent on one email by Police Officer to the generic email – end of shift. No additional work.

     Workshops for the Enquires team by Met Legal, and Detective Inspector Murder team.

     Community reported deaths the same service in and out of hours.

    Met with Kew Archives, British Museum, London Metropolitan Archive – providing advice about best practice and preservation.



    Legal court requires all communication to be in writing.

    Complies with GDPR , handling of sensitive data and the Chief Coroner’s direction - accurate and accountability.

    Records can be interpreted as a reflection of best practice and can be used positively to support the service.

                    Records are a communication tool, keeps colleagues, staff informed of the progress of the case

    The Coroner and Clerk have an overview at all times of the Service monitored through the generic email address.

    The Coroner and Clerk manage all Inquest cases files, Civil Court system. Court record.

    The Coroner reviews and provides directions on every single case

    Caseworker – Clerk, templates, emails – impartial, fair written process.

    Coroner and Clerk manage the Court day. Clerk sits in court provides assistance to Coroner.

    Coroner and Clerk – review and allocate generic emails, task and action.

    Coroner provides judicial oversight, decision making, guidance and policy.

    Clerk provides advice and guidance operational matters and policy. Court Policy - in the form of Communications Policy, Code of Conduct, GDPR.

    Clerk leads the reception team

    Provide joint training operational/judicial workshops to all teams.

     All cases have a set of Coroner’s directions

     Fast track or complex case (ability to cross over)

     Six weeks gap between the reporting of the death and a date being set for Inquest/PIR

     Early engagement family, and other IP’s, working together

     A recognized, tried and tested court system

     Identifies the key issues right from the beginning of the process

     No long delay

     Families main concern is being able to move forward sooner.

     Easy to track /case progression – all cases fall within the same system.

     Court disclosure for Coroner and parties to manage.



     Army tested the system two years ago, no experience, no understanding. Trained Army personnel on database. Disaster planning. Coroner and Clerk annual presentation.

     Met with Chief executives of all 5 Borough Local Authorities, approved first formal out of hours service in line with Registrars – supporting the faith communities

     Met with Deputy London Mayor for Policing. Approved independent Service and Police Community death reporting system.

     Local Mayors and Councilors visited court and endorsed North London Coroner’s Service and

user friendly service.

     Met with Local MP to understand and approve the new Coroner’s Service, supported and

helped bring in the Formal out of hours Coroner Service.

     Met with Local religious leaders and Chief Rabbi who fully support the approach this Service takes to faith deaths.

     Service newsletters providing updates to stakeholders and the community.

     Met Police twice monthly initiatives

     LAS/LFB bi-annual initiatives

     Coroner led -NHS Seminars/Senior management continued improvement program.

     Feedback from Psychiatrist about positive change

     Feedback from Private Change Management consultant

     Daily work review, checking, monitoring by Coroner, Clerk and Enquires team manager.

     Supporting documents – Communication Policy, GDPR notice. Four template letters for the Enquires team, three templates letters for the Inquest process.

     Clerk and Enquires team manager weekly meeting problem solving.

     Continued training and guidance Clerk to Enquires team manager.

     Clerk and Reception team weekly meeting - training and support.

     Providing training, learning opportunities - staff attended post mortems, training at the Registrars, NHS Toxicology department, Funeral Directors, Met Police CID.

     Development of Enquires team and Reception team in- house training workshops.

     All teams Christmas and Summer social.

     Separates the Coroner from the operational responsibility.

     Allows the Coroner to focus on the law, inquests.



     Professional boundaries, pushes up professional standards

     Improves quality of inquest and provide opportunities for test cases, and legal challenge.

     No confusing roles Judicial – Operational – Enquires /investigation process (Met Police) and Inquest process (Coroner). Independence.

     The Coroner is recognized as the head of service.

     Developing IT infrastructure- web page, new ideas, keeping up to date with legislation incorporating changes into the court system

     In line with all other public services – strengthening working relationships and benefiting from a positive, proactive service

     Providing the community with a better Service

     Held a Coroner’s Service open day with Coroner’s, lawyers and Heads of Legal Services

     Requests for more initiatives from the Met, LAS,NHS

     Army Nursing Auxiliary training days, mass fatalities

     Development of scanning/post mortem shared NHS Pathologist Service

     All staff benefit and improvement to work life balance