Written evidence from National Burial Council and Gardens of Peace

  1. At present there is very little consistency between individual coronial areas and it is almost a ‘post code lottery’. Certain coronial offices can be very difficult, either by not engaging with the local community, or by being insensitive to the needs of the bereaved family and insisting on a ‘cab rank’ rule. Provisions for non-invasive post-mortems and an out-of-hours service is sadly lacking, and barring a personal relationship between a faith representative and someone from a coroner’s office, delays and/or invasive autopsies (in cases where non-invasive are just as conclusive, if not more) are almost expected.

We would advocate for the Chief Coroner to be given more legislative power so that all the guidance issued by the Chief Corners office has legal backing. So much good work has been done by the Chief Coroner so far in terms of Post Mortem, faith requirements that need to be taken into account, 2nd Post Mortems (restricting the need) and the appointment of two deputy Chief Coroners. We would support a National Coroner Service for areas where they can bring consistency, centralised funding, and more accountability of individual coroners and their respective offices.


  1. Even a cursory look at the Grenfell disaster and the peak of the Covid pandemic is extremely telling: the lead coroner did manage to seek the help of other coroners and this seemed to work particularly well. I would propose that there be a team of coroners to undertake this role. For example, a ‘National Disaster Team’ could be established in London and regionally, where we would have a lead coroner who would be assisted by other coroners.


  1. The coronial system needs to ensure that there are minimum delays in inquests so that lessons can be learned quickly from negligence as well as preventable deaths. We believe that some of the more routine cases should be filtered and dealt with by the NME team so as to allow coroners the ability to focus on the more complicated cases.


  1. To a great extent, the coronial service coped very well during the pandemic, with the exception of one or two individual coroners. This exception was all the more apparent as we were seeing faster than usual turnarounds from the vast majority of the other offices. With the restrictions that were in place on hospital visits, as well as the restrictions on the number of attendees permitted at funerals, this only exacerbated the grief of the bereaved families. Also worth noting is the initial confusion that (I’m assuming) all communities faced with the lack of information pertaining to the new legislations and processes that were introduced. What aggravated this was the fact that those to whom we would look to for guidance (health professionals etc.) were also in the dark about the legislation changes. What was very apparent is that majority of the coronial offices were able to operate remotely and issue burial orders via emails. Surely this should make it much easier for coroners to provide an out of hours’ service.


  1. With the arrival of the Chief Coroner, much progress has been made in terms of training and guidance. However, we feel that more is required, especially in terms of faith sensitivity as well as local requirements. We also welcome the inception of the NME system as it ‘puts the bereaved at the heart of the service’, but we believe that more can be done by way of training, as mentioned above, with regards faith sensitivity.  


  1. In our view, there are a few areas that require improvement:

i)      Greater consistency amongst the coroners;

ii)    out of hours’ facilities; If resources is an issue, then surely coroners for certain regions could work together to provide this as a shared service.

iii)  more flexibility in offering non-invasive post-mortems at no cost to the family. This is even more pressing given the shortage of pathologists in the system, particularly paediatric pathologists;

iv)  More facilities that can offer Non Invasive PM.

v)    The need to recruit more pathologists and given the time it takes to train someone to become a pathologist, our strong recommendation is that all PM should be referred for a CT scan as a default position. This worked very successfully in the Pilot project that took place in Leicester and still takes place in one or two regions in the country where the local NHS facility carry out the scans at no charge to the families. 

vi)  Better communication from the coroner’s office. Perhaps a dedicated line for bereaved families would be helpful as they sometimes feel that they are kept ‘out of the loop’ which undoubtedly increases anxiety at an already stressful time. 

vii) Better IT systems for all coronial offices so that the paperwork can all be done electronically and remotely.

viii)              To follow the system that is in place in Scotland where in the case of a murder or suspicious death, two Post Mortems are carried out at the same time or soon after. One by an independent pathologist and the second by the coronial forensic pathologist. This will help families a great deal as we have had cases where they have had to wait 2 -3 months before the deceased can be released for burial. The 28day rule is a step in the right direction but we believe that there is no reason why that period cannot be reduced to a minimum that is possible. If we believe that bereaved families are the most important people, then surely we should help them with a speedy burial.


  1. The wording here is somewhat vague. If ‘fairness’ refers to impartial treatment on the part of the coroners themselves, then we would say that we feel that that we are treated fairly. If what you are referring to is equal distribution of funds, personnel and resources to the coroners, I would opine that these should be dependent on the number of cases being handled by a particular office. The other factor is equitable funding; some of the offices are adequately funded whilst some are simply not. Lastly, we believe that there should be higher degree of accountability. At present, it is almost impossible to remove a coroner from their position. Whilst we totally agree on the independence of the coroner, the accountability should be more transparent. In achieving this, our opinion is that the removal of a coroner should either be made the responsibility of the Chief Coroner, or a panel made up of the Chief Coroner, funders and someone from the MOJ.



September 2020