Written evidence from the Ministry of Justice (TCS0054)

Executive Summary

1.     Around 40% of deaths are reported annually to coroners in England and Wales, this resulted in over 200,000 deaths being reported to the coroner and more than 36,000 inquests opened in 2022. The coronial system therefore provides a key service to society. The Government remains committed to ensuring that the bereaved are placed at its heart and continues to work with a wide range of stakeholders to understand what more can be done to improve both the effectiveness of the service and the experience of those who come into contact with it.

2.     The Ministry of Justice (the MoJ) has taken forward key changes following the Justice Committee’s First Report on its Inquiry into the Coroner Service. For example, in the immediate aftermath of the Covid-19 pandemic, a suite of measures in the Judicial Review and Courts Act 2022 streamlined key aspects of the coroner system, thereby reducing the distress of unnecessary delay for bereaved families. We have identified measures to further streamline the system and will take these forward when Parliamentary time allows.

3.     We committed to give further consideration to 10 of the 20 recommendations which the Committee made to Government in 2021, some of which have been successfully delivered or are being progressed. However, other priorities, including our key involvement in delivering cross-cutting Government reforms in the death management sector, have meant that we have not been able to progress some of these issues as far as we would have liked. We remain committed to doing so as soon as practicable.

4.     We continue to commit significant time and resource in working to safeguard the role of the coroner and, crucially, coroners’ judicial independence whilst successfully securing a number of reforms across wider Government policy areas which will further enhance the provision of coroner services for bereaved families.

What progress has been made towards the goal of placing bereaved families at the heart of the coroner service?

5.     Since the Committee’s First Report, the Government has brought forward a number of changes to support its objective of placing the bereaved at the heart of the coronial system.

6.     Key among these is a suite of measures in the Judicial Review and Courts Act 2022 which, by streamlining certain coronial processes, reduce delay and distress for the bereaved. Specifically, they enable:

• inquests to be held in writing in certain non-contentious cases
• an investigation to be discontinued without a post-mortem examination where a natural cause death becomes clear from other evidence
• an inquest to be held without a jury where Covid-19, as a notifiable disease, is suspected to be the cause of death
• pre-inquest hearings and inquests to take place where all participants including the coroner, participate remotely, bringing coroner’s courts in line with other courts

7.     In addition, the Police, Crime, Sentencing and Courts Act 2022 provides for remote access to pre-inquest/inquest hearings.

8.     The Government has brought forward measures in the Victims and Prisoners Bill to establish a standing Independent Public Advocate (IPA) and a power to appoint individuals to act as advocates which will give a greater voice to victims and the bereaved in the aftermath of major incidents and will work to facilitate their engagement with public authorities.

9.     The Government has also helped to ensure that bereaved families can participate in the inquest process by simplifying and improving access to the Exceptional Case Funding (ECF) scheme. Legal aid for representation at an inquest may be available through the ECF scheme, and the Government has removed the means test for representation and associated legal help (advice and assistance) for bereaved families where ECF is granted. The Government has also removed the means test for applications for legal help at inquests where it is reasonably likely that an ECF application for representation at the inquest would succeed.

10. To build on these changes, the MoJ will consult on expanding the provision of legal aid at inquests related to major incidents where the IPA is appointed or in the aftermath of terrorist incidents.

11. The MoJ has a key role in the cross-government programme to streamline and improve the death certification system. This will include putting the medical examiner system on a statutory footing in England and Wales from April 2024, which will ensure that bereaved families have greater transparency on the circumstances surrounding the death of a loved one.

12. The significant increase in natural cause deaths reported to the coroner because there is no medical practitioner qualified to certify them diverts resource away from coronial investigations and therefore impacts the bereaved. From April 2024, this will be addressed through an expansion in the pool of doctors qualified to certify a non-coronial death, and facility for the medical examiner to certify where there remains no medical practitioner who is qualified to do so.

13. The Government will shortly be launching a full public consultation on the complex issue of a role for the bereaved in the registration of their loved one’s death following an inquest, following a campaign by some of the families bereaved by the Manchester Arena attack and their Parliamentary supporters. The MoJ is also updating its Guide to Coroner Services for Bereaved

People to ensure that information on the registration of their loved one’s death is available to the bereaved as early as possible in the investigation process.

14. The Government has introduced provisions in the Online Safety Act 2023 to enable coroners to seek assistance from OFCOM in obtaining and interpreting information from providers where social media data is relevant to an investigation into a child’s death. In addition, the Government is giving further consideration to the scope of a measure in the Data Protection and Digital Information Bill which will enable coroners to secure the preservation of social media data as potential evidence at the outset of a relevant investigation.

15. Since the Committee’s 2021 report, the Government has progressed its programme of coroner area mergers, taking the number of coroner areas from 85 in 2021 to 80 at present. This supports the streamlining of coroner services, helping to improve the standard of service provision to the bereaved.

What progress has been made by the Government in implementing those of the Committee’s earlier recommendations which it accepted in September 2021?

16. Coroner area mergers – the Judicial Review and Courts Act 2022 included a provision to amend Schedule 22 to the Coroners and Justice Act 2009 to enable coroner areas to merge where the merged area would be smaller than the relevant local authority area. This would, for example, enable a merger of three of the four Kent coroner areas, on which the MoJ is currently liaising with Kent County Council.

17. A Guide to Coroner Services for Bereaved People – the MoJ will be publishing an update of the Guide in early 2024 to reflect legislative and operational changes since the refreshed Guide was published in January 2020. We will then aim to publish a fuller revision in 2025, in light of forthcoming reforms such as implementation of the statutory medical examiner scheme and establishment of the IPA. We are working closely with coroner areas to establish a sustainable basis on which to provide both paper and online versions of the updates.

18. Fresh inquests – the Committee proposed an amendment to section 13 of the Coroners Act 1988 to give the High Court greater flexibility in quashing an inquest where appropriate. MoJ has further considered this recommendation and will pursue any necessary change as soon as Parliamentary time allows.

19. Coronial investigation of stillbirths - on 7 December 2023, the DHSC and MoJ jointly published a factual summary of responses to the 2019 consultation on coronial investigation of stillbirths1 which can be found at Coronial investigations of stillbirths - GOV.UK (www.gov.uk) .We are now reviewing the policy issues identified by the consultation, including whether maternity safety initiatives now in place are already achieving, or have the potential to achieve, the overarching policy objective without the need for coroner investigations. A further statement will be issued in due course which will set out whether, and if so how, the Government intends to take further action.

20. We are also working with DHSC to improve the information available to families regarding current investigative processes that may be available following a stillbirth.

21. Coronial pathology – we are keenly aware of the pressures created for coroner services by the shortage of pathology resource, and it is a key priority to find sustainable solutions to the longstanding and complex underlying issues. To support this, the MoJ has established a Ministerial Working Group with representation from relevant government departments, which is supported by an official level Steering Group from relevant departments and arm’s length bodies, the Welsh Government, and key external stakeholders such as the Royal College of Pathologists. Through this mechanism, a cross-government action plan has been agreed, based on the Committee’s 2021 recommendations and including wider objectives.

1  https://consult.justice.gov.uk/digital-communications/coronial-investigations-of-stillbirths/

22. The MoJ has recently launched a review of coronial pathology fees as a first objective within the wider action plan. The review has started with a targeted call for evidence to gather information on the suitability of the existing fees, data to support any uplift, and views to support consideration of the wider objectives included within the action plan.

What progress has been made by the Government in responding to those recommendations which it was unable to address in September 2021?

23. Support services in coroner’s courts – the MoJ has established a comprehensive engagement plan to better understand existing provision, which we are aiming to complete in early 2024. This will inform further consideration of how support services can most appropriately be expanded across England and Wales.

24. Charter of Rights, duty of candour and legal aid for inquests – the Government committed to respond to the Committee’s recommendations on these issues in its response to Bishop James Jones’ report on his review of the experiences of the Hillsborough families2. The response was published on 6 December 2023 and the Secretary of State for Justice wrote to the Committee Chair setting out those aspects which address the Committee’s recommendations.

25. System of appeals and a coroner service inspectorate - in its 2021 response, the Government committed to consider the establishment of a coroner service inspectorate; and whether there is a need for an additional mechanism to enable more inquest decisions to be appealed. As a result of other Ministerial priorities, we have not yet progressed work on these recommendations, but we remain committed to doing so as soon as practicable.

26. Post implementation review of the Coroners and Justice Act 2009 – in February 2023, the MoJ released the draft report on the post implementation review in its form when deprioritised in mid- 2016. A copy was forwarded to the Committee.

Given that the Government has rejected the Committee’s recommendation to unite local coroner services into a single service, what more can be done to reduce regional variation and ensure that a consistent service operates across England and Wales?

27. As set out in its 2021 response, the Government does not consider that a single service would necessarily address the issues facing the coronial system or be the best solution. However, we have continued to promote our merger policy to facilitate greater consistency of practice, improve standards, and create the opportunity for economies of scale. Since September 2020, the number of coroner areas has been reduced from 85 to 80; further merger proposals are in train for implementation in April 2024, subject to the necessary approvals; and the Government’s objective of 75 areas or fewer could be reached later in 2024.

28. In response to the Committee’s 2021 recommendation, the MoJ has made statutory provision for coroner areas to merge where this creates a merged area smaller than the relevant local authority area.

29. The decentralised structure of the coroner system means that service delivery can be better tailored to local communities, and this inevitably results in some degree of variation. Successive Chief Coroners have promoted consistency of standards and practice through judicial leadership, guidance, and regular compulsory training for coroners and coroners’ officers. The Chief Coroner’s Combined Annual Report for 2018-19 and 2019-20203 included the Model Coroner Area blueprint which sets out parameters for a viable and efficient coroner area. We understand that this will be revised and updated in Spring 2024, in light of the findings of his post-pandemic welfare tour of all coroner areas.

2  https://www.gov.uk/government/publications/hillsborough-stadium-disaster-lessons-that-must-be-learnt

3https://www.gov.uk/government/publications/chief-coroners-combined-annual-report-2018-to-2019-and-2019-to-2020

30. The measures introduced by the Judicial Review and Courts Act 2022 are intended to streamline the coronial system, thereby promoting better consistency of service standards. Where appropriate, data on their impact will be collected as part of the MoJ’s annual Coroner Statistics publication. We will seek to take forward further streamlining measures when Parliamentary time allows; and we will continue to engage with the Chief Coroner and his successor to understand what more can be done to ensure consistent service.

Whether more can be done to make best use of the Coroner Service’s role in learning lessons and preventing future deaths. In particular (a) are Coroners across England and Wales making consistent use of their power to issue Prevention of Future Deaths (PFD) reports? And (b) could the way PFD reports are being used to help prevent future deaths be improved?

31. It is for the coroner, as an independent judge, to decide whether their statutory duty to issue a Prevention of Future Deaths (PFD) report is engaged in an individual case. In November 2020, the Chief Coroner published revised Guidance4 to assist coroners with the detail of the law and to encourage consistency of approach in this context. The High Court’s December 2022 judgment in Dillon5 affirmed that the PFD report is ancillary to a coronial investigation, and not its primary purpose.

32. The Committee in its 2021 recommendations; the Independent Advisory Panel on Deaths in Custody in its October 2023 recommendations on enhancing the impact of PFD reports6; and INQUEST in its current National Oversight Mechanism campaign have proposed consideration of how existing independent bodies or a new body could play a role in monitoring and following up on the responses to PFD reports.

33. The Government believes that PFD reports have an important role in contributing to public safety as a vital tool in ensuring that lessons are learned. Our expectation is that recipients will have systems in place to consider the reports they receive, and that they will take very seriously what those responses say about actions that will be taken. Nevertheless, we recognise that more needs to be done to ensure that PFD reports contribute to improving public safety, and we will carefully consider the recommendations made by the Committee and other stakeholders in this regard.

34. Separately, the MoJ has been working with the Chief Coroner to address the Committee’s recommendation on improving the accessibility of PFD reports. The publication of the reports and their responses on the Chief Coroner’s webpage ensures transparency and enables ease of access for researchers and others. Since January 2023, publication directly onto the webpage has enhanced the user experience, including for those using assistive technology.

35. The Chief Coroner’s Office has been working with researchers at Oxford University to develop a Preventable Deaths Tracker website which enables data from PFD reports to be aggregated for academic analysis. Discussions are ongoing, including with MoJ, to ensure awareness and use of the tracker by public and academic bodies, and on how best to share it on the MoJ and Judicial websites.

36. We are also continuing to work with the Chief Coroner’s Office to identify further improvements to the publication, searching and analysis of PFD reports, including the possibility of creating a public database.

4  https://www.judiciary.uk/guidance-and-resources/revised-chief-coroners-guidance-no-5-reports-to-prevent-future-deathsi/

5 Diarra Dillion, R (on the application of) v HM Assistant Coroner for Rutland & Ors - Find case law (nationalarchives.gov.uk)

6 https://www.iapondeathsincustody.org/news/2023/10/16/more-must-be-done-to-ensure-prevention-of-future-death-reports-live-up-to- their-name-says-iapdc

How are Coroners responding to the requirements of faith burials and funerary practices, especially in relation to early release of bodies and provision of non-invasive autopsies? Is there a consistent and satisfactory approach across England and Wales?

37. The Chief Coroner’s Guidance No 287 sets out a practical approach for coroners to expedite decisions where there is a good reason to do so, including on religious grounds; and provides guidance on faith-related requirements, including facilitating early release of the body. However, as the Guidance notes, the provision of an out-of-hours service is dependent on the availability of resource from within local coroner service provision. We strongly encourage the provision of such resource wherever possible.

38. The MoJ recognises the importance of non-invasive post-mortem techniques, particularly for faith communities, and the challenges in making these more widely available. The Chief Coroner’s Guidance No18 sets out the minimum standards for using CT scanners and encourages their use (where available) for families who may wish to avoid invasive, or any, post-mortem examination. Like the Chief Coroner, we continue to engage with faith community representatives to understand what more is needed and will consider this issue further as part of the wider action plan to address coronial pathology provision.

Whether there is evidence that inquests are taking too long to be completed, and if so why, and what can be done in response.

Whether the coroners’ service has recovered from the challenges of the Covid-19 pandemic, and what lessons can be drawn from it.

39. In 2022, the average time taken to conclude an inquest decreased to 30 weeks from 31 weeks in 2021 but remained higher than the 20199 average of 27 weeks. The Government is concerned by the length of time taken for the completion of some inquests. The reasons for this are complex, but include residual pressures from pandemic backlogs, including the halting of many jury and complex non-jury inquests during the first lockdown. Other factors include pressures caused by the shortage of coronial pathology provision; the knock-on effect of delays in related investigations in individual cases; the impact of the increase in deaths reported to the coroner because there is no medical practitioner qualified to certify them; and other resource pressures on funding local authorities.

40. To illustrate some of these pressures the table at Annex A indicates that, comparing 2022 with 2021, there was:

• a 7% increase in deaths reported to the coroner (208,430 compared with 195,180).
• an 11% increase in the number of inquests opened (36,273 compared with 32,762).
• a 7% increase in the number of post-mortem examinations ordered by the coroner (90,191 compared with 84,599)

41. Since its 2021 response, the Government has been liaising with the Chief Coroner on how best to support coroner services’ post-pandemic recovery. The Government provided £6.15 billion in un-ringfenced funding to local authorities in England to support the costs of pandemic pressures, which could be used to help cover additional costs incurred in the administration of coroner services. The Chief Coroner also issued Guidance10 for coroners on how coroner services can best recover from the pandemic, including engaging with local authorities on additional resources where required.

7 https://www.judiciary.uk/guidance-and-resources/chief-coroners-guidance-no-28-report-of-death-to-the-coroner-decision-making-and- expedited-decisions/

8  https://www.judiciary.uk/guidance-and-resources/chief-coroners-guidance-no-1-the-use-of-post-mortem-imaging-adults/

9 Coroner Statistics Annual 2019, England and Wales (publishing.service.gov.uk)

10  https://www.judiciary.uk/guidance-and-resources/chief-coroners-guidance-no-39-recovery-from-the-covid-19-pandemic/

42. The Chief Coroner’s combined Annual Report for 2021/202211 summarises the findings from his national tour of all coroner areas between January 2022 and March 2023. During the tour, which was the first of its kind, he engaged with coroners and their staff to understand local pandemic recovery, as well as their welfare needs. Some areas continue to manage inquest backlogs which may also be exacerbated by pressures within the wider death management system. It is anticipated that the death certification and associated reforms being implemented from April 2024 will help to address these issues.

43. The Government’s reforms in the Judicial Review and Courts Act 2022 are also intended to support and streamline the coroner system. We have identified new measures for inclusion in the annual Coroner Statistics collection to monitor the impact of these legislative changes, where possible.

44. The 2022 provisions include the continuation until June 2024 (unless further extended) of a measure originally included in emergency pandemic legislation to remove the requirement for a jury inquest where Covid-19 (as a notifiable disease) is the suspected cause of death. We are currently assessing whether the measure should be further extended to support continued pandemic recovery.

Whether there are any other changes to the way the Coroner Service operates that could be made to improve its effectiveness.

45. Since its 2021 response, the Government has made a number of reforms to coroner services and intends to take forward further measures when Parliamentary time allows. However, we recognise that more can be done to further improve and build resilience within the system. This will be informed, in part, by our undertaking in the response to Bishop James Jones’ report that we will seek to further understand the experience of the bereaved at inquests where the state is involved.

46. The Chief Coroner’s 10th anniversary lecture12 outlined his assessment of the issues impacting the ability of coroner services to meet the needs of the bereaved. Prime among these is what he terms “the triangle of responsibility” for coroner service delivery between the Senior Coroner, the funding local authority and the local police authority. The Government is also concerned by the issues that this statutory governance arrangement can create, and we are working with the Chief Coroner and other stakeholders to identify ways of clarifying and supporting it.

47. At a more strategic level, the coroner’s role is framed by their statutory duty to determine who died, and when, where and how they died (and in what circumstances where Article 2 is engaged). This does not include the “why” behind an individual’s death; nor do they apportion blame or liability. However, there is a perceptible change in the role that Parliament, stakeholders and wider society appear to want coroner services to play. This may be due in part to a greater general awareness of issues around death management and investigation arising from the pandemic. In addition, a number of high-profile coronial investigations, such as those into the tragic deaths of Molly Russell and Luke Ashton, have highlighted a range of emerging issues - for example, the influence of social media and the provision of mental health support – on which society continues to seek a greater awareness and understanding.

48. Whilst coroners can undoubtedly contribute to this process through the discharge of their statutory duties, the MoJ welcomes the opportunity provided by this follow up Inquiry to focus on the issue of the coronial role in the context of the wider matters set out in this evidence response so that we can work to ensure that we maintain our key focus on putting the bereaved at the heart of the coronial process.

11  https://www.gov.uk/government/publications/chief-coroners-combined-annual-reports-2021-to-2022

12  https://www.judiciary.uk/speech-by-the-chief-coroner-death-and-taxes-the-past-present-and-future-of-the-coronial-service/

Annex

Annex A Table showing coroner stats between 2020-2022

13 Deaths registered in England and Wales - Office for National Statistics (ons.gov.uk)