Written evidence submitted by Dr David Baker (TCS0064)
The coronial service has seen improvements since the introduction of a Chief Coroner. There is greater direction and leadership, largely as a result of improved communication. Fewer coronial districts mean practice is more consistent than it previously was. The length of time taken to process inquests has decreased. Undoubtedly there is increased focus on how families experience the inquest process, more inclusion of families in practice, and more respect paid to religious and cultural sensitivities than used to be the case.
I recognise the Justice Committee is following up on nine key questions emerging from their First Report of Session 2021-22. This submission aims to situate coroners in a wider context both in terms of their work today, and how that work has evolved over time. In short, I believe that the purpose of coroners cannot be properly understood unless: a) it is situated within the broader network of death investigation and regulation; and, b) there is an understanding of the historical development of coroners, particularly with regard to a long-held desire to reform the coronial service.
Reform and stasis
Coroners are a unique resource in England and Wales, but this resource remains underused, under-resourced, and under-researched. The inquisitorial nature of their work sets them aside from all other types of justice. Their role is perhaps best summed up by a quote from Jervis, the coroner’s ultimate reference text – it is: ‘to find out [the] objective truth in the public interest and not the limited “truth” as between and for the purposes of two or more parties’ (Matthews 2014: 282). The central question of how to define ‘the public interest’ has long been evident in debates about what the coronial service is, and could be. To examine it contextual issues need to be taken into consideration.
Calls for significant reform to the coronial service in England and Wales have been made for more than one hundred years (see, for example Brend 1913). The current focus of the Justice Committee’s work should therefore be seen in that context. A succession of major reviews into the coronial service have made pointed reference to how key findings from previous reviews were not adopted or implemented. Hence, the 1971 Brodrick review cited the 1936 Wright review; whilst the 2003 Luce review cited Brodrick and Wright (see Luce 2003). Joshua Rosenberg noted that ‘no other institution in our legal system has survived unchanged for so long’ (Dorries 2004: vii). Luce’s 2003 review labelled the coronial service ‘not fit for purpose’ and identified significant ‘critical defects’, among which were: dealing with individual deaths rather than patterns and trends; no formal linkage to public health systems; a lack of resources for coroners to deal effectively with complex cases; lack of legal aid for families; patchy coverage of pathology services; and a lack of clear relationships between inquests and other forms of death investigation (Luce 2003: 16-17). All of these defects remain today, many of which are acknowledged by the Justice Committee’s last review in 2021. In the 21st century, there is a long overdue need to significantly rethink the role of coroners, how they work, and where they sit within the wider context of regulation in the public sphere. In particular, there needs to be:
At the heart of the need for a national service is the necessity to acknowledge that investigating individual cases blinds us to the reality that deaths can often be caused by systemic and organisational failings. Establishing a national service would represent a first-step in collating and analysing the significant quantities of data produced by coroners each year. Since 2000, Australia and New Zealand has had access to the National Coroner Information Service, which is an online, accessible repository of all findings recorded by coroners nationally (Walter et al. 2012). This represents an excellent learning tool and should be replicated in England and Wales
This submission, therefore, considers how and why we need to re-think the role of coroners in order to more effectively utilise their potential powers. Other coronial jurisdictions in the Anglophone world have considerably more focused and resourced approaches that could be adopted by England and Wales. In Australia, the state of Victoria uses an in-house interdisciplinary team to examine patterns and trends in coronial work. In Canada, the work of Ontario’s coronial service is encapsulated by a simple statement: ‘we speak for the dead to protect the living.’ Both services adopt an overtly preventive public health based approach in their work (Schulz and Dillon 2024).
Harm prevention and human rights
The coronial service has a public interest requirement to provide safeguards and learning for marginalised groups in society as part of its obligation under article 2 of the European Convention of Human Rights (ECHR). Obvious marginalised groups in this regard are: older people; those dependent on physical healthcare; people with mental health diagnoses; people with learning disabilities; and people deprived of their liberty. One obvious absence in coronial practice is the lack of recording of ethnicity on official certification, which represents a remarkable anomaly in 2024. This is replicated in the lack of data on diversity of coroners themselves (see Justice Committee 2021: 12). As human rights considerations have become increasingly part of the coroner’s purview, marginalised groups and the protection of their rights becomes more important – coroner classifications should acknowledge this.
The current localised system of coroners represents excellent opportunities at a variety of levels: in terms of being a public health resource with regards to the prevention of deaths and harms; by providing independent and critical investigations into deaths; by responding to the concerns of local communities and families; by being able to focus on specific geographical areas and/or institutions; and because contentious cases are heard in public before juries further reinforces the unique aspect of localised justice. The remarkable breadth of cases brought before coroners serves to highlight their potential as a preventive, public health function. These include (but are not limited to): drug-related deaths, work-related deaths, deaths in the care of medical providers, suicide, road traffic accidents, deaths in the air and at sea, deaths after police contact, and in prison/immigration detention. The most common comment families make after an inquest is: ‘we don’t want anyone else to go through what we have gone through – we want lessons to be learned from this process.’ Without a national collation and analysis of the data produced by inquests, this is highly unlikely.
Interdependence and scope
There is a cyclical aspect to the areas in which coroners could be better utilised. There is a lack of publicly accessible data produced by coroners, and this means there is a lack of transparency; it also leads to a lack of research into coroners due to the lack of available data. The evident differences in coronial practice are largely obscured by the lack of data and research into their work. One byproduct of this is that significant differences in practice in coroner districts remain largely unremarked, in a way that is unusual in public service organisations in 2024. Given relevant data, it would not be difficult to demonstrate, for example, that neighbouring coroner districts conduct divergent numbers of inquests, post-mortems, and narrative conclusions. If more data were available, it could also be demonstrated that the number of Reports to Prevent Future Deaths (PFDs) produced vary greatly between districts, as does the content of those reports. The variability of coroner practice should be an issue that is examined, rather than being written off time and again as being a matter for the autonomous discretion of each coroner. Organisational learning applies not only to the organisations being regulated at inquests, but also to the regulator themselves, namely: the coronial service.
There is a lack of analysis of the very significant quantities of data generated by coroners each year. Some glaringly obvious areas for analysis would be: firstly, narrative conclusions, the use of which has increased exponentially in the past 20 years (nearly 9000 were recorded in 2022) but which remain largely unexamined in terms of the rich qualitative learning they contain. Secondly, Reports to Prevent Future Deaths (PFDs) and organisational responses to them, as has been identified by the work of Dr Georgia Richards and the Preventable Death Tracker. Identifying best practice with regards to the writing of PFDs and responses to them would seem to an obvious and achievable aim for coroners and other regulators. Thirdly, analysing the conclusion of suicide in the aftermath of the evidential burden of proof changing in 2020 (Graham 2020). It seems likely that this could lead to an increase in the number of suicide conclusions, making it helpful from a public health perspective to understand how and why such conclusions are reached.
The variety of deaths that coroners examine also points to the fundamental interdependence of their role in socio-legal and socio-political terms. Coroners do not work in silos. They rely on a complex network of other professionals to get to the truth in each case: various regulators of public services, criminal justice organisations, local authorities, healthcare organisations, pathology, forensic services, and other expert witnesses. Creating opportunities for the cross-fertilisation of information, learning, training and analysis is essential in improving the holistic effectiveness of death investigation in England and Wales. Effective interdisciplinary working is identified as a key issue by every major inquiry into public services and preventable deaths – the one constant in the examination of such deaths is usually the coronial service. It should be front and centre of improvements to public services in relation to preventable deaths by being a proactive service than aims to prevent future deaths, rather than a reactive service which responds to the aftermath of such deaths.
In 2024, it should be a requirement that all coroner districts have an active online presence. This should include up to date information about the order of inquests, have basic information about what families should expect at an inquest, and online contact details for relevant services. It is beyond doubt that this is not the case at present. The lack of a coherent complaints or appeal function remains another obvious anomaly in 2024. The judicial review route is prohibitively costly, and beyond the reach of most people, many of whom might wish to complain about aspects of the service they have received rather than mount a legal challenge to the coroner’s decision. Whilst there is notionally a system of accountability for coroners (Justice Committee 2021), in practice it is arcane and opaque.
Concluding thoughts
The role of coroners has changed historically to align itself with the socio-political and socio-legal requirements of the time. It originally focused on revenue collection, then shifted to examining unnatural deaths in the aftermath of the industrial revolution, then to establishing foul play in suspicious deaths before the passing of the 1877 Coroners Act (Harris and Walter 2018). I would argue that today, it lacks a clearly defined role – that is one reason for the stasis in which it has found itself for some time now, and which the 2003 Luce review attempted to address. A preventive role based on public health principles would be an obvious choice to pursue as it would meaningfully align with obligations imposed by article 2 of the ECHR.
Maintaining focus on the coronial service is to be commended. Evidently, there are significant political and economic considerations that affect how the coronial service might develop. Having a clear conception of what the role of the coroner is, and what the purpose of an inquest is will be key in shaping how the coronial service develops in the future. Coroners have been embedded in local communities for centuries; they are a unique resource and provide an excellent potential forum for learning lessons about public health issues and preventing future deaths. I am grateful to be afforded the opportunity to make this submission.
Dr David Baker
Department of Sociology, Social Policy and Criminology
University of Liverpool
March 2024
References
Brend, W (2013) ‘The Necessity of Amendment for the Law Relating to Coroners and Inquests.’ Transactions of the Medico-Legal Society. 143-197.
Dorries, C (2004) Coroners’ Courts: A Guide to Law and Practice. 2nd edn. Oxford. OUP
Graham, N (2020) Suicide and the burden of proof. The Law Society Gazette. Available at: https://www.lawgazette.co.uk/legal-updates/suicide-and-the-burden-of-proof/5106554.article.
Harris, H and Walker, A (2018) Interpretation of “Unnatural Death in Coronial Law: A Review of the English Legal Process of Decision Making, Statutory Interpretation, and Case Law. Medical Law Review. 27 (1). 1-31
House of Commons Justice Committee (2021) The Coroner Service: First Report of Session 2021-22. https://committees.parliament.uk/publications/7221/documents/77640/default/#:~:text=On%2027%20May%202021%20the%20Justice%20Committee%20published,Lord%20Chancellor%20and%20Secretary%20of%20State%20for%20Justice
Matthews, P (2014) Jervis on the Office and Duties of Coroners; with Forms and Precedents. 13th edn. London. Sweet and Maxwell.
Schulz, J and Dillon, H (2024) ‘Coronial Law in Australasia.’ In Beran, R (ed) Legal and Forensic Medicine. 2nd edn. London. Springer.
Walter, S, Bugeja, L, Spittall, M and Studdert, D (2012) ‘Factors predicting coroners’ decisions to hold discretionary inquests.’ CMAJ 184 (5). 521-528