Supplementary evidence submitted by HH Judge Peter Thornton QC

Service Deaths

I am writing to provide the information I promised to send to you following my appearance at the Defence Sub-Committee on Monday 1 February 2016. I am very grateful to you and the Committee for giving me the opportunity to come and speak to you.

As you know I have a statutory responsibility to monitor coroner investigations into service deaths and to secure that coroners conducting such investigations are suitably trained to do so: section 17, Coroners and Justice Act 2009. In order to comply effectively with that responsibility I created the cadre in 2013 and have held specific related training: see Chief Coroner’s Guidance No.7. In addition there is annual continuation training for all coroners, designed to spread good practice and encourage consistency of standards between coroner areas. Also, in December 2014 I requested senior coroners to notify me within 24 hours of any service death reported to them.

Since the 2009 Act came into force in 2013 only 18 deaths have been referred to me. 11 of those investigations were conducted by cadre members, mostly by the Oxfordshire coroner. In addition to those 18 cases, one case (Private Cheryl James), ordered by the High Court to be re-heard, is being conducted by a nominated judge, and a second case (Private Gavin Williams) was conducted by a Judge Advocate who is also an assistant coroner.

Cases over 12 months

Of those 18 deaths reported to me under section 17, 11 have subsequently been reported to me as not being concluded within 12 months after the death was reported to the coroner.

The reasons for these coroner investigations not being completed within 12 months varies from case to case, although military deaths often have a degree of inherent complexity which means they can take longer to come to the inquest. The coroner will usually need to wait for other matters to be dealt with first, such as the completion of the Service Inquiry or other specialist investigation, which the coroner may require for factual information and evidence. However the coroner will still be involved at an early stage and there are likely to be one or more pre-inquest review hearings leading up to the final hearing. In some cases the coroner may need to wait for a decision whether criminal charges are to be brought by the Crown Prosecution Service.

Training

I have considered all the training issues you have raised and will continue to do so. I am grateful to you for having raised them. For example I have discussed with the Defence Inquests Unit (DIU) of the Minsitry of Defence (MOD) whether there might be an opportunity for the cadre to learn about the treatment and care pathways available to service men and women, particularly after discharge from the armed forces. This is a matter the MOD are considering.

I continue to have a close working relationship with relevant Ministers in Government and especially with the DIU. The DIU works closely and effectively with coroners investigating service deaths, providing reports, witness statements, documents and other materials, and assisting with witnesses at court. The current working relationship between coroners and the DIU is a good one. I last met the head of the DIU, Mr Nick Pett, on 2 March 2016 and my office remains in regular contact with his.

I am pleased to report that as a result of close monitoring of cases, the establishment of the coroner cadre, training for relevant coroners, good relations with the DIU, and thorough inquests held in public, families of deceased servicemen and women are now better served, in my view, by the coroner process. 

11 March 2016