Written evidence from Andrew Haigh HM Senior Coroner for Staffordshire (South)


  1. There are substantial differences between Coroners’ areas.  Some Coroners have sufficient pathologists. I have no pathologists in my area. I have to direct autopsies to take place on a regular basis and have great difficulties in ensuring they are done.  This can cause delay and distress for family members.  Overall there is a national shortage of pathologists available to carry out coronial autopsies.  The government has been well aware of this for several years but has done absolutely nothing about it. The Hutton report suggested the establishment of large regional centres for autopsies and this made good sense.  It has not been progressed.  My staff maintain regular contact with bereaved relatives to keep them updated and generally I believe I provide a good service in difficult circumstances.  The case for a National Coroners Service can be looked at quite simply – if it was to provide support leading to an overall improvement of Coroners’ services then fine but if it is just going to create an unbeneficial burden of bureaucratic red tape then it should not happen.


  1. Multiple deaths require an adequate provision of staff and facilities to deal with them.  There is also the requirement for routine work still to be handled.  While Coroners themselves have some training to deal with such matters (and there is a cadre of specially trained Coroners) there must remain doubts about the conduct of multiple deaths in public disasters if there is inadequate availability of all the various staff required together with the necessary facilities and equipment.


  1. The Chief Coroner should be properly funded to collate and publish Prevent Future Deaths reports. Either through the Chief Coroner or elsewhere there should be a clear and accessible collection of PFDs specifically covering medical matters.


  1. Covid 19 has changed Coroners’ services. In particular there has been greatly increased use of remote communications. Inquest hearings have been suitably adapted.  I have had to attend (remotely) numerous additional meetings. I have however maintained my service in these difficult circumstances.  It has not been possible to hold the Inquests where Juries are required and there will be a backlog of these.  Consideration should be given to removing completely the need for Juries in the Coroners’ Court as Inquests are not trials.


  1. Compulsory training for Coroners is beneficial. It has been well managed by the Chief Coroner since that role has existed with support from his training team and the judicial training group. As all newly appointed Coroners are now lawyers (a few may be dual qualified) there should be basic (not expert) training about medical matters.


  1. Coroners must be adequately enabled to carry out the role they perform. This must include staff, facilities and access to necessary supportive services. Once again I would mention the terrible shortage of pathologists that affects the service I provide to the bereaved and the benefits of establishing large regional autopsy facilities as recommended by the Hutton Report..


  1. It must be appreciated that Coroners areas differ massively. Some Coroners have no prisons in their areas. I have seven prisons in my area which has a dramatic effect on my workload because all prison deaths require inquests and unnatural prison deaths necessitate inquests with Juries (although, as suggested above, I believe this requirement should be removed).  Please also remember that in addition to deaths Coroners deal with finds of possible treasure as well. Some Coroners have no reports of treasure – others have dozens every year.  Consideration should still be given to the establishment of a national Coroner for Treasure as proposed in the 2009 Coroners and Justice Act (but not implemented).


Despite the difficulties I face I try to provide a decent service. Within the last couple of days I have received an email saying - “I’d just like to add a very big thank you to all of the team at the Coroner’s Office. You have treated us with the sincerest kindness and respect and made a difficult situation easier to cope with”.

August 2020