Written evidence from John Ellery, Senior Coroner, Shropshire, Telford and Wrekin Area


  1. The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service.

Within Shropshire, Telford and Wrekin a considerable amount of historic unevenness has been ironed out since the implementation of the Coroners and Justice Act 2009 (the Act) in 2013.  Prior to the Act the area comprised three separate jurisdictions within the county of Shropshire all with separate coroners, offices, coroners’ officers in local police stations, with multiple inquest venues.  In 2009 and 2012 those jurisdictions amalgamated into one prior to the creation of the new area in 2013.

The service has been streamlined with one coroner, all administrative and coroner’s officers under one roof based centrally at the Shirehall in Shrewsbury.  Additionally we are co-located with  the Shropshire Registration Service (not Telford) and have easy and regular contact between the two.  For example if a bereaved family comes to the Shropshire Registrar to register a death and a problem arises it can frequently be dealt with, with the minimum of delay.  Most inquests take place at the Shirehall which leads to greater efficiency, with better facilities for families, witnesses and other interested persons.  As appropriate separate arrangements are made for jury inquests.  Locally the service works well with the involvement of all relevant stakeholders.

Whereas in the past the Coroners Service has been local with local standards it remains local but with national standards.  Whether there should be a National Coroners Service is a matter for the Government of the day. 

  1. The Coroners Service's capacity to deal properly with multiple deaths in public disasters.

As a coroners service locally, we have not had to deal with multiple deaths in public disasters but have all regularly attended courses and conferences and learned from others both nationally and regionally.  The Chief Coroner and the DVI cadre of coroners are available should ever the need arise.  A recent incident illustrated how resources could work together. A motorcycle accident with a JCB digger resulted in two motorcycle fatalities.  Applying national principles a DVI lite exercise was carried out to assist identifying the multiple body parts.  With the engagement of the family identification was complete.  

  1. Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths.

Regulation 28 of the Act has had a double-edged effect.  It has led to improvements to avoidable future deaths with all reports being copied to the Chief Coroner.  Whereas an inquest looks backward as to how a particular death occurred a Regulation 28 Report looks forward as to what further action is required to prevent future deaths.  If by the time of the inquest all appropriate action has been taken, then a report is no longer required.  For wider public health and safety it might be appropriate for reports to be made where lessons have been learned and actions already taken which otherwise would have triggered a report.

  1. How the Coroners Service has dealt with Covid19.

In Shropshire, Telford and Wrekin we have been indirectly affected as Covid19 is essentially a natural cause which would not ordinarily be reported to us.  The indirect effect however has been significant in terms of how we have maintained our service and our involvement in wider local planning.

At the Shirehall we would ordinarily have 8 or 9 people in attendance whereas typically we now have 2 or 3 with others working remotely and efficiently from home.  We have been able to manage an effective service with the increased use of IT.  Those working from home have access to the office systems and overall have good internet connectivity.  We have regular daily meetings where we meet on screen and review new reports and ongoing cases.  We are moving increasingly from a document-based system to digital and this work is still in progress.  By working remotely the risk to themselves and others has significantly been reduced. 

Regionally we, the coroners in the West Midlands area, have regular meetings and at its peak were meeting weekly.  This has enabled experience and best practice to evolve.

In terms of the local response, again at its peak, twice weekly meetings were held remotely with all relevant stakeholders (normally seventeen to eighteen) in attendance.  Those meetings were well run by an experienced police officer with all participants contributing to the effort.  The net result is that we were ready for the worst case which thankfully in our area did not arise.  Should there be a second wave then we should all be better prepared for it.

  1. Progress with training and guidance for Coroners.

The Act, led by the Chief Coroner and supported by the Coroners Society of England and Wales, has provided regular national training and guidance.  These are well documented and on the Chief Coroner’s website.  Until the pandemic regular conferences were taking place in person and in large measure are being replaced where possible by remote means.   Whereas before coroner training was voluntary it is now mandatory for all coroners whenever appointed and however experienced.  The Chief Coroner’s guidance and law sheets have significantly increased national consistency reducing so far as possible local variation in practice.  

  1. Improvements in services for the bereaved.

As indicated there have been significant improvements for services for the bereaved not only with consistency and efficiencies in service but by way of better and increased use of technology.  For example in our area death reports can now be made electronically through a portal ensuring speed and accuracy of information being passed down the line.  Previously a coroner’s officer would speak with a doctor and make notes of what was said and that in turn would be passed on to whoever then needed to receive it.  There is now a consistent and continuous line of information from the reporting doctor.

There is increasing use of what are called documentary/paper inquests.  We have found that when given the choice many families either have no questions for a witness or may themselves not wish to have to attend.  This has helped bring forward inquests which might otherwise be listed for hearing at a later date.  There are a significant number of fast track inquests which can be opened and closed on the same day with the family’s full agreement. 

It is the initial point of contact with the family which is critical.  Our team of coroner’s officers provide a professional and sympathetic approach to the bereaved.  Whereas a majority of deaths can be dealt with quickly and on the same day some still require a post mortem examination.  Locally we do not have CT scanning facilities, the nearest being 40 miles away and available only at a cost to the family. That cost including transportation can be in the region of £700 which for most families is not a viable option.  A recent death of a member of the Jewish community has highlighted the problem which resolved itself satisfactorily with the family, at its own cost, agreeing to a CT scan which disclosed a natural cause of death.  This avoided an invasive post mortem examination and minimised the time before a funeral could take place.  We apply the same diversity policy to all those with faith or other concerns.  Locally embryonic discussions are taking place with the hospital trust to see whether they can provide a CT scanning facility attached to the mortuary which with a radiology reporting facility would significantly alleviate the problem further.  That said there are families who have no objection to a post mortem examination taking place and positively request one for better understanding of the cause of death.

As to inquests themselves we list inquests as soon as possible with the majority taking place within three months.  Although there is benefit to the bereaved in having local inquests, i.e. close to their homes, that has not proved possible with the closure of most of the Magistrates and County Courts in Shropshire.  Having most of the inquests at the Shirehall we have found that any additional travelling is outweighed by the better facilities available.  A typical journey by car within the county to the Shirehall would be up to ten to twenty miles.

In addition families, and witnesses, have had the invaluable assistance from volunteers from the Coroners Court Support Service.  It has temporarily been suspended pending Covid19 and we welcome its return.  Not only does it support the witnesses it helps free up coroner’s staff time.

Wider still we are involved with both suicide prevention and postvention groups.

In terms of feedback from families it is generally positive with any card or note received being placed with the file and then stored centrally.  Compliments invariably praise the professionalism of the coroner’s staff for how they have dealt with the family.

  1. Fairness in the Coroners system.

The system being funded by but independent of the local authorities ensures a structural fairness as all interested persons are treated equally with the family at its centre.  We very much hope that anyone who has to use our service would feel it was a fair process.

  1. Unfunded new burdens. 

Shropshire, Telford and Wrekin comprises the County of Shropshire which in turn has two separate unitary authorities namely Shropshire Council and the Borough of Telford and Wrekin.  Shropshire Council is the lead authority and shares generic costs with Telford and Wrekin on a 60/40 basis.  This reduces cost and duplication of administration by both authorities. The salaries of the coroner and the two admin staff are paid by the local authority. The six coroner’s officers are employed and paid by West Mercia Police.  We have good working relations with the local authority and the police. The coroners service is managed by the Shropshire Superintendent Registrar who is, with the agreement of the police, the first line of contact with the coroner’s officers.  Most issues and concerns are now able to be dealt with quickly and on an informal basis.  As indicated all staff have effective technology facilities to be able to access work remotely when not at the Shirehall.  Recognising the increasing financial restraints on the local authority we in general have no concerns over funding.

If there is one area of concern however it relates to inquest venues.  We do not have a dedicated Coroners Court.  Based at the Shirehall we have been fortunate to have two suitable venues one of which can accommodate a jury.  Prior to Covid19 one venue could accommodate up to thirty people and the other over fifty.  By making suitable arrangements it has been possible to maintain and continue inquest hearings throughout the pandemic.  However there is an underlying uncertainty as to the future of the Shirehall.  Should the Shirehall relocate, which is being actively considered, we would need to ensure that the move continued to provide adequate inquest venues and from an administration point of view continue to be co-located with the Shropshire Registrar Service. 


31st July 2020