The coroner system in England and Wales can still be regarded as a largely “forgotten service”, the chief coroner said in a coruscating lecture last night. It was timed to mark the tenth anniversary of the Coroners and Justice Act, a limited reform that was passed by parliament in 2009 but not implemented until 2013.
Judge Thomas Teague KC listed a litany of failings in the arrangements for inquiring into sudden, violent or unnatural deaths:
In all but a handful of areas, teams of coroners’ officers are understaffed and overworked, resulting in avoidable delays to cases, lack of resilience, and damage to the officers’ welfare.
Too many buildings are dilapidated and there are still some coroner areas that have no dedicated courtrooms at all. In some areas, the irreducible minimum requirements of a coroner area of any sort are just not being met.
In many areas there are not enough coroners, particularly salaried area coroners. This places senior coroners under excessive pressure, jeopardising their welfare and undermining performance.
Court security arrangements vary considerably and are rarely adequate.
One of the key purposes of the 2009 act reforms was to accelerate the inquest process. Unfortunately, delay remains a significant challenge for the service.
Delays can also impact on public learning, which in the worst circumstances could result in a risk of future deaths not being identified in time to prevent further fatalities. In the eyes of many, that danger is compounded by the absence of any effective system of monitoring the outcome of reports for the prevention of future deaths that coroners issue.
There is an urgent need for action to tackle the shortage of pathologists.
Coroners do not receive the same press support or human resources support as their colleagues in other jurisdictions, nor are they included in many of the national policies that apply to other judges.
Teague said there was a limit to what could be achieved within the reforms introduced by parliament in 2009. “The structure of the coronial service and its funding model are matters for the government and parliament to consider,” he said. As a serving judge, he could not intervene on matters of policy.
But it was not hard to guess what he thought about the current structure and funding arrangements. Coroners are appointed, but not employed, by local authorities. Their staff are funded by local authorities and policing bodies. The obvious reform would be to bring coroners and support staff into the same structure as the rest of the judiciary.
Like everyone else who has ever considered this, I have long argued for a national coroner service. And everybody knows why it has not happened. It’s simply money: the Treasury won’t pick up the bill for a service that, for centuries, has been funded by local government.
But look at the disadvantages that Teague listed in his lecture. For a start, local councils can’t be relied on to pick the right candidates:
Unlike other judicial appointments, which are handled by the Judicial Appointments Commission, the selection of coroners remains in the hands of local authorities. The 2009 act introduced a requirement for the chief coroner and lord chancellor to consent to each appointment. My predecessors and I have taken an active interest in coroner recruitment in order to ensure that local authorities apply and follow a fair process and also to satisfy ourselves that successful candidates are of good character.
However, the chief coroner has no role in interviewing candidates or making appointment decisions. When the chief coroner, or the chief coroner’s nominee, attends an interview, he or she is there simply to observe. As one of my predecessors succinctly put it, the chief coroner has a veto but no vote…
While we have been fortunate in the successful candidates, I do have reservations about the robustness of the process that is used to select senior coroners. There is no judge on the interview panel and usually no one with a detailed knowledge of coronial law…
The senior coroner must have the legal knowledge, judgement and skills necessary to be effective as a judge. I am not convinced that the current recruitment process enables those requirements to be properly tested.
That’s particularly alarming because coroners, being judicial officers, are difficult to sack.
Another problem identified by Teague is the way most coroner areas are run:
The involvement of police forces and local authorities in resourcing most coroner areas creates a “triangle of responsibility”, with the senior coroner, relevant local authority and policing body having to agree many aspects of how the service will function. These complicated arrangements can delay or even paralyse decision-making and are liable to generate disagreement to the detriment of performance.
Although coroners’ officers and other staff work to the direction of the coroner, they are formally employed and line-managed by either the local authority or police force. This can generate conflict and confusion. There are frequent misunderstandings about the boundary between independent direction by the coroner and legitimate line-management by the employer.
For local authorities and police forces, supporting a small part of the judiciary is but one of their many responsibilities. This means that they often lack the expertise to recognise the practical implications of protecting judicial independence; and they may not appropriately allocate funding in the face of completing priorities, especially when their own financial situation happens to be precarious.
Two years ago, the Ministry of Justice rejected a recommendation by the Commons justice committee that there should be a national coroner service. The committee is now following up its original recommendations and has issued a call for evidence.
Still, said Teague, he was proud of what coroners had achieved over the past 10 years:
They are hardworking, dedicated people for whom service to the public, and above all the deceased and the bereaved, is a true vocation. The work they do is important to those who seek answers about the deaths of their loved ones, as well as to society at large. They continue to provide the best service they can in the difficult circumstances that prevail, and I am confident that they will show the same dedication in the years that lie ahead.
And things have got better since 1875, when voters were invited to choose the county coroner for Suffolk. There were three candidates. One was a lawyer, one was a doctor, and the third was an auctioneer. The auctioneer was elected.
That led to an editorial in the Spectator:
We wish other counties would follow the example, and elect coroners still more unfitted for the office by training and pursuits. There would then be a fair chance that this anomalous absurdity in our system, the election of a judge with serious powers and duties, by a mob, would be summarily abolished, and the coroners chosen, like the county court judges, on the responsibility of the lord chancellor.
Almost a century and a half later, we are still waiting.
https://fittedin.org/fittedin/?p=1281&fbclid=IwAR2zD8vkXbKvKOhebX_nO1oBBVQEQHCkqIUfJMcKZy_mUyT9B0QAtWcBk3I
Joshua, I’m sure the lecture was coruscating; but did you mean to suggest that it was excoriating?