Bereaved families deserve justice for loved ones

In September 2012, Judge Peter Thornton QC (pictured) took up his appointment as the first Chief Coroner of England and Wales. At the Howard League of Penal Reform - Parmoor Lecture on 25 October 2012 he set out his vision for a new coronial system in which he plans to place families at the heart of the process and ‘justice’ as the theme of his reform.

These changes will not just be welcomed by bereaved families but by their legal representatives who have been calling for greater accountability in the inquest procedure for years.

The new status quo of a “more flexible, more alive to the needs of the bereaved, more open and transparent” system will improve the way that inquests are conducted and mark a new standard in the deliverance of justice for the public.

The purpose of a 21st century coronial system will also place coroners under a statutory duty, even though such duty is contained in the schedule of the new Act to report to government, local government, agencies and institutions “so that lessons can be learned in the future”.

The chief coroner told Solicitors Journal that “the rule 43 process is really important in avoiding future deaths and reassuring families who have lost a loved one that this type of death will not happen again.” Identifying systematic failures in custody, treatment in prisons or police stations or a lack of warning signs against a special danger for the public are just a few examples which the chief coroner has stated could lead to changes for the better.

“Lack of clarity”

However, such changes have come too late for bereaved families such as the relatives of Kafi Ibrahim, a 14-year-old boy who drowned after jumping into Rainbow Dock, Surrey Quays in Lambeth, while playing with friends. At a two day inquest held at Southwark Coroners’ Court last December, the court heard that local residents had reported the frequency of children swimming in the dock during hot weather on a number of occasions to the dock office but that these reports were unknown to the staff at the London Borough of Southwark.

The coroner, Dr Andrew Harris recognised that “opportunities to explore potential for prevention with schools and the community had not been taken and there was a lack of clarity about reporting duties to the police and the water wardens.” However, he deferred making a rule 43 report until the local council had completed their procedural review.

Unsurprising the rule 43 report was subsequently abandoned once the procedural review was published on the grounds that the local council had addressed the findings raised at the inquest and the coroner could not see any reason to proceed to a rule 43 report. It is unknown whether the recommendations in the procedural review have been implemented.

The inquest proceedings has now concluded so there is no obligation on the local council to provide the bereaved family with an update

It is hoped that under the new Act such situations are not repeated and that there will be a presumption to make a rule 43 report in the future.

The chief coroner has also indicated to Solicitors Journal that there will be a dedicated staff member, from his small team of five, assigned to work exclusively on summarising themes and progress of rule 43 reports and to carry out a follow-up.

Police training

This will be of great significance to the relatives of Karlene Wright in their quest to achieve accountability for her death. Mrs Wright fell from a high storey car park, whilst police officers were in attendance but failed to prevent her death. The inquest held at Croydon Coroners’ Court in January this year heard that there was a lack of training for such incidences as no police policy existed to address this situation. The coroner, Dr Roy Palmer made a Rule 43 Report, for the Metropolitan Police “to consider whether it is possible either to issue some guidance or deal with the matter in basic training, or to update some guidance that may already exist.” The relatives of Mrs Wright have yet to hear from the Metropolitan Police as to whether they have now introduced a policy to cover such incidences in their training or what steps they are planning on taking to respond to the rule 43 report.

It is hoped that the Chief Coroner’s Office will be able to monitor the progress made by the Metropolitan Police in implementing training following this inquest and address any further delays on behalf of the family.

Delay is denial

The new Act will also address the delays in holding inquests, especially those which have not been held within a year of the death. The chief coroner has stated that “justice delayed is justice denied”. The inquest into the death of Mark Duggan, who was shot dead by Metropolitan police officers in August 2011 is planned to commence on 28 January 2013 despite efforts to delay the inquest until the retrial of Kevin Hutchinson-Foster, who has been charged with “selling or transferring a prohibited firearm” to Mark Duggan.

The inquest into the death of Alexander Litvinenko will also be held early next year, six years after he was poisoned with polonium-210 while drinking tea at the Millennium Hotel, Grosvenor Square. It is thought that the Attorney General’s Fiat to quash the verdicts given at the inquest of those who died at the Hillsborough disaster, 23 years ago will also be held next year.

The new Act aims to provide justice to the public, openly and transparently and the chief coroner is ready to take on the challenge to achieve this goal.

It is now up to the coroners in England and Wales to deliver the public justice denied in the past.