Improving the coroner service in England

Last year’s general election hindered the Justice Committee from releasing its much-anticipated report on the coroner service in England and Wales. However, the outgoing Chair of the Committee, Sir Robert Neill KC (Hon) MP, shared critical observations, noting that the service is “chronically under-resourced and underfunded.” The report underscored delays in inquest completions and highlighted severe shortages in pathology services, which have been neglected over many years. Additionally, the Committee recommended the unification of coroner services across England and Wales, a suggestion initially made in 2021. There were also calls for legal representation to be available for unrepresented families at the expense of the state, as they face significant disadvantages in the process. Furthermore, inconsistencies and delays in the issuance of Prevention of Future Deaths (PFD) reports were also identified as pressing concerns.

Exchange Chambers has actively engaged in discussions regarding the necessary improvements. Silk Louis Browne KC remarked on the inconsistent quality of services available to bereaved families throughout the country, emphasising that “this is unacceptable”. He pointed out that a national coroners’ service could ensure that everyone, especially the bereaved, receives adequate support no matter their location. Additionally, he stressed the need for legal aid to be more accessible, stating that “where families are unrepresented at such inquests… they remain at a significant disadvantage.”

David Sandiford from Exchange Chambers also highlighted the pressures faced by coroners and their staff. He noted that many advocates should work together to support the coroner and follow a more unified approach. Sandiford said, “greater consistency across the regions would be welcomed,” advocating for an increased Chief Coroner’s Office and improved resource sharing to alleviate delays. He also reiterated the need for proper funding for legal representation in contentious cases, arguing that “families finding themselves in the middle of this do need proper funding for legal representation.”

Sara Sutherland raised alarms about delays in the inquest process, explaining that “delays are a real issue, not only because many families cannot grieve until the inquest process is resolved.” David Illingworth from Exchange Chambers further emphasised the challenges stemming from fragmentation, lack of funding, and inadequate follow-up mechanisms. He pointed out that each coroner's area has its own practices and accountability lines, making it difficult to share important themes across different jurisdictions. He stated, “the committee was right to note that in contentious and complex cases a family unable to fund legal representation is at an enormous and unfair disadvantage.”

With numerous systemic issues at play, the need for an improved coroner service is evident, and the stakes are high for bereaved families.