Inquests | 27 September 1991

The ancient office of coroner needs an overhaul. Inquests do not properly cater for the aftermath of disasters such as Hillsborough or the Marchioness. Nor are they satisfactory in dealing with deaths in institutions which may be caused by lack of care.

The office of coroner is so ancient that there is no reliable account of its origin. Certainly it existed in the time of Henry I and is referred to in the Magna Carta. Rules regarding coroners are made by the Lord Chancellor with the agreement of the Secretary of State. The major codification of the powers and duties of the coroner took place in the Coroners Acts of 1887 to 1954.

Coroners’ courts faded from public debate until a decade ago. There was a threefold rise of deaths in custody in the 1970s and a series of well publicised and controversial cases, Jimmy Kelly and Blair Peach, for example. Public concern led to an amendment of the Administration of Justice Act 1982, making juries mandatory at inquests on deaths in police custody. The following year Chris Price MP persuaded the government to back his private member’s bill and the law was changed so that coroners’ juries are now selected at random. Lawyers acting for relatives of the deceased, and frequently receiving little or no payment for their work, have since established case law on the right of a family to have an independent post mortem and the validity of the verdict of lack of care.

These lawyers, in association with the voluntary organisation Inquest, have established a formal Inquest Law Group asking for reforms such as advance disclosure of evidence to a coroner’s court to interested parties, enabling juries to describe a death in their own words and legal aid for relatives at inquests.

Lawyers acting for families in the wake of major disasters would go further and want a system that will produce a detailed investigation into how each disaster occurred, how it could have been avoided, the assessment of blame and punishing the culpable. In contrast the present coroners’ juries are estopped from giving an opinion on the evidence or making recommendations for the avoidance of similar accidents. They cannot apportion blame. One solution may be to give the jury the power to refer a case for a wider enquiry as part of their verdict.

Coroners too are suggesting changes to the system. The country’s leading coroner, Dr Paul Knapman, of Westminster Coroner’s Court, is speaking at the Bar Conference this weekend on deaths in custody, the need for a coroner’s jury and ways of enabling the coroner to do a proper job in the disaster cases.

Lawyers working for families at inquests have enabled important issues to emerge on deaths in custody, particularly the use of remands for psychiatric reports and treatment of intoxicated prisoners. In these, as in disaster cases, the potential for inquests to help in ensuring that such tragedies do not happen again is untapped. The proposals of the new Inquest Law Group would improve the system for relatives of victims. However, the Lord Chancellor should also review the place of coroners’ courts in the enquiry into disasters, and in ensuring that tragedies such as the Herald of Free Enterprise never happen again.