Results of coronial reform have been underwhelming

The Ministry of Justice recently carried out a consultation on the impact of reforms to the coronial justice system implemented in 2013. The Coroners (Inquest) Rules 2013 (the Rules 2013) and Coroners (Investigations) Regulations 2013 built on the changes in the Coroners and Justice Act 2009.

While there has been some improvement, sadly the changes have not yet achieved their aim of creating a more efficient and supportive process for the bereaved family.

Postmortems

Part 3 of the Coroners (Investigations) Regulations 2013 set out to improve the use and function of postmortem examinations. In 2013, then Justice Minister Simon Hughes was working with the chief coroner to try to reduce the time taken to carry out postmortems. Many families and religious groups were frustrated at the time taken in some cases for postmortems to be completed and for bodies to be released.

However, the new rules only require that a postmortem take place and the body be released 'as soon as reasonably practicable', with notice to be given to the family if it couldn't be carried out within 28 days. The family have no way to challenge this, other than the difficult option of judicial review.

One of the recommendations made in 2013 was for out-of-hours services at coroner's courts to help speed up the process. However, these have only been acted upon sparingly by some courts.

Another was to offer non-invasive postmortems more frequently, as a traditional examination can conflict with the religious beliefs of the deceased and their family. CT and MRI imaging has been used in some cases. Unfortunately, it has not been used widely as it is more costly.

The chief coroner, His Honour Judge Thornton QC, remarked in September 2013 guidance that postmortem imaging was offered 'certainly not as a free service' and the family would be charged for the extra cost.
This puts a family in a difficult position, having to incur an expensive fee to prevent an intrusive postmortem that is contrary to their beliefs. However, if imaging was paid for by the coroner's office and used more widely, this would save time and inquest investigations would be completed more quickly, saving costs.

Pre-inquest reviews

Rule 6 of the 2013 rules introduced the option for a coroner to hold a pre-inquest review hearing (PIR). The purpose is to meet with interested parties to the investigation, to manage the issues to be considered and the evidence to be heard, including from witnesses.

The chief coroner noted in Brown v HM Coroner for the County of Norfolk [2014] that PIRs are
'an important stage towards the final hearing. In each case the coroner should ensure that all interested persons, particularly bereaved families, have sufficient notice of the matters to be discussed at the [PIR]'.

Unfortunately, the PIR is optional. They are often not used in busier coroner's courts.
With both a target of six months for an inquest investigation to be completed and limited resources, there is simply not the court time. However, the PIR hearings I have attended have been incredibly helpful for the family, and this benefit shouldn't be forgotten. As well as being used to guide the coroner on matters to be considered, the bereaved family also get to experience the tone of the inquest process.

The benefit of this to the family cannot be underestimated. One family I assisted was very relieved that they'd gone to the court before the final hearing. They felt that going to the court for the first time for the full inquest would have been overwhelming.

The best solution is to make PIR hearings mandatory. This will necessitate the appointment of more coroners to deal with the additional workload.

The only alternative would
be to remove the six-month target. To do so would put bereaved families at risk of further delay. Inquests are already often delayed. In the year 2013/14,
the number of inquests that were still incomplete at over 12 months after the death was 2,673.
The figure for 2014/15 was 1,467. There is still work to be done
to reduce this figure further.

It would be useful to monitor the number of inquests that include a PIR. This information
is not covered in the chief coroner's annual report.

What next?

The focus of the changes must be on modernising the system and putting families first.
A balance must be struck between a proper investigation and avoiding a lengthy and painful delay for the family.
The process of investigating the death of a loved one deserves proper investment of time and resources. Once the impact
of the 2013 rules has been considered, I hope that further improvement can be made.

Tom Gough is a senior solicitor in the clinical negligence team at Bolt Burdon Kemp @BoltBurdonKemp