When someone dies unexpectedly, it’s the coroner’s job to find out their cause of death.

Families put their trust in the coroner’s service to piece together what happened to their loved ones. They expect a level of empathy and respect during what is an emotionally raw and new experience for families.

The service can be fantastic but equally there have been reported experiences of the level of service received falling below expectations. The bereaved become the unheard, their concerns dismissed, which can lead to frustration and anger. A negative experience with the coroner’s service is one that the bereaved will remember for a long time, and one which can impact negatively on the grieving process

In November, an inquiry was launched by the justice committee to examine the progress made towards the goal of placing bereaved families at the heart of the coroner’s service. Justice committee chair, Sir Bob Neill MP, said:

“We intend to visit coroners to see how bereaved families’ experiences vary, examining in particular any regional disparities, delays and Coroners’ responsiveness to the particular requirements of faith burials and funerary practices.”

Here we look at some of the issues bereaved families face.

No mandatory standards

You may be surprised to learn that the coroner’s service is not a national service funded by the government. Instead, it is funded and overseen by local authorities. There are 85 local coroner services in England; since 2004, this has reduced from 127 following the decision to merge some neighbouring services. However, there remains inconsistencies in the facilities, services and experience that families receive across regions, with what some would call a postcode lottery.

The issue remains that there are no mandatory standards for how families are treated. This is very different from the criminal or civil justice systems where victims are afforded certain rights throughout the process. As there are no trials at coroners’ courts, there are no safeguards in place like in other courts.

What does the coroner's service do?

The coroner is the figure head of the coronial system, the judge who determines a person’s cause of death. But a lot of the investigative legwork is done by coroner’s officers. These may be civilian police officers or local authority employees who act as a link between the coroner and bereaved families.

Most of the contact that bereaved families have is with a coroner’s officer. From the very start, it is their job to explain to the role of a coroner, outline the inquest process, and answer any questions that families might have.

They should also make families aware of their rights and responsibilities, let them know when hearings are to take place, share evidence and documents with them, and take into account any faith or disability needs. In most cases, families learn more from receiving a copy of ‘A Guide to Coroner Services for Bereaved People’ that was published by the Ministry of Justice in 2020.

If the body cannot be returned within 28 days of the death, then the coroner is required by law to tell the family the reason for delay. If an investigation is taking longer than normal, then the coroner’s office should contact the family at least every three months with an update. But families are often chasing the coroner’s office for an update after being left in the dark.

After the inquest, coroners may use the information discovered to prevent future deaths. They can write a report for others to take action, and organisations must respond within 58 days to confirm what action is to be taken. However, there is no process to follow up on actions proposed. Families are left feeling like their loved ones died in vain, with no lessons learned to prevent other people dying in similar circumstances.

To ensure bereaved families have a positive experience with the coroner’s service, consistency is key. The government has already rejected the idea of a national coroner’s service that was previously recommended by the justice committee. One new recommendation is that the Ministry of Justice should establish a charter of rights for interested persons at inquest.


Discrepancies between services offered

In 2022, 208,400 deaths were reported to the coroner, the highest number since 2019. This accounted for 39 percent of all registered deaths. Around 43 percent of those reported to the coroner led to a post-mortem, and 18 percent proceeded to a full inquest.

If a death is reported to the coroner, it is because it was either:

  • Unnatural or violent
  • Unknown how a person died
  • Happened in prison, police custody, or other state detention

The coroner’s office must then determine the cause of death based on medical records, the pathologist’s findings at post-mortem, and witness statements or evidence from families, police, doctors, mortuary staff, hospital bereavement staff, and funeral directors. This evidence will sometimes be heard at an Inquest hearing at a coroner's court.

At some coroners’ courts, there are private rooms for families to use during the inquest hearing, but again this is not a nationwide requirement. There are also sometimes support services offered free of charge to families where volunteers from charities like the Coroners’ Courts Support Service will talk to families before an inquest and sit with them throughout the hearing.

All inquest hearings must be recorded and families have a right to ask for that recording or the daily transcript. Improved IT systems have enabled remote hearings and witness attendances, but there is still more to be done.

Why do families have to wait so long for an Inquest?

In recent years, there have been huge delays at coroners’ courts. In April 2022, over 4,500 cases took longer than 12 months to complete. The longer it takes, the more anguish for families, as the body cannot be released until the investigation is complete. This means that the death can’t be registered and therefore no funeral can take place. Also, with the passing of time comes faded memories, lost or degraded evidence, and lessons not learned.

In some cases, funerals can take place before an inquest, provided there has been a post-mortem (autopsy) and the Coroner gives permission for release of the deceased’s body.

To reduce the turnaround time, some (but not all) local authorities have funded post-mortem CT scanners. This means that 3D imagining is used to examine the body, rather than the use of a scalpel. Families often aren’t told that, if they prefer for the body to be examined using a CT scanner, they can ask the coroner. There may be a charge for this, and it may not be possible to approve the request depending on logistics and timing.  They might also not know that, while family members can’t attend the post-mortem, they can instruct a doctor to be present. Again, this might incur a cost.

A statutory minimum of local authority resourcing would make a significant improvement to levelling up these inconsistencies.


Families not always treated with respect

The role of a coroner requires a specific skill set. They should be curious, have integrity, remain neutral, communicate empathetically, have good case management skills, and understand both law and medicine. A coroner is usually a lawyer or a doctor for that reason.

A coroner should remain independent throughout the investigation. It is not their job to find someone guilty or blame anyone for a death. Their sole focus is to find out how, where and when a person died.

Most coroners and their officers are sympathetic, sensitive to families’ needs, and acknowledge the difficult circumstances.

The coroner should take care to always refer to the deceased’s name correctly. It might seem trivial, but to grieving families, the wrong pronunciation of a name can cause distress. They should also be mindful of anniversaries or significant dates, and try not to list hearings to coincide with these. However, this practice is not universal. Training for coroner’s officers or a prompt in the IT system would prevent some distress experienced by families.

Families often feel that the clinical and investigative nature of inquest hearings results in the life of a person not being told. The use of pen portraits has become more common in recent years to humanise the hearing. Some coroners like to take the time to understand what a person was like while alive, their hobbies and interests. Families are able to submit pen portraits in slideshow format with photos, video and music, but the discretion lies with the coroner as to whether this will be shown.

As with any branch of the judiciary, the coroner can make errors. There is no right to appeal, but it can be possible to challenge the coroner’s decision or outcome of the inquest via the chief coroner. If a family is unhappy with the coroner’s behaviour for any reason, they can make a complaint via the Judicial Conduct Investigations Office (JCIO).

Inequality of arms

As previously mentioned, inquests are not meant to be adversarial. There is no need to apportion blame, and therefore no reason for any party to defend themselves.

However, where large, state-owned organisations or public bodies are involved, as in the case of patients who died due to errors in the medical care they received from the NHS, it can be difficult for coroners to maintain the inquisitorial approach. This can put bereaved families at a disadvantage during hearings.

These large organisations will usually have legal representation present. But legal aid funding isn’t commonplace in inquests, and families may not have the funds available to appoint their own solicitor. Very few families are told about law firms who offer conditional fee agreements, aka No Win No Fee. If there is a high chance that the family will make a civil case for medical negligence, then a no win no fee agreement would include inquest representation without an upfront cost to the family.

Without legal representation, families can feel lost or unsupported, especially if other people or organisations are trying to limit liability. Interested persons have the right to ask relevant questions at inquest hearings, but this can be daunting.

The provision of medical records in a readable, structured format is also rare. It should be the role of the hospital or coroner to ensure this, but it is usually left to the family’s solicitor. Without this, a family who has no experience of the legal or healthcare system may not fully understand what has been written.

There remain issues with disclosure of some key documents, and resistance from some public bodies with fully engaging with their Duty of Candour. Coroners have the power to instruct the police to seize documents without notice, and that coroners can issue fines and custodial sentences for non-compliance of disclosure requests. But this is rarely done.

Most families seek legal advice late in the inquest process, when hearing dates are looming, which isn’t ideal. A solicitor who has experience of inquests and the coronial system will spend time looking over the deceased’s medical records or any pre-inquest documents and make decisions about the relevant questions that need to be asked of the witnesses. Appointing a solicitor late on in the process could result in applications to adjourn the hearing, so to get better acquainted with the case, which will only prolong the family’s grief.

At Medical Solicitors we would like to see that the literature provided to families and advice from coroner’s officers focuses on advising families to seek early specialist legal advice.

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