The government has outlined reforms to the archaic coroner service. But lawyers fear the loss of local expertise and bemoan the lack of public funding, reports Grania Langdon-Down

The government has condemned the coroner service as fragmented, unaccountable and archaic, and has promised to put bereaved families at the centre of its proposed reforms.


But will the reforms – which include the appointment of a chief coroner for England and Wales to provide national leadership and to hear appeals from coroners’ rulings, and a requirement that all coroners are legally qualified and work full-time – achieve their aims?


The government has so far given little detail of how the reforms will work in practice, promising a draft Coroner Reform Bill in the spring, although it has said the chief coroner should be in post by the end of 2007 with the reforms coming into force in 2010.


However, the figures that have been mentioned have raised serious questions among coroners and practitioners. There is £5 million to meet the cost of the reforms and a reduction in the number of coroners from 111, of whom 28 are full time and 83 part-time, to 60 to 65 full-time coroners covering areas largely aligned with local justice boundaries.


The coroner service costs about £70 million a year. Of the half a million deaths a year, slightly less than half are referred to a coroner. In 2004, 115,800 deaths resulted in a post-mortem examination, with 28,300 resulting in an inquest, 570 with a jury. At this stage, the government has decided against introducing the requirement suggested by the Shipman Inquiry that all deaths should be subject to an additional medical scrutiny by a coroner, arguing it would not achieve the ‘delicate balance’ between cost, risk, delays and the rights of families to proceed quickly with funeral arrangements.


Aidan Cotter is the full-time coroner for Birmingham and Solihull and president of the Coroners Society, although he stresses that he comments in a personal capacity. He deals with about 5,000 deaths a year, of which 850 result in inquests, about 20 to 30 with a jury.


He considers the idea of fewer but full-time coroners to be unworkable. ‘I am not sure you can cover England and Wales just on full-time appointments because you will get localities that won’t get a proper service and that is not fair on the families. Local links will be lost.


‘[Law] firms which have part-time coroners within their practices have also subsidised the service to a significant amount and the government is going to have to appreciate that if they do away with part-timers, they are going to have to provide a lot more resources.’


He says resources for training have improved but are still not good enough, while many other areas, such as pay and infrastructure, are also lagging behind. Salaries for coroners are ‘way below tribunal chairmen, which is a nonsense’, he says, adding: ‘It is no good saying we have to improve the system because coroners aren’t treating bereaved families properly and then find some coroners don’t even have a court to sit in.’


David Halpern is the part-time coroner for Herefordshire and senior partner at Hereford law firm Lambe Corner. He deals with about 750 deaths a year, with 10% resulting in an inquest. The job brings in £21,000 a year – ‘less than I could earn doing my legal work’ – and his firm helps subsidise his role. He does the work because ‘it can be rewarding when you feel you have helped someone draw a line and resolve issues that have been worrying them’.


He questions what the reforms will mean for an area like Herefordshire. ‘If coroners are more centralised, they may be able to do the work physically but is that all we really want? I have been in Hereford practically all my working life. If someone has a problem, they will ring me. They won’t do that if they have to ring some amorphous body in Birmingham.’


Under the reforms, coroners will continue to be paid by their local authorities – with full-time coroners currently paid between £66,000 to £81,000, taking into account the population of their areas – rather than be part of either a national coroners’ service or the Courts Service. They will keep their current status as individual office holders rather than employees of the council.


Andre Rebello, the coroner for Liverpool, last year dealt with 3,016 deaths and held 459 inquests. He says it is ‘probably right’ to have fewer, full-time, legally trained coroners – at present, coroners can be doctors – but he points out: ‘We don’t come under the working-time directive. I work seven days a week apart from when I am on holiday. I don’t have any coroner’s officer cover at weekends or at night.


‘In Northern Ireland, they have set up a coroner service with one coroner and two deputies, all full-time, who are paid on the Department for Constitutional Affairs’ judicial scale equivalent to district judges. This is some £15,000 to £20,000 more than coroners are paid in England and Wales. Yet they will each do less than a third of the work I do. How attractive is this job going to be to get the best lawyers to leave private practice unless they have a passion for the care of the bereaved?’


Former criminal defence solicitor John Pollard is the coroner for South Manchester and chairman of the Whole Time Coroners Group. Speaking personally, he says coroners ought to be full-time because of the complexity of the work and the pressures of combining it with private practice.


‘But it is rather naive to think 65 coroners can do the job. Although I still deal with roughly the same number of deaths – about 3,500 a year with about 400 inquests – as I did when I started 11 years ago, the demands on my time have doubled.’


He says it is a ‘Cinderella service’ when it comes to resources. He has to sit in a magistrates’ court, which has no loop facility for the hard of hearing. ‘I don’t think that is good enough in the 21st century.’


Michael Burgess, former honorary secretary of the Coroners Society, is coroner for Surrey, recently conducted the inquest into the controversial death of a young soldier at Deepcut Barracks. After the jury returned an open verdict, Mr Burgess said the Ministry of Defence should have ‘nothing to fear’ from a public inquiry.


Away from the spotlight, he has a permanent court but it is too small to hold a jury inquest, so he has to book a suitable one 18 months ahead. He deals with 4,000 deaths a year, of which about 410 result in an inquest. ‘Last year, we had four deaths in custody but I was only able to hold an inquest into one and that took three weeks. We are running on resource overtime.’


The one proposal that has received general support is for a chief coroner, although Mr Pollard questions whether one person will be able to deal with the number of queries that could be raised by the public. The chief coroner, who will be accountable to government, will hear appeals from coroners’ rulings, be responsible for coroners’ training and be able to bring judges in to handle complex cases. He will be supported by a coronial advisory council and backed by an inspection system.


Mr Cotter welcomes the idea. ‘The chief coroner should be a High Court judge so he can oversee what we do and give us some direction. He should also deal with appeals so we don’t have to have judicial reviews, which are grossly unfair to coroners. This way, appeals could be heard more quickly and fairly.’


For Louise Christian, partner at London firm Christian Khan and chairwoman of the pressure group Inquest, the move could end the ‘little fiefdoms’ that sometimes develop, with coroners taking very different approaches. ‘We would welcome better accountability, better training, more consistency in approach and to have coroners regarded as more regular members of the judiciary,’ she says.


However, the government’s proposal that in limited cases, such as some suicides or child deaths, coroners should have a new discretion to complete their investigation and decide on the facts without holding an inquest ‘where no public interest is served by doing so’, has met with strong views.


Mr Cotter says: ‘There should be no form of justice which is done behind closed doors. At the moment, we get terrific pressure on us not to hold an inquest. I may get a death in Birmingham and have 13 city councillors asking me whether I have to hold one, and whether I realise how much tragedy is involved.


‘But I can say “sorry, the law requires me to hold an inquest”. If I get pressure now, just imagine how much pressure there will be if this goes ahead. And where do you draw the line? The government talks about distress to families. But suppose you have an extended family and some are not being told anything? Suppose you have a baby death and the father wants an inquest and the mother doesn’t? What do I do? Spin a coin or see who has the loudest MP acting for them?


‘I cannot imagine why the press aren’t kicking up about it. The only real virtue of the coronial system is that it is all in public.’


Raju Bhatt, founding partner of London law firm Bhatt Murphy and a member of Inquest’s advisory board, agrees: ‘If you start sacrificing public scrutiny, you start sacrificing notions of justice.’


However, Mr Burgess, who has been a coroner for 20 years, argues that there are cases where there is no public interest in having an inquest, for instance where an elderly person falls and hits their head. ‘I don’t think it would open us up to pressure. We are entrusted with a lot of things and surely we should be entrusted to make those decisions, which will always be appealable.’


Most coroners agree with the proposal to limit jury inquests, which they currently have to call if the death is also reported to other statutory authorities. Mr Burgess says: ‘Juries don’t necessarily produce the best answers.’


However, practitioners regard it as a ‘vastly retrograde’ step. Ms Christian says the proposal would not affect deaths in custody cases but it would be ‘absolutely catastrophic’ if it restricted juries in other cases raising article 2 (right to life) issues under the Human Rights Act 1998. ‘A jury gives controversial inquests their legitimacy. We already have problems getting juries on [death by] clinical negligence cases,’ she says.


For practitioners, the ‘critical sore’ running through all the proposals is the lack of any commitment towards public funding for legal representation in controversial cases. Mr Bhatt says: ‘The government claims it is putting bereaved families at the centre but they are nowhere without funding.’


Ms Christian explains: ‘It is a constant battle to get funding. It is now relatively straightforward to get funding for deaths in custody [cases] but the stupid thing is you can get funding for a death from natural causes in a death in custody but you can’t get funding for representation in a major rail crash. When you can get it, the rates are very low, yet these cases often involve major public safety issues. And there is the awful situation where families are not represented but there are all these public bodies who have employed QCs at the taxpayers expense.’


She is currently judicially reviewing the Department for Constitutional Affairs over its failure to allow funding for her client David Main, whose partner and daughter died in the 2004 Ufton Nervet train crash. His savings put him slightly over the legal aid limit but he is having to live on them to look after his young son, she says. ‘We applied to the Lord Chancellor to use his discretion to allow exceptional public funding under the principles of ex-parte Khan, the clinical negligence case where it was decided the Lord Chancellor had the discretion to override the financial limits on article 2 cases. The Legal Services Commission recommended it should be granted but the legal aid minister Bridget Prentice refused to grant it.’


Ms Christian says no-one is arguing that people should have legal representation at all inquests. ‘But if the death was preventable by a public authority or it is a death at work or through clinical negligence, then there should be a normal legal aid certificate paid at normal rates.’


Coroners also support more legal aid for complex cases as good representation helps them as well as the families. Mr Burgess says there can be two extremes – the aggressive counsel who has an agenda and tries to conduct a trial within the inquest, and the weak advocate who fails to ask the right questions. ‘Someone in the middle who is productive, knows what questions to ask and has educated their client on the limitations of the present system is very useful.’


For Mr Halpern, an important reform would be to give a more defined role for bereaved families so it is not left to coroners with a ‘social conscience’ to ensure it happens. He would also like to see verdicts widened so coroners could say if they believe someone is to blame.


The government has made great play of giving the bereaved ‘proper legal standing’ in the system, including allowing relatives to ask a coroner for a second opinion.


However, Mr Cotter says: ‘There isn’t a single thing that has been suggested so far that the families don’t already have. I am very happy for it all to be set out in a charter but there is nothing new.’


Overall, Mr Burgess says the mood among coroners is one of ‘great disappointment that maybe the efforts we have put into many years of discussions and blue-sky thinking has not brought anything of substance. I think we have lost a real opportunity.’


Grania Langdon-Down is a freelance journalist