Investigating deaths

When the Government implemented its reform for the coronial service in the Coroner & Justice Act 2009, which came into force on 25 July 2013, it pledged to review its impact after 18 months; we are at that point. The Ministry of Justice has launched a review and call for evidence which closes on 10 December 2015. 

The aims of the 2009 Act are a far cry from the origins of a service which started in 1197 as a medieval tax gatherer and today stands as an independent judicial officer charged with the investigation of sudden, violent and unnatural death.

In those early years suicides were investigated on the grounds that the goods and chattels of those found guilty of the crime of ‘self murder’ would be forfeit to the crown.  The discovery of buried treasure in the community - treasure trove - was a medieval duty that was to remain for centuries. The role continued to adapt. Not until 1836 when the first Births and Deaths Registration Act was passed did public opinion and concern (neither of which are therefore modern concepts) challenge the way in which matters were recorded.

In 1846 Sergeant William Payne wrote to coroners to form the Coroners’ Society. With the introduction of the Coroners Act of 1887, coroners became more concerned with determining the actual medical cause of sudden, violent and unnatural deaths for the benefit of the community as a whole. Fast forward over 100 years and the Shipman Inquiry and Luce Review both concluded systems for certification and investigation of deaths in England and Wales were out of step for a modern society.

In response, the Government published a paper on Reforming the Coroner and Death Certification Service in March 2004 which accepted many of the recommendations made in those two reports and pledged to provide a draft Bill.  That draft Bill on Coroner reform was eventually published on 12 June 2006, resulting in the 2009 Act.

The ramifications of the Act centred, quite rightly, on the bereaved family and created, from the service’s perspective, a more organised force which could serve both the public and Government.  One fundamental change was the creation of a Chief Coroner whose responsibility was to those above and below, inside and outside the service.  With the post came the requirement for presentation of an annual report to the Lord Chancellor (available online), the coordinated appointment and training of all coroners and the creation of equalised coronial areas, some of which may, geographically, be quite large.  Coroners now have a duty to consider Prevention of Further Deaths reports whilst undertaking their inquests with a strict timetable for respondents to provide their replies.  Copies are sent to the Chief Coroner and are posted online.

For families, there was (and still is) a drive to question delays in hearings so that they can move on. More fundamentally it placed the family at the centre of the whole process.  Bodies can be released earlier without the necessity of opening inquests, allowing the grieving process to continue; delays of more than 12 months must be reported to the Chief Coroner.

Nevertheless, the coronial service remains a local service, paid for by the Local Authority, staffed by officers who support the Senior Coroner, their deputy and assistants.  Not every jurisdiction has equal support and funding.  Approximately 220,000 deaths are reported to coroners each year; approximately half will involve a post mortem.  One of the mainstays of the new Act is a greater emphasis on investigation and preliminary enquiries and less on the inquest.  This shift in focus can often lead to a much earlier conclusion without the need for an inquest which should, in the medium term, lead to fewer inquests.  Another change is removal of the necessity for a jury inquest for deaths in custody when the death is from natural causes.  In the conclusion of the first annual report, the Chief Coroner believed the reforms were beginning to take effect, a position with which I wholeheartedly agree.  They will continue to do so.

The current review is a welcome opportunity to assess progress and ensure that families remain at the heart of the process.

Julian Morris is a Partner at Parabis Law LLP