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This is a classic case of coroners who are out of control and believe they account to no-one. You have a Chief Coroner who is that in name only and has no power to deal with the conduct and performance of coroner's. Add into the mix a completely ineffective judicial conduct office and this is what you get. Basically the system is flawed and designed to let the people who matter most - bereaved families down. Had the independent coroner inspection regime first mooted in the draft Coroner's and Justice Act been implemented, but dropped by government presumably because of cost, rogue coroner's like this would be found out and properly held to account much sooner. It's time the government and the Ministry of Justice ( the government department with responsibility for coroners) got a grip otherwise more bereaved families are going to be completely let down by the system, let alone the poor staff who have to work with these coroners.