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November 2013 — Reforming The Coroner Service

Minutes of the All-Party Penal Affairs Parliamentary Group held on 5th November 2013

Reforming the Coroner Service

Speaker: HHJ Peter Thornton QC, the Chief Coroner

With additional information about deaths in custody from Deborah Coles, co-director of INQUEST


Lord Ramsbotham, in the chair
Lord Bradley
Lord Dholakia
Lord Fellowes
Paul Goggins MP
Lord Harris
Baroness Howe of Idlicote
Lord Judd
Baroness Miller of Chilthorne Domer
Madeleine Moon MP
Charles Walker MP
Lord Woolf

Lord Ramsbotham opened the meeting by welcoming HHJ Peter Thornton QC. He noted that the Chief Coroner’s post, which Peter Thornton had held for just over a year, probably existed only as a result of interventions in the House of Lords. The meeting very much looked forward to hearing what he had to say, and to the additional comments from Deborah Coles of INQUEST.

HHJ Peter Thornton began by thanking the meeting for its kind invitation to say something about coroner reform.  He continued: ‘This has been a long time in the making.  The Broderick Committee in 1971, Tom Luce and his review in 2003, Janet Smith in her Shipman Report in 2003, all called for a national coroner’s service, funded by government, led by a Chief Coroner with appellant powers. Well, you have got the Chief Coroner, but not the rest.  It has taken a long time to get the Coroners and Justice Act 2009, and it has taken rather a long time for the 2009 Act of Parliament to come into force. Mostly, it has come into force from July of this year. It was a bill with more or less broad all party support. There was no national scheme set out in the bill because there was no money for it. It was rather a muted scheme to change, but whatever it produced it was to be led by a Chief Coroner.

I was appointed on 6th May 2010, which is not an auspicious day for appointments. You will remember the day if not the date. It was the date of the last general election. As a result, the new Government decided that not only did they not want a new coroners’ service, a national service, which had already been decided, they did not want a Chief Coroner either. Ken Clarke who was then Lord Chancellor said, quite shortly: ‘Too much money: too much government’. So the office was placed into the bonfire of the quangos, through the Public Bodies Bill. In the meantime I conducted the inquest into the death of Ian Tomlinson. Two years later, after my original appointment, and after much work in the House of Lords, particularly by Baroness Findlay, and lobbying by the Royal British Legion and others, in May I was reappointed, and took up my post in September of last year. So there is no national scheme, the Chief Coroner has no appellant powers – that means that there’s just judicial review of the occasional case, and section 13 of the Coroners Act 1988 applications, with the consent of the Attorney General – but there is a Chief Coroner.  I think it was Alun Michael, who many of you know, who, considering the administrative side of the Chief Coroner’s world and looking at the Bill, said: ‘Well the Chief Coroner is a judge, so he’s not necessarily competent to run anything’. I make no comment about that.

A quick sketch of my reforms so far, and how I am implementing them, and I hope that will link in with your work and interests, and with the work of INQUEST, particularly on deaths in custody. The reforms, in short, should lead to fewer inquests, the earlier release of bodies for burial and cremation, inquests with dates set earlier, and completed in the main within six months – if they are not completed within twelve months I have a statutory duty to investigate – all with a view to providing bereaved families, who are rightly placed at the heart of the process, with a more efficient, effective, and modern coroners’ service.

My role is to facilitate change in that direction, and there are four strands to my full package. Firstly, the new act: the Coroners and Justice Act 2009 is new, and the 2013 Coroners Rules and Regulations.  The previous act, the Coroners Act 1988, placed the focus on the inquest. If you imagine a cardboard box: the coroner would make his enquiries, would obtain witnesses, statements, medical records, prison records, whatever it was, place them in the box, and when the inquest date eventually came, open the box, see what was there, and take everything out of it. Witnesses were inclined to have to wait all day because they were required to be there: they might be needed, they might not. Everybody had to attend, and the focus was very much on the end product.

The focus now under the new regime is much earlier; on the investigation itself, and even before that, on the preliminary enquiries with a view to seeing whether an investigation may not even be needed. So there is a greater focus on the earlier phases to decide whether this witness is absolutely necessary, whether there is any discussion about it, whether a statement can be read, whether there is a need for all of these documents or just some of them, and so on. And the shift of emphasis should have quite a big impact because there will be fewer natural causes inquests, reducing the number of inquests by as much as 20 per cent. Because coroners can now focus on early enquiry, if the case can be resolved early, with or without a post-mortem examination, and signed off as natural causes, so much the better for families; no inquest needed, no delay. Under the new rules, bodies can now be released earlier without the need to open the inquest. In the past, the opening of the inquest was the magic date, when everything took place, the order of the coroner for the release of the body for burial or cremation. There was therefore pressure to open an inquest, and, once opened, it had to be completed. Now the body can be released where appropriate at an earlier stage, without the need to open an inquest, and this should be particularly welcome for faith groups, especially Muslim and Jewish, who want early burial.

In addition there is a whole raft of procedural provisions, to modernise office procedures and to reduce delays. Delays have been a very big problem, and they continue to be a big problem. If there is one thing that comes across my desk on a regular basis, which is more distressing than anything else, it is families writing, saying: Why has there been three years’ delay? Why has there been five years’ delay? Why has there been seven years’ delay? Why has there been no date? Why don’t I have a date for anything? When is my inquest going to be? What about my family? We are all distressed. One case came in my direction recently where the High Court had ordered a coroner to resume an inquest. He had decided that there was no need to resume the inquest, and was going to leave it at that.  But the High Court decided otherwise. So they ordered the coroner to resume the inquest. Unfortunately that case got forgotten about. The papers got put on a shelf in the back of the office for six and a half years. When it was brought back, the family not surprisingly wanted a new coroner to conduct their inquest. I helped them, and they got one. So delays are really poor, and they need to be reduced.

There are also signs of a lack of a modern approach amongst some coroners’ offices. I went to one coroner’s office in the north, I won’t say where, where there had been problems with delays, and they were using typewriters. That was a symbol, it seemed to me, of a problem of lack of organisation, and of efficiency. If you don’t have efficiency, you will have delays. You will put that case at the back of the shelf and forget about it because it is a bit troublesome. So there are procedural reforms which have a rather more modern look to them. They involve opening inquests in public, recording all the hearings, setting a date for the next hearing, hopefully the final hearing, at an early stage, and giving directions to experts to provide reports and statements within a short period of time. One coroner said to me: ‘I have a pathologist who’s a bit slow. Usually it takes her a year to produce a report.’ I said ‘That’s not a report. That’s a guess about what her notes mean.’  So, anyway, that has changed in that particular jurisdiction.

Generally we are putting in place case management structures to check on the progress of cases on a monthly basis. This should mean completing the vast majority of inquests within six months, and if they go over twelve months I will investigate. That is my statutory duty. So instead of allowing their pathologists to take a year to produce a report, what coroners need to be doing more is going into hospitals and GP surgeries, getting to their toxicologists and talking to them: saying ‘this is what is expected. They can say “it’s not my fault: this is what the Chief Coroner expects”. So we are going to have a procedure whereby the time structures are as follows, and I am sure we can work together to do this’. A lot of good coroners are doing this already. They are out there making sure that there is good discussion, good consultation and good cooperation. That is good practice and I want to encourage that.

Coroners have got to work collaboratively. It is no good for the coroner to sit back in his office, with the typewriters clicking away in the next room. He has got to work with that rather peculiar triangle within which he has to operate. A senior coroner is appointed by the local authority but not employed by them, so their line manager is the Chief Coroner, or possibly the Lord Chief Justice. Then you have coroners’ officers, employed by the police. Their line manager is a detective sergeant, or some other officer. Then you have administrative staff, who are employed by the local authority, and line managed by someone there. So you have that peculiar triangle, and it only works if everybody is working together. Talking about problems, making sure where there is a disciplinary problem in the office and getting that sorted out, keeping a review of cases on a monthly basis, discussing, collaborating.

So, fewer natural causes inquests: that could reduce the number of inquests by as much as 20 per cent overall, across England and Wales; reduced delays; inquests held earlier; bodies released earlier; families receiving information earlier and having greater access to documents and evidence; and greater collaboration. That is the first thing: the Act and the Rules and Regulations, the statutory reforms.

Secondly, all coroners now have compulsory training. They didn’t before. There was quite a bit of training thorough the Coroners’ Society of England and Wales, but now it is compulsory. I have six strands of training: it is the only thing for which I have got money. I work with the Judicial College. I have six course directors who were appointed by me and the Judicial College after an open competition. There have already been regionally based courses on the new Act, Rules and Regulations. All 400 coroners have been trained. We thought it was going so well after the first ten that we invited a lot of other people to come afterwards: police, the CPS, pathologists, lawyers, local authority managers, police and crime commissioners, health and safety, MOD investigators, charities, and others with an interest in the coroners’ service. So we have completed the initial training for all coroners and some coroner’s officers. Secondly I have got a new three day induction programme. We have done the first one which was excellent, with good feedback. We have a new continuation training for all coroners next year and beyond, and coroners’ officers. I have got a new-starter course in development for coroners’ officers, so that they will get some training on the basics right from the start. In February of next year, all senior coroners will have a course on leadership, organisation and management.

As to the bigger picture on leadership, there are 96 coroner areas now, so there are 96 senior coroners. I want to reduce the number of areas to about 75, for now. Tom Luce recommended 60. 75 will get us to a more or less standard number of reported deaths, the right size of area, a senior coroner in place with a deputy, three or four assistant coroners, the right size team of coroner’s officers and administrative staff. If we can get that standard model to work, and to work more efficiently and effectively, that will be good ultimately for all the families who have to suffer an inquest. That rationalisation is already under way. When the new regulations came into force in July, the Lord Chancellor agreed a number of amalgamations. When a senior coroner retires, the local authority starts discussing with their next door local authority, for example Gloucestershire.  Gloucestershire has a brand new court centre, with a brand new court, brand new offices, a brand new mortuary round the back, which means they can’t have marriages on Saturday like some coroner’s courts do, to make a little bit of money. They are quite a small county, in terms of deaths reported. But they have very good facilities, which could be used, possibly, by a merger with the next door county.

Still with training, in addition there is specialist training next week for my newly created cadre of coroners to investigate deaths of personnel on active service. I have a special duty under the Act to monitor all service deaths and the inquest process, and to make sure that coroners are trained for it. So I am creating a cadre of ten coroners who, where necessary, will conduct military inquests. If for example it is a relatively straightforward inquest, it may be the inquest of somebody who has died in training, and the local coroner is experienced, that will be sufficient. But if there is something particularly difficult, or there is a need to move the inquest, then I will use one of the specialists. Next week’s training day will involve discussion with all those involved: the MOD, the military police, the Royal British Legion and others, to see how we can improve procedures and avoid delays.  For example, one of the things in relation to delays, both in relation to military inquests and to Health and Safety Executive inquests, and possibly deaths in custody inquests too, is to look and see whether there is some way of not having to wait for ever – it seems to families anyway – for the final report. The final report may cover absolutely everything, may be more than the coroner or the inquest needs, and we want to see whether there is a way of having an earlier report, in the right case. So the coroner would not have to say: ‘I am so sorry, I can’t tell you how long this will be. It could be two years, it could be three years.  I have no idea.’  We would like to change that process, and have some inquests in those fields which are earlier rather than later.  In relation to military deaths I keep abreast of all the major inquests. I advise and help, without interfering. I am developing, in the custody field, a particular interest in areas such as asphyxia restraint deaths, of which there are one or two from time to time. There are three such inquests at the moment, one has been convened recently, and two are to come.

As to the third strand: I have overhauled the appointments process, from top to bottom. Previously, local authorities made some coroner appointments, and coroners made the rest. So some coroners were appointing their wives. For example the North London coroner appointed his wife to conduct the Amy Winehouse inquest. Unfortunately she was not qualified to sit as a coroner. She had a legal qualification in Australia but not in England, and the local authority did not know that they were partners, because he had not disclosed it. If there had been a complaint about the inquest, which there was after a fashion, the coroner would have had to deal with it. So the coroner would be dealing with the complaint against the assistant coroner, his wife, presumably over the kitchen table before dinner. That has all gone. Statutory appointments are all made by local authorities, and in all cases the Chief Coroner, and the Lord Chancellor, have to consent.  In order for me to consent fully I am very much involved in the process. Where there are senior coroner appointments, either I or one of a limited number of trusted nominees is there in the process. I am there looking at the sift. I also keep an eye on the interviews. I am there on a number of senior coroner interviews. I have made sure that the process is open. When a Local Authority recently advertised for a new coroner they put the advertisement up on their website for five minutes and told people to apply within eight minutes. So they were a bit surprised when nobody replied. That kind of process is going. We need to make sure everybody gets to know about it, the process is open and fair, and the best candidate gets the job. And if there isn’t a good enough candidate to be appointed, do it again. Coroners can no longer appoint their spouses and partners as assistant coroners. Previously coroners had no retirement age, but by statute, new appointments have to retire at seventy.

Fourth and last: guidance and websites.  I write written guidance, a bit like practice directions, for coroners in the work they do. There are ten now already: the appointment of coroners; location of inquests; opening inquests; recording hearings; warnings to juries; coroners for service deaths; reports to prevent future deaths; post-mortem imaging; pre-signed forms; oaths and robes. I also do law sheets, although they are not very well developed yet because I have been busy on the other things. All of that is now published, on the judiciary website, which is available for everybody, and the coroners also have access to the judicial intranet, which is private, where there is all of that and much more.

In addition to that, apart from my day job, which is at the Old Bailey, where I was until twenty five past four, I sit in the high court, in the divisional court of inquest cases, judicial review cases. I sat on the Hillsborough case, with the Lord Chief Justice, on the Azelle Rodney enquiry case, and on other cases which will hopefully help coroners with topics like unlawful killing, which can be tricky.

I would like to emphasise one point from the guidance: the reports to prevent future deaths. I always say that coroners have two functions: one is to explain the unexplained, for the families, and also for the health and welfare of the nation as well; and secondly to report where appropriate to prevent future deaths. That is a very important part of coroners’ work. I have been emphasising it, and reports are up, from about 400 a year to 600. There has been a big increase. There has been a big focus on it, there is guidance on it, there is now a template that is easier for coroners to use and for responders to respond, and at the end of it I will get all these reports and responses and I will have a look and see what can be drawn out of it, in some cases. Where there is something important, for example in regard to asphyxia restraint, where there should be something new, I will recommend action. Coroners report, they do not recommend specific action. Some of them do, of course, but they are not supposed to. What they are supposed to report is that action should be considered – by an individual, an organisation, an agency, or a government department. So for example in the report on 7/7, Heather Hallett said ‘You should consider reviewing this part…or that part… of your procedure.’ So that is a very important part of the work, and I will extract issues which I believe need to be taken up and moved on into practical or legal action.

I have been on the old training for coroners who do military inquests at Warminster, where the military show you, over a couple of days, their procedures, their equipment, and what is happening in Helmand, in Afghanistan, I suppose soon it will be Somalia or somewhere else. I was impressed when from time to time a senior officer would say: ‘well that was the equipment we used to use. But the one next to it is the one we now use as a result of a report by a coroner. We used to have that procedure but now we have changed it as a result of the report from the coroner.’ That was impressive.

So those are my four areas. There is much more to do.  I have a three year plan.  I feel that as reform progresses, coroners deserve a greater recognition and understanding of their work in the administration of justice.  A lot of it is very good. I talk about the bad things only to show the extremes.  A lot of coroners are doing very good work, and as the President of the Supreme Court said recently, citizens should be aware of what their courts and judges are doing. Coroners are independent judicial office holders. They are trained by the judicial college, appointed with a judge legal qualification. And in some respects a coroner is much more important than a judge who decides a matter between two private parties. Each coroner in each case is making a public finding, a conclusion that matters, of course to the family but also to the health and welfare of the country. That is an important public function. I want to show that it is a good and valuable public service and that it is improving through the reforms. Coroners are no longer, as Chaucer wrote, ‘Lord and Sire, Full oftentimes Knight of the Shire, A Shreve had been, and a Coronour’, but as I wrote in the Times recently, they are hard-working judicial office-holders, proud  of their independence, acting for the public good, and with a fair wind these reforms will bring back public pride in their work.’

Lord Ramsbotham thanked the speaker most warmly. He said this demonstrated how much the post was needed, and how impressed the members of the meeting were at all that had been achieved in the year.  He invited Deborah Coles to make some additional remarks about the custodial situation.

Deborah Coles began by saying how much INQUEST had welcomed the creation of the speaker’s post, and the increasing transparency of the coronial system. She continued: ‘Our role as an organisation has always been to try and maximise the preventative potential of the coroner’s inquest. I thought it might be helpful just to flag up some of the challenges we are facing at the moment.  One of them Peter has already mentioned, and that is delay, which is still a significant problem. Not only does it impact on the bereavement process of the family, and also on any staff who have to attend the inquest; our biggest concern is the way in which it frustrates the learning process, because it is the first time for a scrutiny of what happened, and therefore the opportunity to take action to remedy any system failures is frustrated.  We recently had an inquest on the death of a young man in prison where it took nine years before the inquest was heard. I have to say that that is thankfully quite unusual, but in many jurisdictions around the country you are looking at a delay of two or three years, which is unacceptable and takes a real toll on everyone concerned.

Lots of people know us because of our focus on custodial deaths but we also deal with enquiries from anyone who has to go through an inquest process. In the last seven months we have had 222 new enquiries.  82 of these were custody enquiries, and 140 were non-custody enquiries. This was despite a reduced service in July and closure in the month of August.  The new custody enquiries were 43 prison deaths, 10 of which are currently classified as natural causes. I will come back to that.  17 deaths involved contact with the police.  25 were psychiatric detention deaths and one of them was a military death.  Of the 140 non-custody enquiries, 41 related to enquiries around potential medical negligence issues, 37 related to community mental health concerns, a further 59 sought general information about the inquest process, and 2 were Hillsborough-related enquiries.  I think that demonstrates a real concern that we have about the lack of advice for families going through that process.  That is yet to be properly dealt with by the Ministry of Justice, which is ultimately responsible for coroners.

Another concern we have is around the new Coroners and Justice Act provisions on natural causes deaths. All deaths in custody are subject to an inquest, and the majority of those would be under Article 2 of the Human Rights Act in terms of their scope.  But in terms of natural cause death there is now no longer the provision that all coroners should sit with a jury in those cases. Whilst there is an acceptance that in some cases that is absolutely right, one of the concerns we have got is that some coroners are limiting the scope of inquests.  For many natural cause deaths there will be very important questions about the treatment and care of the person whilst in prison, particularly where they are dependent on others for their medical care.  We have had some disturbing cases recently where well-conducted inquests with juries have returned a series of findings and coroners’ reports to prevent further deaths where they have raised concerns about system failures within the prison, quality of medical care and other issues. We are worried about a decrease in scrutiny in these cases. This also coincides with the Prisons and Probation Ombudsman limiting their own involvement in natural case deaths because of the 25 per cent cut in their resources.

One of the frustrations for those of us who work at INQUEST is that the same issues come up time and time again, with depressing regularity, which is why we have put a lot of work into trying to get a more effective mechanism for the joining together of the findings that come out of the investigations and inquests that are held into these deaths.  Peter and I have discussed these things in the past. We did a report into learning from deaths in custody inquests, the launch of which Lord Ramsbotham chaired, which looks at how we can have a better system where the outcomes can be more effectively monitored, analysed, audited and followed up, to see what compliance there has been with actions that have been recommended by coroners or as a result of jury findings.  Whilst we welcome the work that the Chief Coroner’s office is going to do, we still need a central oversight body to ensure a more effective monitoring of what actually goes on.  What families say to us time and time again is that they want the truth, they want accountability, but most importantly they want to know that no other family will have to go through a similar experience and that action is taken. At the moment there is a real accountability void, and many of these good reports and good recommendations can just disappear into the ether.

The other issue, which we have noticed is impacting more and more on our families, concerns problems about getting access to public funding to be represented at these inquests. Bear in mind that at every inquest into custodial death you will have the police, or prison service, or DoH represented out of public funds. There are increasing problems for families who are denied any public funding whatsoever, or are being required to make very significant contributions to the costs. That is really worrying because in many of these cases it is extremely difficult to expect a family to represent themselves.  Many coroners recognise the important role a family’s representation can play in how they conduct their investigation, or in terms of any follow-up action for judicial review.

I will end with some comments on prison deaths. This year, as of last week, there have been 146 deaths in prison. 51 of these have been classified as self-inflicted, and 95 as so-called natural causes – and as I have said before there may well be cases that involve important questions about medical treatment and care. Most recently, last week, we had the inquest into the death of a woman in Bronzefield Prison, who died as a result of methadone toxicity, as a result of the methadone she had been prescribed by the prison doctor. That represents an area that is of concern to NOMS, who are doing their own work on this, about the particular vulnerabilities of people involved with drugs, toxicity, and prescribing generally.  So whilst we very much welcome the Chief Coroner’s role, we still feel that in terms of maximising the significant contribution that the coronial service can make both to the prevention of deaths but also to the conditions of safe custody, we need to invest more, to make it a more dynamic role, and one which can really reduce the number of deaths of people in custody.’

Lord Ramsbotham thanked Deborah Coles very much for her remarks, and opened the floor to questions.