Inquiry into the Coroner Service

In November 2023, the Justice Committee launched a follow up inquiry into the Coroner Service. The inquiry seeks to examine changes made since the publication of its previous report on the Coroner Service in 2021.

JUSTICE has responded to the Committee’s call for evidence, drawing on our Working Party When Things Go Wrong: the response of the justice system (2020). Our submission identifies areas where progress has been made and offers a roadmap for improving the Coroner Service and promoting transparency, accountability, and dignity for bereaved families.

Progress on Placing Bereaved Families at the Heart of the Coroner Service:  

  • JUSTICE acknowledges positive changes to legal aid. This includes the removal of means testing for exceptional case funding (“ECF”) and the provision of non-means-tested legal help for cases that meet the ECF criteria. However, limitations in ECF eligibility criteria mean that many bereaved families are left navigating legal processes without adequate support.
  • The Government has committed to consult on expanding legal aid for inquests following public disasters and introducing advocates for victims of major incidents. However, there remain concerns regarding the effectiveness and reach of these measures in addressing the broader needs of bereaved families.

Reducing Regional Variation and Ensuring Consistency:

  • JUSTICE advocates for measures to reduce regional disparities and ensure a consistent service across England and Wales. Proposals include establishing a Coroner Service Inspectorate to monitor standards and a full-time Chief Coroner appointment to uphold leadership and standards.

Optimising the Coroner Service’s Role in Learning Lessons:

  • Emphasising the importance of Prevention of Future Death (PFD) reports, JUSTICE underscores the need for greater accountability and oversight to ensure meaningful action on report findings. We support proposals the establishment of a National Oversight Mechanism dedicated to monitoring and implementing PFD recommendations.

Addressing Delay and Duplication in Inquests:

  • JUSTICE identifies delays and duplication in the inquest process, proposing measures to increase co-ordination between investigating agencies, for instance through collaborative witness questioning to streamline proceedings and alleviate distress for bereaved families.

Read our response here.