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questions - who the deceased was, and how, when and where the deceased
came by his or her death (para 2.47).

Coroners and the Office of the Chief Coroner

10. The position of the Chief Coroner should be made a full-time appointment
(para 2.35).

11. A small Coroner Service Inspectorate should be established. The Inspectorate
would monitor timeliness of process, standards and suitability of the physical
environment and the provision of prompt and clear information to families
across the coroner system (para 2.36).

12. The Office of the Chief Coroner should explore how best to compile and
publish narrative conclusions online where those conclusions highlight
systemic failings (para 2.39).

Special Procedure Inquest

13. A new special procedure inquest should be established to reduce duplication
across inquests and inquiries, and ensure deaths arising from a pattern of
systemic failure are investigated in context. The special procedure inquest
should be opened to investigate:

i. multiple fatalities, i.e. two or more deaths occurring in circumstances
giving rise to serious public concern or for other good reason; and
ii. any death which a coroner has reason to suspect requires investigation
and which, by reference to another death or deaths, may give rise to
issues of systemic failure. The issues may arise either:
a. from an inquest or inquests already held or;
b. from a death or deaths (including deaths in other coroner
jurisdictions) in which no inquest has yet been held.

The possibility of the special procedure inquest should not prejudice
Government’s ability to establish a public inquiry under Section 1 of the
Inquiries Act 2005 (paras 2.41, 2.51 and 2.60).

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