Page 28 - When Things Go Wrong

2.26 There are 88 coroner areas in England and Wales, roughly mirroring the
boundaries established by local authority districts. Section 24 of the 2009 Act
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requires the relevant authority to provide “whatever officers and other staff are
needed by the coroners for that area to carry out their functions” and to provide
accommodation that is “appropriate to the needs of those coroners” (although
these requirements apply only where the relevant police authority does not
provide such officers and staff).
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2.27 There are advantages associated with the local authority-administered
structure. One practical benefit is that unlike public inquiries, coroners’
investigations and inquests are not seen as “an expensive anachronism in the
eyes of a cost-conscious central government”. Adherence to tight local
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authority budgets and sharing of facilities with police forces has meant that
local coroner services have evolved organically, without recourse to central
funds. Coroners may also acquire considerable local knowledge and
understanding. Our consultees confirmed our experience of local coroners
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bringing to bear their knowledge of previous, similar cases from within the
local area.

2.28 The 2009 Act marked a significant restructuring of the system. Adopting many
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of the recommendations in the Luce and Third Report of the Shipman Inquiry
reports, it instituted the Chief Coroner as a new national head of the system;
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introduced the new concept of “investigations” into deaths; reduced the
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55 Ministry of Justice, 'Coroners Statistics Annual 2019 England and Wales’ (14 May 2020).
56 See also Explanatory Notes to CJA 2009, para 221.
57 Stephen Sedley QC, ‘Public Inquiries: a Cure or a Disease?’ (1989) 52 MLR 469, 472.

58 See Death Certification and Investigation in England, Wales and Northern Ireland: The Report of a
Fundamental Review chaired by Tom Luce (Cm 5831, 2003), p. 180, para 15.
59 Dame Janet Smith DBE, The Shipman Inquiry Third Report: Death Certification and the Investigation
of Deaths by Coroners (Cm 5854, 2003), pp. 21-22.
60 Coroners and Justice Act 2009, s. 35 and sch 8.

61 Ibid, s. 1.
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