Page 29 - When Things Go Wrong

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number of coroner areas; and moved towards a system of full-time and
legally qualified coroners.
63

2.29 The Chief Coroner provides judicial oversight of the coroner system, with
responsibilities including the provision of support, leadership and guidance for
coroners; setting national standards, developing training; approving all future
coroner appointments; keeping a register of coroner investigations lasting more
than 12 months and taking steps to reduce unnecessary delays; directing
coroners to conduct investigations; providing an annual report on the coroner
system to the Lord Chancellor; and collating, publishing and monitoring PFD
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reports. To date, the two Chief Coroners in post have issued 39 detailed
65
Guidance documents and five ‘Law Sheets’, a significant body of work to
standardise practice across the system.

2.30 However, in her 2017 Independent Review of Deaths and Serious Incidents in
Police Custody, Dame Elish Angiolini found that “while the introduction of
the role of Chief Coroner is a significant advance for the system…
inconsistencies in approach are inevitable while the system remains
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fragmented”. Dame Elish found significant variation in the standard of
coroners’ decision-making; a lack of uniformity in the ways that coroners are
67
68
resourced and supported; and that the service is “largely dependent on a
‘grace and favour’ relationship with other agencies (some Coroners report even
relying on other agencies to help with photocopying for disclosure at
69
inquests).”

62 Ibid, s. 22 and sch 2.
63 Ibid, s. 23 and sch 3.
64 Chief Coroner of England & Wales, ‘The Chief Coroner’s Guide to the Coroners and Justice Act
2009’, 2013, para 8.
65 See ‘Chief Coroner’s Guidance, Advice and Law Sheets’, Courts and Tribunal Judiciary.
66 Angiolini, supra note 15, para 16.68. The report renewed the recommendation for a National Coroner
Service, see para 16.78.
67 Ibid, para 16.72.
68 Ibid, para 16.12.
69 Ibid, para 16.14.
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