Page 30 - When Things Go Wrong

2.31 Our consultees confirmed this impression of the system. Some concerns were
practical: we were told that the Gwent Coroner Service does not have an email
system for the receipt of documents. Other concerns related to sufficient
expertise, with particular anxiety in relation to local coroners without requisite
experience presiding over complex Article 2 ECHR inquests involving issues
of systemic failure. We note, in contrast, the convention in the criminal
jurisdiction, where judges are authorised (“ticketed”) to hear cases of
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escalating seriousness.

2.32 We heard further concerns regarding open justice. PFD reports have only been
published online since 2013. Further, narrative conclusions are not compiled
or published in an accessible form, despite the fact that a majority of inquests
do not produce PFD reports and so narrative conclusions play an important
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role in highlighting systemic failures.

Oversight of the coroner system

2.33 The Working Party recognises that the introduction of a national coroner
service may have significant benefits for allocation of resourcing and
consistency of standards. We note that even the current Chief Coroner is of the
view that “there remain some problems with a local as opposed to a national
coroner system”, despite moves toward a more judicial service.
72

2.34 A recommendation to create a national service capable of accommodating all
deaths reported to coroners and all inquests (in 2018, 210,900 and 30,000
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respectively) lies beyond our scope (see Chapter I, paras 1.19-1.24). We
suggest that the issue of centralisation should be kept on the agenda and note
that the Government is yet to publish its response to post-legislative

70 Criminal Practice Directions 2015 Division XIII Listing, D: Authorisation of Judges.
71 As a consequence, INQUEST maintains its own record of narrative conclusions from the cases it is
involved in.
72 HHJ Mark Lucraft QC, supra note 29, para 20.

73 Ministry of Justice (2020), supra note 22.
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