Page 31 - When Things Go Wrong

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consultation, due in “early 2016”. However, recognising the concerns raised
in previous reviews and by our consultees around inconsistency of service and
practice, we make three recommendations aimed at oversight and transparency
of the coronial system.

2.35 First, we recommend that the position of Chief Coroner be made a full-time
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appointment, as envisaged by Luce in 2003. The current Chief Coroner has
combined this role with sitting as a Senior Circuit Judge at the Central Criminal
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Court and has recently been appointed Recorder of London. The Working
Party appreciates that combining the role with sitting duties may make the
appointment attractive to a number of able candidates. However, given the
decision-making, oversight and advisory role we envisage for the Chief
Coroner in the special procedure inquest, we consider that a full-time
appointment is highly desirable so that the Chief Coroner’s duties are not
compromised. The role has been universally recognised by our consultees as
valuable in giving leadership to the jurisdiction, driving up standards and
providing public information through annual reporting. Moreover, the Chief
Coroner presides over inquests at least as serious and complex as murder cases
tried in the Old Bailey.

2.36 Second, in the light of the Working Party’s concern regarding considerable
variation in standards, we recommend the establishment of a small Coroner
Service Inspectorate. This recommendation once again develops a proposal
in Luce’s 2003 Fundamental Review:

74 Ministry of Justice, ‘Post-implementation review of the coroner reforms in the Coroners and Justice
Act 2009’, 2015.
75 Death Certification and Investigation in England, Wales and Northern Ireland, supra note 61, p. 186
para 51.
76 See Lord Chief Justice of England and Wales, ‘Recorder of London appointed’, (Courts and Tribunals
Judiciary, 8 April 2020). The Lord Chief’s announcement confirms that “Judge Lucraft QC will take on
some of the responsibilities of leadership at the Old Bailey with immediate effect. However, in the light
of pressures on the coronial system as a result of the current pandemic, Judge Lucraft QC will remain
in post as the Chief Coroner. He has agreed to do so over the coming months and this dual role will be
kept under review”.
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