Page 32 - When Things Go Wrong

Its concern would be with timeliness of process, standards and suitability
of the physical environment and the provision of prompt and clear
information to families. The inspectorate could also examine complaints
made by members of the public and could deal with those complaints
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which cannot be resolved by the area coroner.

The Working Party considers this to be a workable proposal. It would also
strengthen implementation of our recommendations as to early communication
with bereaved people (see Chapter III, paras 3.31-3.37), their ability to make
administrative complaints (see Chapter III, para 3.5) and suitability of
hearing venues (see Chapter IV, paras 4.23-4.28).

2.37 Luce recommended that such an Inspectorate would require only six people.
Given the moves toward fewer coroner areas and the work already undertaken
by the Chief Coroner in producing annual reports for the Lord Chief Justice,
the Working Party considers that this number is sufficient.

2.38 Although we recognise that implementation of this recommendation would
necessitate some expenditure of central funds, we note that such an
inspectorate function was to be discharged by HM Inspectorate of Court
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Administration (HMICA). On the abolition of HMICA in 2011, the
Government stated its commitment to “joint inspection of the criminal justice
79
system”. No such commitment was made to the coronial system.
Implementation of this recommendation would fill a sorely needed gap in
quality control.

2.39 Third, the Working Party recommends that the Office of the Chief Coroner
should explore how best to compile and publish narrative conclusions
online where those conclusions highlight systemic failings. We appreciate
that this task will involve providing some context for each conclusion and so
may be more resource-intensive than simply uploading text.

77 Death Certification and Investigation in England, Wales and Northern Ireland, supra note 58, p. 176.
78 Coroners and Justice Act 2009 (as enacted), s. 39.
79 Ministry of Justice, ‘Impact Assessment: Abolition of HM Inspectorate of Court Administration, IA
No: MoJ 118’, 2011, p. 4, para 7.

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