Page 40 - When Things Go Wrong

Coroner web page, as well as notified to the families and media. The judge or
Senior Coroner should follow the Protocol for notifications.

2.66 The judge or Senior Coroner should notify the relevant investigating agencies
(as appropriate) to attend for directions. The judge or Senior Coroner,
exercising their power of investigation under Section 1 of the 2009 Act, would
have the option to request agencies to conduct specific inquiries. Without
impinging on operational independence, the judge or Senior Coroner may ask
the agencies whether and how they are working with one another, and what
they are doing to minimise delays (see Chapter III paras 3.6-3.10 on
coordination of investigations generally). 103

2.67 A draft agenda should be drawn up ahead of the first preliminary hearing (with
reference to the Protocol), to cover necessary case management. 104 Families
and agencies should be notified of the draft agenda and invited to raise issues
and concerns (either in advance of or at the first preliminary hearing).

2.68 The first preliminary hearing should cover the topics on the draft agenda and
should take place in public (preferably in a local coroner’s court). Further
preliminary hearings should take place in public and should cover any
remaining matters, including: progress of investigations; further investigation;
scope; the list of witnesses; disclosure; the jury bundle (if a jury is to be
empanelled); and the date and venue for the final hearing. Provision should be
made for bereaved people and survivors to attend and participate in the first
and subsequent preliminary hearings.

2.69 The final hearing should be conducted in public (except where it is necessary
to consider closed evidence). Interested persons should be able to ask questions
of witnesses. The hearings should be completed within 12 months, unless there
is good reason for a longer timeframe.

103 As a comparator, see also Crime and Courts Act 2013 s. 5 and sch. 3, which provide the Director of
the National Crime Agency with the power to request or direct another police force to fulfil a task.
104 Items might include: terms of reference; a provisional timetable; directions to agencies to provide a
progress report (within 21 days); the identity of interested persons; representation; whether Article 2
ECHR is arguably engaged; whether a jury or assessors are required; whether closed evidence is likely;
and preliminary issues of scope (including potential systemic issues).
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