Page 50 - When Things Go Wrong

by consultees. Equally, we are aware that different cases may necessitate
different lead agencies. This may depend, for instance, on whether the police
are implicated in the fatal event or an agency has specialist expertise.

3.10 However, we note Dame Elish Angiolini’s caution that “independence does
not require isolation”. 130 We agree with her suggestion that in cases where
specialist agencies are involved in investigations concurrent with an inquest,
coroners should hold prompt and regular pre-inquest hearings with
investigating agencies requiring them to liaise closely and account for the
progress of their work and coordination. 131 Building on this
recommendation, our proposed SPI incorporates a pre-hearing at which it
would be open to the judge or Senior Coroner to request agencies to conduct
specific lines of inquiry, 132 and to report on whether and how they are working
with one another, and how delay is being minimised (see Chapter II, para
2.66 and Annexe, row 12).

Witness questioning

3.11 A related issue, raised frequently in the course of our work, is the experience
of bereaved people and survivors giving evidence on multiple occasions. This
may occur at the early investigative stage, where a number of agencies with
discrete objectives require witness evidence relating to a single event.
However, the burden of retelling one’s story may stretch over several years:
for example, where a person gives evidence at an inquest into the death of a
relative and then finds themselves in the witness box once again at a Medical
Practitioners Tribunal hearing.

the HSE; Police Scotland; British Transport police; Ministry of Defence Police; the United Kingdom
Atomic Energy Constabulary; and fifty specialist reporting agencies. The Lord Advocate issues policy
guidelines on how agencies should interact with each other. For example, see the ‘Investigation of Road
Traffic Deaths – Lord Advocate’s Guidelines’, 5 December 2017.
130 Angiolini, supra note 15, para 14.9.
131 Ibid, p. 240, recommendation 49.
132 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. We
do not propose that the SPI judge or Senior Coroner is given powers of direction.

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