Page 55 - When Things Go Wrong

3.24 Given that the Senior Coroner holds a duty under Section 1 of the Coroners
and Justice Act 2009 (“the 2009 Act”) to conduct an investigation “as soon as
practicable”, our proposals in this section predominantly relate to
investigations conducted by coroners.

Notifying next of kin

3.25 Next of kin, or personal representatives, of the deceased are afforded more
extensive rights than other interested persons in a coroner’s investigation. For
example, under Regulation 6 of the Coroners (Investigations Regulations)
2013, the coroner must attempt to notify the next of kin or personal
representative of the decision to begin an investigation. Under Regulation 17,
the next of kin must be notified of the cause of death in any discontinued
investigation. 146

3.26 But the term “next of kin” has no legal definition. The 2014 edition of the
Ministry of Justice’s ‘Guide to Coroner Services’ suggests that “next of kin”
means the person identified by the coroner or coroner’s office to act as the
main point of contact to receive information”. 147 However, there is no guidance
for coroners’ officers or indeed for families as to who should serve as the “main
point of contact”.

3.27 This presents a particular problem in the case of divided families, where there
is “no common approach” between relatives. 148 Coroners’ officers may simply
accept that the first person who makes contact should be registered as “next of
kin” irrespective of the nature of their relationship with the deceased. Reform
in this area should accommodate circumstances where more than one person
might require notification from the coroner’s office in order to participate
effectively. 149 The Chief Coroner should issue guidance defining “next of

146 See also regs 9, 10, 13, 13, 14, 18 and 20; Coroners (Inquests) Rules 2013, rr. 9, 10 and 25, in addition
to regs 6, 9, 10, 13, 14, 17, 18 and 20 of the Coroners (Investigations) Regulations 2013.
147 Ministry of Justice, ‘Guide to Coroner Services’, 2014, p. 37.
148 Leslie Thomas QC, Adam Straw, Daniel Machover and Danny Friedman QC, Inquests: A
Practitioner’s Guide (3rd edn, LAG 2014), para 19.298. See also para 13.2.
149 We note that this issue is anticipated in the Ministry of Justice, ‘Guide to Coroner Services for
Bereaved People’, 2020, p. 6. Bereaved people are advised that “if more than one person needs to be a
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