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The Coroner Service: Where are we now?

By Ayse Ince, medical negligence lawyer at Irwin Mitchell

This morning I created some space, some thinking time to really absorb the Government response to the Justice Committee Report on the Coroner Service. I hope that by writing this blog some conversations are initiated.

I speak for an immeasurable number of bereaved families and inquest practitioners when I say that I was overwhelmed by the news that the committee had recommended that there should be no means tested Legal Aid for inquests.

The committee did not think that bereaved people should have to go through the process of meeting the Exceptional Case Funding requirements and means test for Legal Aid where public authorities were legally represented at inquests in to the death of their loved ones.  Furthermore, it was recommended that, the Ministry of Justice (“MOJ”) should by 1 October 2021 “where all inquests where public authorities are legally represented, make sure that none means-tested Legal Aid or other public funding for legal representation should also be made available for bereaved people.”

Equality of arms, justice action

From personal experience I can say that navigating the Exceptional Case Funding requirements and means test is complex and can add more stressors to a bereaved family when all they want is a voice and to be heard.  I applaud this recommendation, the plight of INQUEST and all of the families who have prepared detailed responses that have helped drive this change.

Whilst this is an incredible milestone, the other recommendations must not be overlooked as they will serve to shape the vital public service that has a; “significant impact on many bereaved people when they are at their most vulnerable”.

Putting bereaved people at the heart of the Coroner Service

There have been recommendations to make inquests more sympathetic to bereaved families, in fact the MOJ prepared a Guide of Key Principles that the Government and lawyers need to follow to ensure that bereaved families are at the heart of the inquisitorial process.

It is accepted that access to evidence needs to be made available to bereaved families who are usually at a disadvantage when it comes to sharing of information; again this highlights the need for all lawyers to support the disclosure of all relevant and disclosable information to the coroner.

The committee considered that the Health and Social Care bodies failed to fulfil their duty of candour to the bereaved families during coroners’ investigations and inquests.  I welcome the recommendation that the MOJ should amend the Coroners’ Rules and to make clear that the duty of candour is to be extended to the Coroner Service.

Inquest practitioners fight tirelessly to ensure that disclosure is made available to the bereaved families, these are unnecessary battles, needless costs are incurred and delays in listing inquests are experienced.

Honouring the sleeping babies 

The report also explored the coronial investigations of stillbirths.  The committee recommended that the MOJ should revisit the difficulties faced by those bereaved by stillbirths, to enhance the investigation process including the recommendations aimed at improving maternity care and sharing the learning from investigations across the health system to help prevent future and avoidable stillbirths.

I am keen to read the joint response to the consultation process by the Department of Health and Social Care and MOJ.

If we do nothing from the learning of these extremely sad cases, then what is our role in the inquest process?

The committee supported the notion of implementing a Coroner Service Inspectorate to oversee the Coroner Service.  I can only regard this as extremely positive, and another step towards standardising the Coroner Service without implementing a “National Service”.

This leads on to their next consideration with regards to addressing fatal risks identified by coroners and inquest juries.  The committee recommended that the MOJ should consider devising an independent office to report on recurring issues where used in Prevention of Future Death Reports (“PFD”) to communicate with regulators / public bodies and to follow up the PFD Reports.

PFD’s are an essential tool to enable regulatory staff / public bodies to learn from these tragic mistakes and or errors.

In conclusion the report is enlightening and I sincerely hope that we will place the bereaved at the heart of the inquest, treating them with respect and compassion when they are at their most vulnerable.

As humans, we all strive to improve, to be better people. If we fail to learn from the lessons that inquests are able to teach us, then we are failing as practitioners and on a personal level, humans.  Let no death be in vain but serve as an opportunity to improve our services that are offered to people who need our help during critical periods of their life.

Find out more about Irwin Mitchell's expertise in supporting families establish following care issues at our dedicated medical negligence section.

In conclusion the report is enlightening and I sincerely hope that we will place the bereaved at the heart of the inquest, treating them with respect and compassion when they are at their most vulnerable.”