Extraordinary Report of the Chief Coroner – issues within the coroner service

Written 20th March 2024 by Martha Odysseos

The Report of the Chief Coroner published in January 2024 explores the remaining issues with the coronial service despite the improvements introduced by the Corners and Justice Act 2009 (the 2009 Act) which aimed to not only modernise the service but also ensure a more responsive and consistent approach to how deaths are investigated and inquests conducted. Although the report touches on the improvements made to the service by the 2009 Act, it very much highlights the issues still to be addressed within the service.

The Chief Coroner’s findings

The findings regarding the coroner services include that:

  1. The service has insufficient personnel;
  2. There is an unacceptably wide variation in the provision by local authorities of material resources including the courtrooms and buildings used;
  3. There remains a general need for more salaried Area Coroners;
  4. The ‘triangle of responsibility’ creates operational difficulties;
  5. Judicial independence is impacted by the current resourcing structure;
  6. Court security arrangements vary considerably and are rarely adequate;
  7. Recent work increases are likely to be permanent.

The Chief Coroner states that ‘coroner’s officers are understaffed and overworked resulting in avoidable delays’. This is an issue facing the justice system in general. Without adequate staff in the system delays in coronial proceedings will continue and undoubtedly worsen.

These delays are added to be the lack of material resources. The Chief Coroner’s concerns include the dilapidated buildings, insensitively sited accommodation and a lack of dedicated courtrooms. The impact that the buildings may have on cases is well-known, take for example the recent issues that criminal courts have had with ‘defective RAAC’ forcing closures and adding to the backlog of cases.

In addition to this, the Chief Coroner states that the involvement of both police forces and local authorities in resourcing most coroner areas creates a ‘triangle of responsibility’. This means that the police forces, local authorities and the senior coroner have to agree many aspects of how the service will function. There are also funding issues which impact on the time scale of key decisions being made.

Although there are other issues mentioned in the report, the main substance of the report is that all these issues are contributing to the delays faced in the coroner’s service. Delays as we are all aware can cause many issues, including impacting the quality of evidence but mainly impacting families who are waiting for answers regarding the death of a loved one.

What next?

In the report the Chief Coroner explains what they have put into action to help improve the service. For example, they are encouraging local authorities and police forces to consider simplifying the funding model.

However, it is noted that further funding is needed in the system more generally to ensure that justice is no longer delayed. Such matters are for Parliament and the Government to address and as such it is an unfortunate reality that there are limitations on what can be achieved by those who struggle day to day to keep things moving as best they can.

Olliers Specialist Inquest Team

At Olliers we have extensive experience of representing those who may be required to give evidence at an inquest. We are able to guide you through the process of the coroner’s investigation as well as any subsequent inquest hearings.

If you need any assistance in relation to inquests, please contact our specialist team on 01618341515 or email enquiries@olliers.com

Martha Odysseos



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