This article is taken from the July 2021 issue of The Critic. To get the full magazine why not subscribe? Right now we’re offering five issue for just £10.

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The government should be commended for its decision to review coroner services in England and Wales. Bereaved families and others with experience of inquests were invited to say how well — or badly — they thought recent reforms were working.

“We are analysing your feedback,” the Ministry of Justice currently says on its website. “The government’s response will be published in early 2016.”

Early 2016? That’s more than five years ago. And why are we still waiting for the report to be published? According to Alex Chalk MP, the minister currently responsible for inquests, one of his predecessors had decided not to “prioritise” it. And because so much has changed since the review was conducted in 2015, its findings would be “of very limited import”.

Chalk’s excuses are entirely unconvincing. As the Commons justice committee says in a recent report, publication of the review would allow his assertion to be tested “and no harm can be done if the report’s conclusions truly are obsolete”.

Judicial independence is a fine thing, but some coroners behave as if they are a law unto themselves

In more than three-quarters of the unnatural or unexplained deaths that are referred to them, coroners authorise burial or cremation without holding a formal inquest.

Most coroners are sympathetic to the needs of bereaved and bewildered relatives — including the religious requirements of Jews and Muslims for non-invasive autopsies and speedy funerals. But when a coroner seems unwilling to follow national guidelines, there is little that can be done — short of seeking judicial review. 

Unlike all other members of the judiciary, coroners are funded by local authorities in England and Wales. We don’t know how much they are paid because there is no national pay-scale, but some are bound to get more than others. The same applies to support staff, offices and courts: some are better resourced while other coroners struggle. To make matters even more complicated, coroners’ officers — who liaise with relatives — may be employed by local police forces.

As a result, standards vary hugely. Dr Mike Osborn, president of the Royal College of Pathologists, told the justice committee that one of the hospitals where he worked was covered by two different coronial jurisdictions. “In one,” he said, “I can pick up the phone and call somebody, get an answer in three seconds and everything is sorted out. In the other, I have absolutely no idea how I would get in touch with somebody, other than send an email that, if I am lucky, might be answered in three or four days’ time.”

In evidence to his fellow MPs, Chalk stressed the benefits of local autonomy: different parts of the country faced different challenges. But it would still be possible to meet local needs while complying with national standards.

A national coroner service would be “extraordinarily expensive”, Chalk said, and the case for change would have to be “absolutely compelling”. It would certainly mean increased spending by the Ministry of Justice, which would have to take over costs currently paid by local authorities. But why shouldn’t the reform be funded by reducing the money they receive from central government?

“The Ministry of Justice should unite coroner services into a single service for England and Wales,” the Commons justice committee recommended in May. That conclusion is shared by almost everyone who has ever reviewed the service. We can be confident that there is a similar message in the review the government wants to bury.

Faced with the prospect of a crowd-funded legal challenge, that coroner was eventually persuaded to stand down

Instead, the government is putting its faith in the much more modest reforms enacted in 2009 and partly implemented in 2013. The establishment of a chief coroner has indeed improved the quality of service through leadership, guidance and training. But, said the MPs, there is still an unacceptable variation in the standard of service between areas and there are still pockets of bad behaviour by coroners.

Take the case of Collette McCulloch, an autistic woman who was killed by a lorry at the age of 35 because she was wandering along an unlit dual carriageway in the middle of the night. Could the care home where she was living as a voluntary patient have done more to protect her?

Like all bereaved parents, Andy McCullough was hoping the inquest could help prevent such a tragedy from happening again. But, he recalled, “the coroner arrived late at the pre-inquest review and brusquely stated that he wanted no shouting in the court”. He looked at McCullough and his wife aggressively “and said only one of us would be allowed to speak and only for two minutes”.

Faced with the prospect of a crowd-funded legal challenge, that coroner was eventually persuaded to stand down. His replacement displayed a completely different attitude and went on to conclude that the tragedy had been totally avoidable. The two coroners were so unalike that McCullough couldn’t believe they were doing the same job.

Judicial independence is a fine thing but some coroners behave as if they are laws unto themselves. The local authorities who recruit and pay them have little experience of choosing judges and no powers to sack coroners who should never have been appointed. After 800 years of tinkering at the edges, it’s time for fundamental reform.