The coroners’ system has come under considerable scrutiny since 2003 culminating in the Government’s draft Bill for coroner reform (the Bill) published in June 2006 and a post-consultation report published by the Department for Constitutional Affairs. It was recognised that the current system is antiquated and perceived as not user friendly by those most affected by an inquest, namely the family of the deceased. An analysis of the proposed changes to the system follows.

Organisation of the new system

The coroners’ system will be headed nationally by a Chief Coroner who will be responsible for training, responding to complaints and hearing appeals. He will be supported by 60 – 65 full time legally qualified coroners who will continue to be appointed and funded by Local Authorities.

The Coronial Advisory Council will provide advice and make recommendations to the Chief Coroner and the Lord Chancellor on policy and operational matters. It is intended that the Council will include members of the public who have had dealings with the service. A charter for bereaved people will provide guidance for bereaved people, including their rights and roles, during coroner investigations and inquests.

The coroner’s duties

The Bill separates the coroner’s duty to investigate a death and a duty to hold an inquest. The inquest is seen as the final part of the whole investigation process.

A senior coroner must conduct an investigation into the death of a person if the coroner has reasonable cause to suspect that: 

  • The deceased died a violent or unnatural death. 
  • The cause of death is unknown. 
  • The deceased died whilst in prison or otherwise lawfully detained in custody e.g. in police custody.

A senior coroner must conduct an inquest as part of the investigation unless the coroner has reason to discontinue the investigation.

The investigation

The purpose of the investigation remains the same, namely to ascertain, who the deceased was, when, where and by what means by which he came by his death and for the purposes of Article 2 of the European Convention on Human Rights (relating to cases involving agents of the state) the purpose of the investigation is extended to ascertaining in what circumstances the deceased came by his death. It is intended to give coroners a new statutory power of entry, search and seizure which is to take the form of written permission from the Chief Coroner. The coroner will also have the power to require a witness to sign a written statement and to compel attendance at the inquest and to produce documents. There are concerns as to how those powers will be implemented in practice, in particular how they will interact with the Police and Criminal Evidence Act (PACE) and the Health and Safety at Work Act.

Outcome of the investigation

The provision requiring that a verdict may not be framed in such a way as to appear to determine any question of criminal or civil liability on the part of a named person is preserved.

A senior coroner who believes that action should be taken to prevent the reoccurrence of similar fatalities to that which is the subject of the investigation may report the matter to: 

  • A person who may have power to take such action, and 
  • The Chief Coroner.

Juries at inquests

The Bill proposed to restrict cases where the coroner is required to sit with a jury at an inquest to cases where the deceased died whilst lawfully detained in custody or as a result of the act or omission of a police officer in the purported execution of his duty. The coroner also retained a discretion to summon a jury in any other case where the public interest demands. However in the post-consultation document the Government has stepped back from this approach and retained the current mandatory requirement to summon a jury in respect of workplace deaths.


It is proposed that there be a right of appeal to the Chief Coroner against decisions and determinations made by coroners in connection with investigations and inquests.

The Chief Coroner will have powers to compel a coroner to hold an inquest or to quash a verdict from a previous inquest. “Interested persons”

The draft Bill expands the list of “interested persons” to include a catch all category of “any other person with a sufficient interest”.


Undoubtedly the coroners’ system is in need of reform and modernisation. The draft Bill and the consultation exercise have however failed to resolve a number of weaknesses apparent in the current system

  •  In the absence of a truly national system, the system will remain fragmented and inconsistent particularly because coroners will be expected to deliver a service judged against national objectives whilst coroners are to continue to be funded locally. 
  • The failure to remove the mandatory requirement to summon a jury in respect of workplace deaths, the vast majority of which are straightforward and result in a verdict of accidental death, is a major failing of the reform process. Whilst most coroners saw the granting of discretion to summon a jury as an appropriate solution the Government has bowed to political pressure exerted by the trade unions during the consultation exercise and has decided to maintain the current position. 
  • The application of Article 2 of the European Convention on Human Rights to coroners’ inquests is an area where clarity was sought from the draft Bill. Clarity remains work in progress as it is stated in the explanatory notes to the draft Bill “it is not intended to define the precise circumstances where a coroner should conduct an Article 2 investigation, however it is intended that guidance will be issued before the Bill is implemented to ensure a broad consistency of approach”.


The draft Bill and the modifications proposed as a result of the consultation exercise have missed an opportunity to rectify significant failings in the coroners’ system such as those outlined above. Whilst the draft Bill implements an organisational restructure and cosmetic procedural amendments in an attempt to give the impression of modernisation it by no means delivers the overhaul that the system so desperately requires