HM Coroners have served society since 1194 and the coronial system has seen little reform since 1887.  In 2003 two reports: A Fundamental Review of Death Certification and Investigation and the Shipman Inquiry identified significant weaknesses with the coronial system. Among approximately 118 Coroners, over 300 deputies and assistants there is little consistency in their practise and service levels vary with location. For instance the time until inquests begin differs across the country - in some cases inquests do not start until well over a year following a death. This postcode lottery caused particular concern, alongside the general need for an efficient system that supports bereaved families.

Following a period of consultation a new Bill was placed before Parliament on in January 2009 with the aim to:

  • Introduce a national coroner service for England and Wales, headed by a new Chief Coroner;
  • Improve the experience of bereaved people coming into contact with the coronial system:
    • A right of appeal against coroners’ decisions was to be allowed.
    • The general standards of service that bereaved people were expected to receive was set out.
  • To reduce delays and improve the quality and outcomes of investigations through improved powers and guidance for coroners, and the publication of statistics and reports to prevent deaths; and
  • To introduce a system to ensure that deaths not investigated by the coroner that enables independent scrutiny and confirmation of the medical cause of death in a way that is proportionate, consistent and transparent.

A proposed charter for bereaved people who came into contact with the coronial system was proposed.  The charter was intended to set out the services bereaved families could expect in a reformed coronial system, and what they could do if these standards were not met.

Central to all of the proposals was the new role of Chief Coroner who would be accountable to Government.  It was intended that the Chief Coroner be responsible for providing and driving forward improvements in standards and offering leadership.

Following the formation of the Coalition Government, Ministers indicated they intended to axe the post of Chief Coroner over a lack of funding as part of David Cameron’s ‘bonfire of quangos’.  At this point, senior circuit judge Peter Thornton QC had been appointed but had yet to take up his duties. Despite the post being under threat, in September 2012 following a great deal of pressure from campaigners, Peter Thornton was confirmed in the role with an obligation to lead the coronial service and provide (for the first time) leadership and supervision. However, he is hampered by a limited budget and a condensed role.

Sadly it is the nature of clinical practice that when errors occur they can be extremely serious and have devastating consequences.  If a death occurs it will usually be discussed with the Coroner and they have a legal obligation to hold an inquest if the initial enquiries give reasonable cause to suspect that the death was unnatural, the deceased died a sudden death and the cause was unknown, or the person died in prison. Unnatural was defined more than a century ago as a reasonable suspicion that there may have been something ‘peculiar in the death: that it may have been due to other causes than common illness’.

Proceedings and evidence at the inquest are directed solely at ascertaining who the deceased was and how, when and where they came to their death.  Issues of blame and fault are not directly established and no civil remedies (such as damages/compensation) can be awarded. There is no determination as to whether any criminal offences have been made out. During the inquest ‘interested persons’ such as families do not have a right to representation: there is no entitlement to disclosure of evidence or documents, and it is the Coroner who decides on and calls witnesses. No cross examination is allowed. 

Specialist medical negligence solicitors, such as those at Kinglsey Napley, are often approached when a clinical negligence case is contemplated following a death. When an inquest is to be held we often represent a client (regarded as an ‘interest person’) through the inquest process.

But why should the relatives seek representation if the coroner does not determine any criminal or civil liability?

It is helpful to attend the proceedings to listen to, question and explore the evidence given by the witnesses (such as the medical staff and hospital managers) to ascertain what happened during the deceased’s clinical journey and to obtain information that may be helpful in later civil proceedings.  As specialist solicitors, we know the inquest process well, and will gain as much information as from the proceedings as is possible.  Because of our experience we are able to ask probing questions ensuring our client’s interests.  After the inquest and following consideration of the facts we are more likely to reach a decision as to the likely merit of commencing civil litigation.

Despite the problems with the current coronial system it is essential that potential claimants are represented and it is hoped that the proposed changes will improve the system, demonstrate more understanding of families’ needs and provide consistency throughout the service. The inquest process can be difficult and complicated.  Family members usually have to face this process at one of the most difficult times of their lives.  It was hoped that the proposed coronial reforms would improve the system and make it easier to navigate and more responsive to the needs of the deceased.  However, the financial climate has resulted in some of the original proposals to be put in place.  As a consequence, we have to be realistic about the changes that will occur and the ability of the Chief Coroner to begin the modernisation of this ancient service.