Last week His Honour Judge Mark Lucraft QC, chief coroner, published the fourth annual report which covers the period 1 July 2016 to 30 June 2017.

The report provides an excellent overview of the operation of coroner services, reflecting on the past year and identifying areas to move forward. In particular his report sets out:

This year

  • The average time from death to inquest was 18 weeks
  • 375 PFDs were issued
  • From a sample of PFD reports on deaths in prison key themes were thought to include: communication between agencies, lack of awareness around procedures and how to trigger an emergency medical response
  • The training programme for coroners now includes a one day course on medical issues, with a different focus each year. In the coming year, the focus will be the heart

Continuing work

  • There will be a continued focus on nationalisation of the service to assist with standardisation and consistency.
  • A decision is still awaited about the national introduction of the medical examiner scheme. Since the pilot started, there has been an increase of 35% in inquest work in that area.

Looking forward

In order to improve coroner services further, the chief coroner recommends that consideration should be given to changing the law in the following key areas:

1. Merging of coroner areas

Merging smaller areas into one to assist with flexibility.

2. Discontinuance of investigation

To allow for discontinuance where the cause of death is identified through another source other than a post mortem.

3. Inquests without a hearing

Where the facts are not contentious and there is no need for oral evidence, consideration should be given to an inquest on paper.

4. Representation for families

Amending the guidance for legal aid at an inquest where the state has agreed to provide representation for another interested person. This will likely have an impact on healthcare inquests.