Articles

Coroner's Inquests: Calling for a change in the law

Release Date:	17 April 2008
Author:	Victoria Piggott
Original Publication:	The Lawyer

This article was first published in The Lawyer, April 2008.

It would be wrong to draw too many lessons from the Diana and Dodi inquest or to use it as a basis for reforming the law. It was "no ordinary inquest" (per Lord Justice Scott Baker, Summing up, 31 March 2008 Morning Session). The coronial system is in need of reform in areas such as standardisation of the service, an increased role for the family, decreasing delay, giving greater power to the coroner and implementing preventative measures. A draft Bill was published on 12 June 2006, Coroner Reform: The Government's Draft Bill, Improving Death Investigation in England and Wales, but not all areas of concern were covered.

Coroners courts operate disparate methods of practice and standards due to the varying professions of coroners and levels of funding available from individual local authorities.

A key reform is to introduce national leadership, a new Chief Coroner and Coronial Advisory Council to establish national standards and a Charter for the bereaved.  Being a coroner will become a full-time job and all coroners will be legally trained with boundaries being reshaped to improve distribution of work.

However, with no national coronial service nor centralisation of funding it is unlikely a chief coroner will be able to function effectively as a force for standardisation leaving the system to continue as a 'post-code lottery,' a fragmented, non-standardised service.

Families often feel that their rights and concerns are overlooked due to inquests operating under a narrow legal remit, namely, the cause of death. There is no government funding available for families to be represented at inquests, nor any government funded information services or automatic right to disclosure of information - leaving families poorly informed and frustrated.

The draft Bill gives families a clearer standing within the investigation and inquest, including a new appeals system and the Charter. However, without funding for legal representation, mandatory disclosure of information and a fully accountable Coroner Service, it will be difficult for families to enforce their rights as outlined in the proposed Charter.

Inquests often conclude several years after the death of the person in question. For example, the inquests of Anne Marie Bates (hanged in prison) and Roger Sylvester (suffocated in psychiatric ward), took 5 and 4 years respectively. Delay impacts on bereaved families and makes investigations into events more difficult after a passage of time. This in turn delays the implementation of preventative actions. 

The draft Bill makes no mention of the issue of delay. Inquests need to take place as soon as practicable after the death to enable timely public scrutiny of the circumstances, maximising the preventative potential of an inquest and limiting the length of the process for the family.

Coroners do not have the power to compel witnesses to attend, having to rely on people co-operating with their inquiries. The draft Bill proposes new powers for coroners to obtain information and to summon witnesses, including new powers of entry and seizure.

The current system has no mechanism to monitor inquest findings or to take any follow up action. The draft Bill fails to introduce statutory obligations to monitor and analyse inquest findings or implement recommendations. The focus should be on death prevention - including publication of results, central collation and analysis of both coroner reports and jury verdicts.

The current system of inquests is arcane, fundamentally flawed and in need of reform. Whilst the government's proposals go some way to improving our coronial system, there is a need for greater reform to secure a nationally funded and organised coroner including better monitoring and follow-up of the outcomes of inquests – potentially saving lives by preventing similar incidents occurring in the same way. Changes should also be made to improve the experience of the process for bereaved families whilst creating a democratic and accountable system for investigating contentious deaths.