Keeping the deceased at the heart of the inquest

Death and taxes: the past, present and future of the coronial service
 A lecture by the Chief Coroner of England and Wales, HHJ Thomas Teague KC, celebrating 10 years post-reform

The Chief Coroner’s speech on the tenth anniversary of the implementation of the Coroners and Justice Act 2009, delivered on 22 November 2023 and available here is essential reading for all Coroners and inquest lawyers.

Aided by a historical perspective going back centuries, it constitutes a full, frank and fearless assessment of the structural deficiencies that remain embedded in the Coronial system. All too often, the system of Coronial investigation in England and Wales is not able to live up to its ideals and values. It remains a ‘forgotten service’. But the speech is a call to action, not just a lament. Its argument for Coronial work as the fulfilment of a ‘posthumous duty to the deceased’ should act as an inspiration for any Coroners, practitioners, and coronial staff perhaps struggling to get through the day given some of the challenges the system faces.

The Coroner is the oldest continuously existing judicial role in England and Wales. The history of the office is entertaining – the venue for many nineteenth-century inquests was the pub – but is not just of antiquarian interest. Whilst the Coroner’s role as a glorified tax collector has been eroded, the modern system is still a residue of its historic origins:

  • The Coronial system remains a means of administering local justice, removed from the national judiciary. A national Coronial service remains an ideal for which there is no apparent political appetite whatsoever. Coronial staff remain formally employed and line managed by local authorities and regional police. As all inquest lawyers know, there remains inconsistency of practice between areas.
  • Whilst all new Coroners must now be lawyers, there is a long history of debate and uncertainty over what professional standards are required of appointed Coroners. The selection of Coroners is still in the hands of local authorities, and not the Judicial Appointments Commission. There is no judicial member on the recruitment panel for Senior Coroners: the Chief Coroner is a silent observer with ‘a veto but no vote’.
  • Inquests, particularly held with juries, have long been a vehicle for anti-establishment and even radical political sentiment. Inquest jurors have consistently conceptualised their role as being one of holding the state to account.

Piecemeal Reform 

The CJA 2009 itself echoes the history of Coronial reform: half-implemented, half-hearted, and half-completed. So piecemeal has been the process of legislative reform over the last two centuries that, arguably, Coroners may still be entitled to hold inquests in pubs if they see fit. The Chief Coroner has recently completed a national tour of Coronial regions and saw how often accommodation for courts and their staff was ‘inadequate’ and ‘dilapidated’: holding hearings in the pub may seem to some Coroners like an upgrade.

The Chief Coroner spoke of his vicarious pride in the achievements of Coroners and their staff: ‘hardworking, dedicated people’, inspired by vocation and providing the best service they can.

However, in the Chief Coroner’s assessment, the circumstances in which they work remain far too difficult:

  • In all but a handful of areas – a truly striking statement from the national Chief – Coroners’ officers are understaffed and overworked. ‘Far too low’ staffing levels are the norm, not an exception. This is destructive to staff welfare and results in avoidable delays.
  • In many areas, there are simply not enough Coroners. Too many areas rely exclusively on fee-paid assistant Coroners, rather than salaried area Coroners, meaning there is no flexible cover for the Senior Coroner.
  • The antiquated ‘triangle of responsibility’ for the function of the service between police, local authority and Coroner ‘paralyses’ decision making. Funding models must be simplified.
  • Court security arrangements are ‘rarely adequate’, and Coroners do not have proper support in dealing with HR issues or the press.
  • There is an urgent shortage of pathologists. In some areas, obtaining a specialist report can take more than 12 months.

This is all happening in a context where the number of reported deaths is rising and the complexity of Coronial investigations and inquests is increasing.

The office of Chief Coroner is perhaps the most visible innovation of the CJA 2009. Ten years on, it is clear that the role’s value lies partly in the ability of an individual to take a bird’s eye view over an otherwise siloed system of regional areas, and then to act as an advocate for the entire profession to the government, drawing these profound issues to ministers’ attention.

A last posthumous service to the deceased from the state

The Coroner ended his lecture with a clear statement about what an inquest is for. It is the deceased who are at the heart of the inquest process. Coronial investigation and death certification are a last, posthumous service to the deceased from the state. This is a legal duty upon Coroners but also a moral one, to be taken with the utmost seriousness.

The status of the bereaved family at the heart of an inquest follows from the status of the deceased. It is not prior to it. Coroners occasionally face situations of conflict between family members, between family members and the deceased in life (perhaps in circumstances of pre-death estrangement), or where legal representatives instructed by the family seek to present a case which bears little resemblance to the views and values of the deceased. In rare situations of conflict, the Chief Coroner has given Coroners a clear direction: it is their duty to the deceased which comes first, and the inquisitorial nature of the process should ensure that the duty to the deceased prevails.

Even in situations where family members disagree profoundly with the Coroner’s approach, it is the duty to the deceased which must be fearlessly privileged and pursued by all Coroners. And where family members are not involved or represented, the Coroner must ensure the deceased remains the heart and focus of the case. Whilst the presence of a dead body triggers the Coroner’s jurisdiction – a blunt residue of the office’s medieval origins – an inquest is not about a corpse. It is about a person.