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Chief Coroner’s report: Assessing the service and recommending reform

On 8 September 2016, the Chief Coroner published his third and final annual report assessing the state of the coroner’s service and setting out recommendations for reform.

For those working in coronial law, the report makes for interesting reading and a full copy is available by clicking here.


The Coroners (Inquests) Rules 2013 require coroners to complete inquests within six months of the date on which they are made aware of the death or ‘as soon as reasonably practicable after that date.’ However, since 2014 coroners are also required to report cases exceeding 12 months to the Chief Coroner.

In his report, the Chief Coroner has celebrated a decrease in the numbers of cases not completed or discontinued within 12 months, with a reduction in the number of cases outstanding from 2,673 to 1,285.

Reporting of deaths by medical practitioners

The Chief Coroner remains concerned that there is currently no statutory criteria for medical practitioners reporting deaths to coroners. The written advice provided with death certificates is woefully inadequate and the Chief Coroner reports that of the 236,406 deaths referred to coroners by doctors in 2015, only 32,857 proceeded to inquest. The remaining 203,549 were sent by coroners for registration as deaths from natural causes without formal investigation or inquest.

This points to some confusion amongst doctors as to the circumstances which warrant reporting. The Chief Coroner recommends the introduction of a clear statutory framework and guidance for doctors referring deaths to coroners. That framework would of course need to be accompanied by appropriate training for practitioners.

It is likely that the proposed medical examiner system may also contribute to addressing this issue (see below).

Medical examiners

The Chief Coroner has also welcomed the proposed implementation of the medical examiner system, in particular in reducing the number of inappropriate referrals from doctors to coroners though the provision of medical advice as to the cause of death.

Concerns have been raised, however, as to the funding of the scheme, in particular in respect of a likely overall increase in cases referred to the coroner, many of which will be complex cases.

Since the imposition of a pilot scheme in Sheffield, the area has seen an increase of 35% in its caseload. Understandable queries are raised as to the ability of the system to cope with such an increase, in circumstances where coroners are already working to clear a backlog of cases with limited resources.

Inquests without a hearing

One suggestion from the Chief Coroner in a bid to reduce pressure on the service is to allow for non-contentious inquests to be concluded by a decision on the papers with a written ruling. Such an approach would only be appropriate in cases where there are no witnesses to be called and the family do not want an inquest.

In cases where there is a public interest in a hearing, an inquest would also need to be held. The Chief Coroner has suggested amendments to the Coroners and Justice Act 2009 to introduce the scheme and it remains to be seen whether this sensible suggestion is adopted.

Should you have any questions, please contact:

Isabel Turner
T. 020 7227 7246


This briefing is for guidance purposes only. RadcliffesLeBrasseur LLP accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.

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