Coroner inquest reforms need to go further

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”, as Lord Justice Scott Baker said when summing up. But 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 from local authorities.

Reform includes the introduction of national leadership, a new chief coroner and the 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 neither a 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 postcode lottery.

Families often feel their 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.

The draft bill gives families a clearer standing within the investigation and inquest, including a new appeal 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 a death. For example, the inquests of Anne Marie Bates (hanged in prison) and Roger Sylvester (suffocated in a psychiatric ward) took five and four years respectively. Delay impacts on bereaved families and makes investigations into events more difficult. This in turn delays the implementation of preventative actions. The draft bill makes no mention of the issue of delay.

Coroners do not have the power to compel witnesses to attend, having to rely on people cooperating 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. While 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, while creating a democratic and accountable system for investigating contentious deaths.