• It has been over 12 months since the Coroner’s reforms were introduced and in a timely reminder of the objectives the Chief Coroner has now published his first annual report.

    Overall he believes it is his role to bring consistency, good practice and good justice to the Coroner service but notes there are structural issues to be addressed to achieve this. His principal concerns are timing and consistency.


    The Chief Coroner has written to all Coroners reminding them of the need to hold most Inquests within 6 months of death and advised them to seek medical reports within 4-6 weeks of the Inquest opening. Delay in producing reports is unacceptable and there are likely to be many more Schedule 5 Notices issued and served on witnesses who do not respond within that time limit. Coroners are obliged to notify the Chief Coroner of any investigations that are taking place more than a year after death.

    National Consistency

    The Chief Coroner requires consistency of approach in standards across all coronial areas. To support this initiative, training is now compulsory and he has issued 14 separate items of guidance relating to merging of areas, appointments, where to hold Inquests, opening Inquests, recording hearings, PFD(Preventing Future Death) reports and the use of Post Mortem imaging as an alternative to invasive examinations.


    The report indicates that the reforms need time to bed in but there are already considerable signs of positive change. He is confident Coroners are embracing that change and believes the reforms are beginning to take effect.

    For legal advice, support and training, please contact johnsheath@brachers.co.uk or telephone 01622 776406.

    This content is correct at time of publication

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