More data on death: Chief Coroner’s annual report for 2023

The Chief Coroner has described 2023 as a difficult year for the coronial service owing to difficulties in many areas still struggling with backlogs (which had built up during the COVID-19 pandemic) and changes to medical practice, leading to greater numbers of natural deaths being reported to coroners.  Alongside this, the Chief Coroner attributes many coronial difficulties to the financial crisis severely affecting the ability of many local authorities and police services to appropriately resource coroner services. “Under funding of the service remains a serious and pervasive problem” according to His Honour Judge Thomas Teague KC.

Future changes

Medical examiner system

One of the most significant areas of work for the Chief Coroner during 2023 was advising the Government about the impact on the coroner service of the forthcoming implementation of the statutory medical examiner scheme. The Draft Certificate of Cause of Death Regulations were published on 14 December 2023 and implementation is expected in 2024.

He describes how the Regulations will, in his view, provide a more principled distinction between medical certification and judicial certification and provide a more structured distinction in relation to corresponding duties for each side. This will inevitably lead to what the Chief Coroner describes as “wide-ranging changes to coronial processes.”

The introduction of the medical examiner has already started to contribute to the rise in the complexity of cases before coroners, with the Chief Coroner explaining that “complex cases where reportable factors might previously have been missed are now being identified and reported to coroners for investigation”.

Law changes

Other changes the Chief Coroner would like to see include:

1. Enabling the High Court, in appropriate circumstances, to be able to amend the Record of Inquest without ordering a fresh inquest when it quashes an inquest.
2. Power for a coroner to apply to the High Court without needing to first seek authority from the Attorney General to quash an inquest and hold a fresh investigation (eg where further evidence has come to light).
3. Enabling a British Sign Language interpreter to assist deaf jurors serving on an inquest jury, in line with provisions already in place (section 196 Police, Crime, Sentencing and Courts Act 2022 for jurors in the criminal or civil Court cases).
4. Clarifying statutory arrangements for the provision of coroner’s officers and other staff, this would be an amendment to section 24 of the 2009 Act.
5. Holding treasure inquests in writing. Currently, section 9c of the 2009 Act allows for the coroner to hold a non-contentious inquest in writing, subject to certain conditions, however this only applies to death investigations. Treasure inquests are still governed by the Coroner’s Act 1988 and Coroners Rules 1984. The Chief Coroner would like treasure inquests to be held in writing.
6. Putting coroners’ oath on statutory footing. It is currently set out in guidance, but coroners are not currently bound to take the judicial oath.  
7. Enabling retired Circuit Judges to be nominated to conduct judge-led inquests. Currently, only a sitting circuit judge can conduct an investigation into a person’s death.

You can read the Chief Coroner’s annual report 2023 here.