The Coroner’s Service (or lack of)

We recently heard from someone who is at their wits’ end. They are waiting for an inquest into their parent’s death. Their parent died on the Isle of Wight in May 2020. The coroner was involved, and an inquest is required. But here we are, 120 weeks on, and a date for the inquest has not yet been scheduled.

According to the Ministry of Justice’s most recent version of ‘A Guide to Coroner Services for Bereaved People’, section 5.2 states ‘The inquest hearing should take place within six months or as soon as reasonably possible after a death has been reported to the coroner. 

Our correspondent has been waiting more than two years for the inquest to take place. They still don’t have a date for it. They have tried every avenue to attempt to get an answer as to why they are waiting so long, and been rebuffed at every turn.

Unfortunately, the MP responsible for the Isle of Wight constituency, Bob Seely. is unlikely to step in and help, because our correspondent is not one of his constituents. This is notwithstanding the fact that the person who died – and whose inquest is so extremely delayed – was a constituent of his. Previous attempts to solicit his support by our correspondent elicited this response; “It is against parliamentary convention that an MP correspond with another MP’s constituent.”

Perhaps, as the vote of our correspondent’s parent is no longer available to him, he sees no need to assist their bereaved and increasingly distraught family who sought his support. Or maybe he is just too busy. He does, after all, have the largest electorate of any constituency of the Houses of Parliament. 

Step forward a representative of the Upper Chamber. In July, having met our correspondent and been appalled at the length of time they have had to wait, Fiona Hodgson, or rather The Baroness Hodgson of Abinger CBE, tabled the following written parliamentary questions:

To ask Her Majesty’s Government whether there is a backlog for holding inquests as a result of the COVID-19 pandemic; and if so, how this varies across the regions of the country. (HL2019)

To ask Her Majesty’s Government whether there is a backlog for inquests in the Isle of Wight; and if so, what steps they are taking to clear that backlog. (HL2020)

To ask Her Majesty’s Government what is the average time it takes from death to holding an inquest, where necessary. (HL2021) 

To ask Her Majesty’s Government what assessment they have made of the experience of families waiting for an inquest to take place; and what bereavement support they are providing to these individuals. (HL2022) 

The response from Lord Bellamy, Minister of Justice, grouped the questions together to provide the following answer:

The Coroner Statistics 2021: England and Wales, published on 12 May 2022, indicate that, on average in 2021, the time between the report of a death to the coroner and the completion of an inquest increased to 31 weeks (up from 27 weeks in 2020), although almost a third of coroner areas completed inquests within 24 weeks. Figures are also published by coroner area: for the Isle of Wight coroner area, the average time for completion of an inquest was 56 weeks (from 40 weeks in 2020).

Coroner services are locally based and funded and administered by the relevant local authorities. The Government recognises that local authorities have experienced a number of pressures as a result of the pandemic. During 2021, coroners dealt with both the impacts of the early stages of the pandemic and the ongoing effect of Covid, including a second lockdown and continued social distancing measures which, in particular, affected the ability to hold jury and other large and complex inquests.

We have provided £6.15 billion in unringfenced grant funding to local authorities in England to support the cost of pandemic pressures which could include additional costs incurred in the administration of coroner services. Funding for local authorities in Wales is a devolved matter. The Chief Coroner has issued guidance to coroners on how their services can best recover from the pandemic, including engagement with local authorities on any additional resources required. He is also undertaking a tour of all coroner areas to engage with them on their post-pandemic recovery plans.

In addition, we included a package of measures in the Judicial Review and Courts Act 2022 to streamline coroners’ court processes and support the coronial system with post pandemic recovery plans.

The Government’s priority is to ensure that the bereaved remain at the heart of the coroner system. In January 2020, we published a revised Guide to Coroner Services for Bereaved People which provides support and information for the bereaved about what they should expect from coroners’ investigations and inquests, and includes information on sources of bereavement support. The Guide is available at:

Hmm. Not exactly answering those very specific questions posed by the Baroness. More of a ‘not our fault guv’ kind of response.

So, what is going on? Particularly, what is going on on the Isle of Wight?

Reading in more detail the paper referenced by Lord Bellamy, section 10 refers to the time taken to process an inquest. It states:

The time taken to process an inquest varies by coroner area – the maximum average time taken to process an inquest in 2021 was 75 weeks in Inner South London, and the minimum average time was 11 weeks in Liverpool and the Wirral. This disparity between regions is mainly due to differences that exist from one coroner area to another. Some of these differences are:

  • Availability of resource, staff and judicial resources
  • The presence of facilities like hospitals and prisons situated near boundary lines
  • Socio-economic make up of regions’

In their Response to the Justice Committee into the inquiry into the Coroner Service the Royal College of Pathology indicated that they also are concerned about the wide variation in coronial service across England and Wales.

We understand that the Isle of Wight inquest hearings were halted during the various coronavirus pandemic lockdowns because of public safety. Isle of Wight Coroner Caroline Sumeray explained in an article written in February last year that there was no dedicated space for inquests as the coroner’s court shared space with the Island’s other court services, and that the room inquests usually were heard in did not comply with government guidelines due to a lack of ventilation. 

She also said that another reason inquests were being held up was because witnesses from the Isle of Wight NHS Trust are involved but as they are treating and caring for many people still suffering with the virus, “treating the living must be their priority”.

But we also note that we are now in August 2022. And there are still unacceptable delays.

We had a look at the website for the Isle of Wight Coroner to see if any further light could be shed on the excessive delay experienced by our correspondent waiting for the inquest into their parent’s death. None was forthcoming – the home page simply informed us that:

The Coroners office is currently closed to the public.

To remain covid safe this service is being delivered remotely. Currently no officers are working from the Seaclose Offices.

Due to these unprecedented times the Coroners Office workstreams have increased. It will take longer for a Coroners Officer to respond to any telephone messages. 

Please email your enquiry to where the response may be quicker.’

The FAQs section of the website was even less helpful.

The Inquests page of the same website indicates that our correspondent is not alone in having to wait an unforgiveable length of time before an inquest takes place – on the ‘regularly updated’ list of inquest dates it cites an inquest scheduled for 01.08.22 for a young man who died on 16.12.2019 – a wait of more than 135 weeks.

(Interestingly, and completely coincidentally, an article appeared in one of the Isle of Wight papers this week on exactly this subject, and the paper managed to secure a response from Ms Sumeray which goes into much greater detail about the increased workload and practical restrictions that are impacting her and her team).

We took a more detailed look at the Judicial Review and Courts Act 2022, referenced by Lord Bellamy in his response. The Act received Royal Assent in April, and with our limited understanding of legal terminology, seems primarily to make provision for uncontested inquests to take place in writing rather than in person and to allow inquest hearings to be conducted wholly or in part by the ‘electronic transmission of sounds or images’, along with some other changes to requirements of coroners. 

In passing, and taking us somewhat off on a tangent, we noted, with resignation, that a proposed House of Lords amendment to the Act that would have provided bereaved families with publicly funded legal representation at inquests where public bodies such as the police or hospital trusts were involved was voted down by the government ‘because it would involve a charge on public funds’.  

This leaves us with the status quo continuing, wherein public funding for bereaved families to receive legal representation at inquests is only available in exceptional cases and the application process to obtain such legal aid is extremely demanding for families, at a time of their greatest need. Eligibility for legal aid in these exceptional cases is then subject to means testing. 

Under the system that the House of Commons voted to continue by defeating the proposed amendment, many families are forced to represent themselves, or privately fund legal representation at significant cost. The proposed amendment would have undoubtedly gone some distance in bridging the ‘inequality of arms’ that exists between bereaved families and state bodies who have access to publicly funded legal representation, but despite the best efforts of members of the House of Lords, the government have deemed this inequality must continue.

So, if our correspondent’s parent were to have died because of actions or inactions by a NHS Trust, for example, not only is our correspondent suffering from the prolonged wait of well over two years for the inquest to take place, but they will also have to fund the costs of legal representation when the hearing does happen.

It is hard – if not impossible – to see how this, in any way, meets the government’s statement that their priority is to ensure that the bereaved remain at the heart of the coroner system. The public coffers appear to trump the needs or rights or wellbeing of bereaved families, hands down.

Thank goodness, therefore, for unelected peers. 

The indefatigable Baroness Hodgson is not letting this case go. She is not simply accepting the brush-off from the Ministry of Justice. She’s in ongoing communication with our correspondent, and she has offered to put down further parliamentary questions when the House returns from recess to pursue this matter further. Unlike the elected MP for the Isle of Wight, Baroness Hodgson is going out of her way to try and help a bereaved family who are, as yet, without any idea when the inquest into the death of their beloved parent might take place.

On behalf of all families who are in a similar position, we would like to express our gratitude for the Baroness’s tenacity and determination to help someone who has lost their parent and who is waiting for answers as to why.

And we sincerely hope that the situation on the Isle of Wight in particular shows significant improvement in the very near future.

Dark ops or what?

We’ve had a lot of correspondence here at the GFG since Dispatches flung that stuff about Co-operative Funeralcare in our eye (5 mins of telly souffléd into half an hour with a dollop of unleavened ombudsman).

It’s been complaints, mostly, and of course I can’t go into detail about any of them. But almost all of them  illustrate systemic problems in the funeral industry.

One of those problem areas is the conduct of funeral directors who hold a local authority contract for coroners’ removals.

The specific problem here is the way these contracts work. They are often awarded to a funeral director who pitches below the viable commercial rate for the job. The protocol that contracted funeral directors must observe, often, is that they must not solicit for business but they may leave a business card with the family.

Which looks a bit like soliciting for business, yes?

More important, how do councils suppose that undertakers carrying out removals at a loss are going to make it pay? Isn’t there only one way they can make it pay?

How much oversight is there? Do procurement officers ever get out to check up on their contracted undertakers?

Does a failure to find out how contracted undertakers make it pay amount to tacit collusion in questionable practice? We’re not suggesting that council officers are getting backhanders.

How could an undertaker who keeps to the rules hope to win one of these contracts, and why would she want to?

We don’t know the answers to any of these questions, nor do we want to jump to conclusions before getting all the facts. We rely on you to fill us in, if you would be so kind.

What’s it all about?