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Coroners’ inquests: a ‘postcode lottery’?

Within a recent briefing, a UK medical defence organisation has criticised the current coronial system in England and Wales.


Within a recent briefing, a UK medical defence organisation has criticised the current coronial system in England and Wales, proposing that the system should be nationalised to avoid disparity between the way individual coroners conduct their investigations. Within their briefing, the Medical Protection Society (MPS) warn that under the current system doctors face a 'postcode lottery' because 'practice, policy and resource provision can all vary considerably from one locality to another'.

What are the MPS’ concerns?

In a briefing setting out priorities for the Government elected in December 2019, the Medical Protection Society (MPS) have called for the creation of a ‘National Coroner Service’ across England and Wales.

The MPS confirm that the health professionals they represent across the country may in some areas currently face prolonged coronial investigations, in comparison to their colleagues elsewhere who would face no investigation by the coroner at all.

The MPS believe that the creation of a single national coroner service in England and Wales would provide a more consistent, robust system that made better use of public resources.

Within their briefing, which addresses a number of other hot topics amongst medical professionals, the MPS assert that it should not matter whether a patient’s death occurs in Swansea or Sunderland, the investigation of the death by the coroner must be carried out in a consistent and robust way.

The MPS believe that the inconsistency between different coronial jurisdictions amounts to a ‘postcode lottery’, which serves no one, particularly the deceased’s family, who can be held in the coronial system during an unnecessary or very long investigation, waiting to get the answers they deserve. It is the MPS’ view that an inconsistent approach to inquests is also unfair on healthcare professionals, who may be subjected to the stress of a needlessly long or unnecessary coroner’s investigation.

The MPS suggest that a national approach to inquests would yield more positive results than the system currently in place in England and Wales, where there can be marked differences in the way each coronial jurisdiction conducts their inquest procedures.

In the ‘Report of the Chief Coroner to the Lord Chancellor, 2017-2018’, the Chief Coroner himself leant his support to a national coroner service, adding that there was 'much to be gained from such a move in terms of standardisation, consistency and implementation of reform'. Little appears to have been implemented in this regard since the publication of his report however.

With this in mind, it is important for healthcare professionals, and those organisations that employ them, to be aware that their experience of attending Coroners’ Court is likely to vary markedly from coroner to coroner and locality to locality. A problem, unlikely to change until such a time as national reformation of the coroner service is introduced.

Conclusions and implications

Moving forwards, healthcare professionals and their employers will need to remain vigilant to the ongoing risk that they may be involved with protracted inquest proceedings for matters that they may not consider require such intense scrutiny. It will also be important that this same group of individuals are aware of the differences in practice between each individual coroner and between each coronial jurisdiction within their locality. Legal representation can be sought to offer guidance and support to healthcare professionals, their employers and any witnesses attending at inquests. Looking towards the future, application of pressure from organisations such as the MPS may result in the coronial process in England and Wales undergoing reform to introduce a national coroners’ service. At present however there does not appear to have been any definitive steps taken to support a move in this direction.

If the content of this update raises any issues for you, or you would like to discuss, please liaise with Jessica Swift, Associate at, James Rowley, Partner at, Martin English, Principal Associate at or Richard Jolly, Partner at

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