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The Chief Coroner’s Annual Report 2018 – Summary of key points

A summary of the key points from the Chief Coroner's Annual Report 2018.

No government department willing to provide nationwide post-mortem examinations

The Chief Coroner is concerned regarding the declining availability of pathologists to carry out post-mortems at the request of coroners. Significant differences are seen between the approaches of local authorities to the provision of pathology services. Some local authorities are paying additional fees to secure them, however this is resulting in a disparity in pay among pathologists, as well as problems relating to provision of services in areas unwilling to pay such additional fees. Inconsistency with the provision of pathology services is worsened by the fact that no government department is willing to take control of service provision. The Department of Health and Social Care and the NHS do not consider that they have responsibility for pathologists in this area of work. The Home Office will only take responsibility for forensic pathologists at present.

Prevention of future deaths reports (‘PFDs’)

PFDs are issued by coroners in order to raise issues of concern regarding matters arising as result of an investigation or an inquest. The Chief Coroner’s assessment of PFDs for this annual report focused on deaths in prison. Several themes emerged in this assessment including a lack of awareness of staff regarding procedure and a lack of clarity in relation to emergency medical responses. Lack of awareness and clarity fed in to inconsistent application of procedure. Other key themes identified a need for staff training, failures in information sharing, and problems with prison facilities. The Chief Coroner will request additional resources to support the production of PFD reports. The aim is to create an easier to use reporting mechanism in order to provide clarity and consistency.

New legal duty on doctors to report in specified circumstances

Concerns have been raised regarding the number of deaths reported to coroners by medical practitioners. The Chief Coroner has identified a gap in the law in which medical practitioners are not required to report deaths to coroners. The Chief Coroner has recognised it is a matter for Parliament but has suggested that a statutory obligation to report deaths which provides a clear framework for the referral of deaths to coroners would be beneficial. On one side doctors would develop greater confidence and accuracy about death certification, registration, and referrals. On the other side coroners would benefit from statutory criteria detailing a uniform practice for referrals, which would address a current culture of inconsistent practice among senior coroners.

Suggested amendment to allow inquests to be quashed without calling for a fresh replacement

The Chief Coroner has suggested an amendment to the 2009 Act to allow some inquests to be concluded without the need for a fresh inquest to be ordered. The current law requires that a fresh inquest be ordered when a previous one is quashed. The Chief Coroner believes changing this would be of use in cases where the facts are not contentious, no witnesses are required, the outcome is clear (at least on the balance of probabilities), the family does not want an inquest and there is no other public interest for conducting an inquest in a public hearing.

Current plan for medical examiners will not address issues raised in Shipman Report

The Chief Coroner has expressed disappointment that a scheme regarding the coverage of all deaths by the medical examiner system is not currently implemented. The Chief Coroner considers the aim to have coroners performing more specialist roles in relation to their legal jurisdiction, as envisaged in the Coroners and Justice Act 2009, should be the ultimate objective; the conclusion drawn being that until this objective is reached, the issues raised in the Shipman Report and other inquiries will not have been properly dealt with.

Legal reform suggested allowing the High Court to amend a Record of Inquest

The Chief Coroner has suggested an amendment to section 13 of the Coroners Act 1988 that would allow the High Court to amend a Record of Inquest. This would differentiate from the court’s current power to quash a coroner’s decision and order a fresh inquest; the rationale for this being that it is not always the case that a fresh inquest is required.

For further information about Weightmans LLP or to discuss any of the issues in this update, please contact David Reddington, Employed Barrister on 020 7822 1925 or

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