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In November 2023, the Justice Committee launched a for England and Wales, calling for evidence from anyone involved in or affected by the service.

�������ϲ����� hosted a special Shared Insights session in December 2023, to discuss the inquiry and specific questions posed by the Committee. Our to the Call for Evidence incorporated the views of those who attended the session. The Committee also heard oral evidence from senior figures, including former Chief Coroner His Honour Judge Thomas Teague KC. However, the recent general election announcement and the dissolution of Parliament have disrupted the inquiry, and the Justice Committee is no longer able to produce its planned report on the coroner service.

The outgoing Chair of the Justice Committee, Sir Robert Neill KC (Hon) MP, has however , setting out the Committee’s findings so far. We have highlighted some of the key points from this letter:

• The primary message is that, in the words of the former Chief Coroner, the coroner service is “chronically under-resourced and underfunded.” The Committee saw evidence of worsening delays in the completion of inquests. Any new government is urged to enact change with urgency.
• There is concern that pathology services for coroners have been neglected over many years and there is now a severe shortage. The Ministry of Justice is encouraged to publish a strategy for improving coronial pathology, with an indication of when coroners can expect to see improvements in this area.
• Recommendation for the unification of coroner services into a single service for England and Wales has been reiterated (that recommendation having previously been made in 2021). The Committee is of the view that the advantages of a national service would far outweigh its costs, and that it would help to standardise the service, allowing scope for national minimum service levels, and more consistency across England and Wales. The Committee accepted however that there is little appetite for this proposal.
• Other possible reforms to improve consistency and accountability across the coroner service were advocated, including a national inspectorate for coroners, appointing more Deputy Chief Coroners with a regional focus, providing the coroners’ court support service with funding from central government and providing legal aid funding to bereaved families in “contentious” inquests.
• The Committee recognised the inconsistencies in how Prevention of Future Deaths (PFD) reports are made. It recommended that the government commission research into the drivers for the use or non-use of PFD reports. It also suggested that coroners be granted further powers to follow up on responses to PFDs they have issued, including the power to publish names of non-responders or to report non-responders to relevant regulators. Concerns have been expressed about the wider “accountability gap” – the fact that no person or body is responsible for judging the adequacy of a response to an individual PFD or for the thematic assessment and analysis of all relevant PFDs to identify patterns of preventable death.

Although the Committee’s work has now been halted, it has nevertheless highlighted several issues that require urgent attention and reform. All the evidence heard and submitted will remain on the Parliament website and will be available to inform the sector and other stakeholders. It remains to be seen whether the initial findings of the inquiry will be considered by the new government and what steps, if any, will be taken to address the chronic under-resourcing and underfunding of the service and to improve consistency and accountability.