UK: Inquests

Originally published in September 2003

Proposals to change the Coroners system The Luce Report, commissioned by the Home Office, was published this summer. It makes 122 recommendations for reforming and bringing up to date the procedures for certifying and investigating death and the office of H M Coroner. However, no system for investigating death could ever be free from controversy and these proposals will not satisfy everyone as the following points show.

• Coroners will be employed by a national body instead of being appointed by the local authority. This may lead to a loss of links between the coroner and the local community.
• Juries will be empanelled only in cases involving the death of someone compulsorily in the care of the state, or where the death may have been caused by agents of the state and Article 2 of the European Convention on Human Rights (the right to life)may have been breached. This would exclude juries from most clinical negligence cases and deaths in the workplace where they have a valuable role.
• There is no proposal to extend public funding to cover legal representation of family members or other interested parties at all inquests, although there will be more liberal interpretation of the criteria for public funding where a public authority is represented. There will continue not to be ‘equality of arms ’for all participants in the inquest process.

There will be subtle changes in the distinctions between inquests and other forms of legal proceedings. For example, there will no longer be a right to refuse to answer questions which might lead to self-incrimination. Instead,a witness will be required to answer all questions in return for an undertaking that the testimony will not be used against the witness in any criminal trial. This will increase the effectiveness of the inquest as an inquiry into the facts.

The rule against making submissions on matters of factual evidence is likely to be changed. There are also likely to be rules providing for disclosure of documents. In these ways, the inquest will become more like the civil litigation process.

The existing form of verdict will not be used in future. There will continue to be a form of classification of each death investigated at an inquest but this will not be in terms implying criminal or civil liability, or its absence. The inquest outcome is to be primarily a factual account of the cause and circumstances of the death.

However, there will be analysis of whether there were systemic failings, and of how the activities of individuals bore upon the death. These changes will give increasing scope for findings similar to the present verdict of ‘system neglect ’.

Deaths by suicide will be handled differently, and will not routinely include a public inquest. The word ‘suicide ’will in future be avoided. Such deaths will be classified as ‘death from a deliberate act of self-harm or injury ’.

Public concern at recent high-profile cases is reflected in some recommendations:

• Family members will have rights to information on timing and representation at autopsies, and regarding the retention of any organs or tissues.
• A new process for verification and certification of death will require two professional opinions before disposal of the body (whether by burial or cremation)is authorised.
• Inquests after a disaster involving multiple deaths will be held by the head of the coronial jurisdiction or the equivalent.

In exceptionally complex or contentious cases inquests will be taken by a judge including,in certain cases, a High Court Judge sitting as coroner.

Ministers are considering their response to the recommendations in the Luce Report before the reforms are taken forward. They will also be influenced by the recommendations made by Dame Janet Smith in the Shipman Inquiry. The Home Office has not yet indicated when new legislation will be introduced.