AvMA welcomes Justice Committee’s report on the Coroner’s Service

Published: 27 May 2021

The report makes important recommendations for change, in our view there are three key recommendations which offer an opportunity for significant improvements to healthcare inquests. These recommendations if implemented, should enable the coroner’s court to fulfil its potential as an effective forum for change.

The first recommendation is for the introduction of a new body which has the power to ensure that risks to public safety, identified by the coroner during their enquiry are followed up. All too often the expense and integrity of the coroner’s enquiry into how someone died is ultimately lost because no one external body has the authority or power to check and monitor whether the changes promised to improve public safety have been implemented.

This recommendation, on its own has the potential to give teeth to prevention of future death (PFD) reports made by the coroner, equally ensure representations made by hospital trusts of their own volition and contained in their action plans for change are fulfilled. If acted upon, this recommendation could demonstrate that changes have been made and with it significant improvements to patient safety in healthcare throughout England.

The report recognises that there continue to be inconsistencies in the coroner’s service. AvMA fully supports the recommendation that “A National coroner’s service is the only way bereaved people can be provided with consistent services of an acceptable standard”.

Most welcome is a further recommendation that non-means tested legal aid should be automatically available at the most complex inquests such as those following public disasters and/or in cases where public bodies are legally represented. Previous calls for improved availability of legal aid and with it, access to justice and fairness in the proceedings have not been acted upon. AvMA applauds the committee’s commitment to this and its clear call for the Ministry of Justice to implement this by no later than 1st October 2021!

Where parties are properly represented and the bereaved given a voice, the inquest presents a unique opportunity for robust but fair questioning. The power is in the independence of court, that the coroner is impartial and should have no affiliation to the healthcare provider. Unlike the healthcare complaints process or internal hospital investigations process, the coroner is not marking their own homework. Families often feel that this is their one real opportunity to get answers to the questions about their loved one’s death.

For healthcare inquests, these changes can make significant inroads to improving patient safety and access to justice. The recommendations if implemented will require funding, but they will offer a unique opportunity to save money in the long run through improved patient safety. Bereaved families want to be given a voice so they can seek answers to their questions. They want to make sure the same thing does not happen again to someone else; they want change. Rarely do families want litigation.

The committee has made bold and significant recommendations. It is our hope that government seizes this opportunity to move forward with a timetable to give effect to the recommendations and of course, critically the funding required to make this happen.