New Inquest Process: is it working? | Bolt Burdon Kemp New Inquest Process: is it working? | Bolt Burdon Kemp

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New Inquest Process: is it working?

The Ministry of Justice has announced a post-implementation review of the inquest process, following changes to the rules in 2013. These aimed to improve the system, so that bereaved people were more engaged in the coroner’s investigation.

A consultation on the changes is ongoing. The Ministry says that they want to hear from anyone with experiences of the coronial system within the last 18 months.

The Coroner’s and Justice Act 2009 set about to change the coronial system in the UK, to improve what was seen as a disorganised and outmoded justice system. This often left families and bereaved people feeling confused and isolated. The amendments were implemented in 2013.

What changes were implemented

Key changes were:

  • The appointment of a Chief Coroner to manage and maintain the standards of all inquests and coroners in England and Wales;
  • The requirement to tell families that an inquest investigation had been opened within one week from the coroner making this decision, and to make all information available to the family free of charge;
  • The requirement to investigate and hold an inquest hearing within six months from the date of death;
  • The commitment to work with families when considering whether to arrange for a post-mortem examination, and to consider less invasive options where appropriate;
  • The requirement to consider whether to meet with families and other interested parties before an inquest hearing to discuss relevant issues at an initial meeting, called a ‘Pre-inquest Review’.

Did the changes work?

Many of the changes have been effective. The introduction of the role of Chief Coroner is a positive step. The intention of this role is to oversee the coronial process, bringing the hope of improved consistency to ensure that the inquest process is less of a postcode lottery for families.

Coroner’s officers, usually the main point of contact for families, work hard to ensure that documents are provided to families with sufficient time to prepare for inquest hearings. They are very helpful when communicating with families about the process and what is required. They work closely with families and coroners to make the experience as straightforward as possible.

However, from my experience I am concerned that there are a number of areas where the there is further work to do.

The Pre-Inquest Review

The Pre-Inquest Review (“PIR”) is a meeting that is held at the discretion of the coroner. So there is no requirement for it to be held. Most coroners are very busy and with a target of six months within which to conclude their investigation, simply do not have the court time to hold a PIR.

The PIRs I have attended with families have been very helpful to help them understand and feel included in the process. They have the opportunity to be in the coroner’s court before the inquest hearing, which helps them to be more comfortable on the day.

One family I acted for told me that they were very relieved that they’d gone to the coroner’s court before the inquest hearing. They felt that had they gone to court for the first time to attend the inquest, it would have been overwhelming. It is often the first time family members have been in a court room. It is also useful to experience the tone of the inquest process, which many find quite clinical.

Coroners have a tough and very busy job to undertake, but they should be mindful not to forgo a process that is very beneficial to families.


The current system of arranging post-mortem examinations needs considerable review if the Chief Coroner and Ministry of Justice are to meet their goal of improving the experience for bereaved families.

There have been a number of high profile examples of conflicts between religious communities and coroner’s courts. For example, the dispute between the Muslim and Jewish communities and St Pancras Coroner’s Court, over both the delay in carrying out post mortems, and their invasive nature. 28 days is too long to wait for the release of the body for many families, and steps need to be taken to reduce this delay. In 2013, Justice Minister Simon Hughes was working with the Chief Coroner to try to do this. Recommendations were made for out-of-hours post-mortem services, however these have only been used infrequently in a handful of courts.

Use of less invasive post-mortem methods was encouraged where this was appropriate, using CT or MRI imaging. Unfortunately, this has not been as readily taken up as hoped, given that the family are asked to pay for this as an additional service. By comparison, the more usual invasive post-mortem carried out by a pathologist is carried out at no cost to the family.

The Chief Coroner remarked in guidance in September 2013 that the offering of post-mortem imaging was “certainly not as a free service”. The approach seems to be on the basis that it is an extra service, and if the family want it, they have to pay for it. However, this is very difficult where a family’s religion means that the usual post mortem is not appropriate, and they are unable to fund imaging. The technology exists, and can provide a process which is far less distressing to families without affecting the quality of the post-mortem process.


The six month deadline was an attempt to deal with the very real problem that the coronial system suffered from considerable delay. There are a number of reasons that delay remains in the system, but perhaps the most significant one is a shortage of coroners.

The longest delay I have seen between a death and an inquest hearing has been over three years. By the time the inquest had taken place, most witnesses had the impossible task of trying to recall events that had taken place a considerable time ago. The family had been waiting for over three years to get answers on why their loved one had died. More common are delays of around one year. Families often feel that the inquest is a step they have to move beyond as part of the grieving process. They describe feeling a weight lift afterwards, and they can finally register the death. Coroners are simply overwhelmed, and unable to do the work in time to meet the deadline of 6 months.

In 2014, there were 25,889 inquests. Although this is a large number, it is actually a reduction of 14% from those held in 2013. The changes implemented have helped focus efforts upon a smaller number of inquests, but even so, the courts are still unable to meet the six month target.

The only solution is for more coroners and assistant coroners to be brought into the system. Inquest should not be rushed, and PIR hearings cannot be avoided to save time. This only leads to the family feeling disengaged from the process. The system needs significant investment. Without this, the current system cannot hope to reach the rightly high standards that the 2013 changes seek to achieve.

Consultation – Your voice is important

The consultation on how well the changes have worked provides an excellent opportunity for anyone who has experience of the coronial system with the last 18 months to provide feedback. This is on what they feel went well, and what they were unhappy with. This will improve the system for future bereaved families. I will be submitting my comments and would suggest that everyone who has recent experience of the inquest system does the same. Hopefully this will lead to the system improving further, with the aim that it assists and supports families as they are going through the grieving process.

We are able to help families with inquests where there are concerns with the medical treatment provided and we are investigating whether this was negligent.

I am a Senior Solicitor at Bolt Burdon Kemp specialising in Medical Negligence claims. If you are concerned that your doctor or nurse has not provided you or a loved one with a reasonable standard of treatment and would like to discuss a claim for compensation, please contact me, free of charge and in confidence, on 0207 288 4820 or at for specialist legal advice. Alternatively, you can complete this form and one of the solicitors in the Medical Negligence team will contact you. You can find out more about the Medical Negligence team.

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