Inquest delays – a never-ending story

The delays to inquests proceeding in the coroners’ courts in England and Wales have been a recurrent theme for many years.

Following last year’s recognition of increased demand on the coronial system, the Commons justice committee announced the launch of a new inquiry into the coroner service to examine changes implemented since 2021. The opening of a new inquiry was well received and there was collective hope for reform.

Some 69 organisations provided formal submissions responding to the committee’s questions. Bolt Burdon Kemp’s submission focused on addressing topics including but not limited to the following:

a) The impact of a delayed inquest on a grieving family

There is a woeful lack of support available to bereaved families in England and Wales. An unreasonable burden is often placed on families to navigate their own way through the coroners’ courts while they are at their most vulnerable. It is only at the inquest that a family can finally gain a proper understanding of how their loved one came about their death. Prolonging that closure can prolong a family’s grief. Furthermore, with the passage of time, a delayed inquest may dilute the integrity of evidence as memories and physical evidence erode. Consequently, the public may lose faith in the justice system.

The submissions raised awareness of how damaging a delayed inquest can be to a grieving family. The hope was that by emphasising these issues more urgent attention would be paid to preventing the delays, or to implementing better support services.

b) The benefits of a National Coroner Service

The delays to inquests in the coroners’ courts pre-date the pandemic and there is often vast regional disparity in performance depending on resources and funds available to different coroner areas. Accordingly, although the pandemic has undoubtedly compounded the issue of delay in some coroner areas, ongoing delays are more likely attributable to poor management of resources and/or funding allocated by local authorities. It therefore seems plausible that such delays could best be addressed by centralising the coronial system into a more homogenised operation.

Many organisations made submissions calling on the government to standardise the coronial service to ensure that sufficient support is provided irrespective of location.

c) Timely publication of a prevention of future deaths report

A delayed inquest could inadvertently place lives at risk. When an inquest is delayed, so too is the issuing of the prevention of future deaths report which may prevent others from losing their lives in similar circumstances.

On 6 February 2019, cadet Olivia Perks tragically took her own life. On 30 November 2022, a service inquiry report was published and 61 recommendations were made to the Ministry of Defence identifying a multitude of failings. Devastatingly, by this time other service personnel had taken their own lives in alarmingly similar circumstances. For example, Jaysley Beck took her own life. It is unclear whether earlier publication of the recommendations issued in Olivia’s case could have effected enough institutional change to save lives, but this is certainly not inconceivable when observing the timeline of events.

There is a real risk that lives will continue to be lost if more is not done to speed up the process. In the absence of any fast and meaningful changes to inquest delays, one option is to provide coroners with the power to issue preliminary prevention of future death recommendations. This would operate as a warning system to encourage early institutional changes.  

Delays to addressing delay

Ironically, not only are the coroners’ courts plagued with delay, but there are also now delays in addressing the delays.

The committee had planned to report its findings in the summer but the 4 July general election meant this was aborted by the wash-up of parliamentary business.

After the election was announced, the former chair of the justice committee, Sir Bob Neill, wrote to now former justice minister Mike Freer MP to summarise the committee’s findings. Neill noted that the chief coroner himself had stated that ‘the coroner service in England and Wales is, with very few exceptions, chronically under-resourced and underfunded’. He also encouraged the new government to ‘enact change with far more urgency than has been the case up to now’.

A new justice committee is presently being constituted under a new chair, Andy Slaughter MP. It is unclear if it will take forward Neill’s recommendations. I will be writing to the secretary of state for justice to request she does so. The new government must act to quickly reduce delays to prevent any future avoidable deaths and to ensure grieving families can access justice in a timelier fashion.

Jennifer Ellis is a solicitor in the military claims team at Bolt Burdon Kemp, London