Coroner reform: 25 years in the making

The President: Ladies and gentlemen, tonight’s talk is the Minty Lecture. It is every two years; it alternates with the Presidential Address; and it is my pleasure to introduce the Chief Coroner, His Honour Judge Peter Thornton. I understand that the coronial office is a very old one, eight or nine hundred years, so it certainly, I think, antedates the Society, although it may not antedate some of our members; I am not quite sure about that. (Laughter) We had Professor James Furness to talk to us about 18 months ago, I think, so the Society has heard the discussions about the coronial system and the changes, and I understand that Kenneth Clarke, according to the BBC, made a U-turn and that the Coalition refusal has now turned to an acceptance. I am not going to say any more. Please come and address us. (Applause)

Judge Thornton: Well, Mr President, ladies and gentlemen, thank you very much for inviting me to speak here; I have never been here before. I don’t know if John Leslie Thornton, in 1890, was one of my ancestors, but I am glad to see him there as a President, on the board behind me.

Thank you very much for inviting me to speak. I am afraid I never had the pleasure of meeting Leonard Minty and I was very sad to read that his death came about, nearly 30 years ago now, after being beaten up by burglars, a wicked crime and one, unfortunately, I get to see now and then at as a Judge at the Old Bailey, although I can at least say to a London audience that the murder rate in London is lower now than it has been for 20 years. I discovered that Dr Minty, a PhD doctor, had quite a few books to his name, mostly in banking law, such as “American Banking Methods by Leonard Le Marchant Minty…” (a great name) – do I detect a flavour there of Scotland –“with an Introduction by Sir Drummond Drummond Fraser”? (Laughter) They certainly don’t make them like that any more. And I particularly like the sound of his book The Legal and Ethical Aspects of Medical Quackery, 1932, £40 used on Amazon. I think second hand would be rather more gracious. He used to be a Magistrate in Bermuda, where I used to practise at the Bar from time to time.

But I want to start in another country. I went recently to Australia, not the country but the exhibition at the Royal Academy, and I was struck by the special light which had inspired painters who went and lived, or in some cases were forcibly sent to that country by Judges like myself at the Old Bailey. But I really went to see a painting painted by my uncle, Tony Tuckson, which is in that exhibition. He flew to Adelaide as a Spitfire pilot during the war. He met a local girl, he waltzed her (Margaret, not Matilda) and stayed, and that was my Aunt Margaret, still going strong in her 80s, playing tennis twice a week and shouting at me down the telephone. (Laughter) Tony Tuckson did a few jobs, first as a cleaner, and later he got work at the Gallery of New South Wales, where eventually he became Deputy Curator and a specialist in Aboriginal art, as he called it then. Meanwhile, in a shed at home, in the evenings and at weekends, he painted, and he painted, and he painted, and often he could not afford a canvas, so he used paper or cardboard, and it was only when a colleague from the gallery came to see him on a social visit and saw them one day by accident that he and a very large body of work was discovered.

Hiding their light under a bushel, not shouting about their work but getting on with it, carefully and industrially with talent, is what some of my coroners do best. They do not hit the headlines, except perhaps the one today who has pleaded guilty to fraud, not in his coronial role but as a solicitor. He had the cheek to say that he would resign; that’s fine, but he said he would resign from November 1. Why can’t he resign from today? (Laughter) So generally they do not hit the headlines, except in a few high profile cases. They get on with serving the public, explaining the unexplained, making reports where appropriate to prevent future deaths. They put bereaved families, compassionately, at the heart of the process. They are timely in setting dates and providing full disclosure; they are judicial and judicious in their investigations and in the way they conduct inquests; they are respected in their communities for their sympathetic approach to faith groups who want early burial. Their working arrangements are modern and effective. They work closely and collaboratively with the police and their local authority, who provide the staff and the money, and they find ways to make the best use of scarce resources, because it is public money being spent.

But unfortunately not all coroners are like that and the public has rightly come to expect rather more from this important public service; more consistency, more openness and transparency, more sympathetic handling, less delay; in short, a more modern, efficient and effectively delivered coroner service.

So let me put this justifiable aspiration in the context of numbers. In broad terms, as you probably know, there are about 500,000 deaths a year in England and Wales, quite a steady figure. For comparison, there are nearly 730,000 births per year, quite a surprising difference, and rising; up to 800,000 babies are born in the UK as a whole; and, as many of you will know, over 60% of all deaths in the country are from circulatory diseases or cancer, about half and half, and the next highest category is from respiratory disease, at 40%. So, of those 500,000 (half a million) deaths each year, just under half, some 220,000, are referred to coroners. About half of those deaths, some 95,000, will undergo post-mortem examinations by pathologists, a figure which I believe is too high and I shall try and reduce it – sorry, pathologists. Only one-third of those undergoing post-mortems, some 32,000 deaths, will lead to inquests, and just 450 of those inquests are with juries. Nevertheless, that is all quite a lot of coroner work. In Nottinghamshire, for example, a large coroner area, there are 6000 deaths reported to the coroner there each year; that is more than 16 per day. There are now 96 full-time coroners, known in the new language as senior coroners, one for each coroner area in England and Wales, and they are assisted by over 300 mostly part-timers.

So, amongst all those figures, what exactly has not been going well that has needed reform? Well, for a start, as coroners would be the first to acknowledge, there have been inconsistencies of practice across the country. This is not surprising. Coroners are all doing the same job, but they are appointed locally by the local authority, often with variable local support and varying local conditions. Some coroners have splendid facilities, like the new centre with a new court at Gloucester. They have got a whole new coroner centre there, which has been built with county money. They have got a post-mortem examination area around the back and a mortuary. So they can’t have weddings on Saturdays in that complex or citizenship services on Fridays, but there are new courts at Beaconsfield and Hatfield where they do precisely that because there are no mortuaries, so the local authority is making a little bit of money. On the other hand, some coroners are spread out countywide, with difficult court arrangements, having to book a slot with the Court Service and pay for it. And you will find that some coroners are in police stations, some are in solicitors’ offices, some are in the Registrars’ offices and some are at home, where they do their work. Then there is the sometimes uncomfortable relationship between the independent judicial office holder coroner on the one hand and local authority on the other. The hard pressed local authority, which funds the service, provides accommodation, pays for the coroner, staff to support the coroner and pays all the medical bills, such as post-mortem examinations and toxicology, which is 70% of the annual coroner bill, and the tension between the independence of the spender, the coroner, who is not employed by the council, and the frustration of the funder, who would really like coroners to be brought into the fold as chief officers, is not always an easy relationship.

And there have been delays. Some places are worse than others. When the coroner of a big city recently retired I discovered that 46% of his outstanding cases were more than 12 months old, compared with an average of about 8, 10, 12%, and not surprisingly families complain when there is a delay. If there is one thing that comes across my desk more than anything else it is families who are saying “My son died in 2008. There has been no inquest. I don’t know when it is going to be held. I haven’t got a date for any hearing at all. I have not had good communication from the coroner.” Uncertainty today means distress; more delay means more distress. Not having a date for a hearing is not good justice; justice is delayed. Well, you know the rest.

Inefficiency and poor organisation can lead to inquests being delayed. I had to step in recently when a coroner ordered by the High Court to resume an inquest forgot about it for six and a half years, for which he apologised. Not surprisingly the family wanted a new coroner, and they got one. A modern approach often heralds modern efficiency. I recently came across the use of typewriters in one coroner’s office where things were not going too well, and it may be that the fax is on the way out, too. You probably know what the High Court Judge said some years ago when a document had not been brought up to London for the hearing and Counsel was suggesting how to deal with it. “Fax it up, my Lord?,” he said. “Yes, it does rather,” said the Judge. (Laughter)

But I do not want to be too gloomy. The whole purpose of reform is to be positive, forward looking, optimistic; and I am positive. There is much to be positive about, much to build on, although I have to recognise that there has been enough disgruntlement for there to be repeated calls for reform. There have been three major reports on coroners; the Broderick Committee report in 1971, the Luce Review in 2003 and Dame Janet Smith’s Shipman Inquiry reports, also in 2003; and all of them recommended a fundamental change. They called for a national coroner service across England and Wales, not just a national framework, as at present, but a national scheme, a coroner judge scheme paid for and run by the Ministry of Justice, central government, like other judges. However, that has not happened; that is not on the horizon; that is not likely to happen, particularly now. The Government is not going to say “Yes, of course, we‘ll spend, spend, spend.”

Hence the continuing local nature of the coroner jurisdiction as it always has been. You could say that coroners are survivors. After all, as your President said, they have been around for at least 800 years, with references to them in the Articles of Eyre in September 1194. But for 25 years now, there have been steadily louder calls for reform. I say 25 years because that is roughly the time since the last Act of Parliament about coroners, the Coroners Act of 1988. That Act has now been mostly repealed and replaced by the Coroners and Justice Act 2009. Well, that doesn’t sound very recent either, but it has crept slowly into force, with new rules and regulations this year. 25 July 2013 was implementation day for new coroner reforms.

I am the Chief Coroner, privileged to be the first Chief Coroner, and it is my duty to lead the Coroner Service into a new era. It is my brief, the Government said, to drive up standards and cut delays. Of course, as you probably know, there very nearly was no Chief Coroner at all, so no national scheme, no Chief Coroner. The Coroners and Justice Act 2009 was one of those Acts of Parliament which is slightly unusual, in that it was created with broad all party support. That somehow makes it not a very radical document. It is not the most radical in terms of change, but at the heart of it was something new, the creation of a new post, The Chief Coroner, who must by statute, be a senior judge. So, after an open competition, I was appointed by the Lord Chief Justice, who consulted with the Lord Chancellor, as the Act requires. I received my letter of appointment on 6 May 2010, but unfortunately that was not an auspicious day for appointments: it was the day of the last General Election. (Laughter) The new government was not keen on having a Chief Coroner. I was appointed under the old government. The Lord Chancellor Ken Clarke’s words to me were short and to the point: “Too much government, too much money.” Civil Servants came to see me with gloomy faces and I was very politely told to keep up the day job at the Old Bailey. It’s not often you get an apology in person from the Lord Chief Justice and the Lord Chancellor on consecutive days; they were really very nice about it.

So the Chief Coroner (and all his powers) was duly placed into that well-known Schedule 1 of the Public Bodies Bill, which I am sure you all have at your fingertips, but it was commonly known then as the “bonfire of the quangos”, placed there for abolition. The House of Lords, in their amending and revising role, led by the impressive Baroness Finlay, a doctor (Dr Finlay) and Professor of Palliative Medicine, voted in December 2010 by a very large majority to keep the Chief Coroner off the funeral pyre; but the Government remained unimpressed.

Meanwhile, I had been appointed to conduct the inquest into the death of Ian Tomlinson, who died during the G20 protests in the City of London in 2009. It was my first experience of the loneliness of the long distance coroner and there was a little divergence of opinion amongst the pathologists in that inquest which had to be sorted out.

However, the post was finally reprieved. I have not been told why that decision was made. There was certainly a lot of lobbying before it was made by the Royal British Legion and other groups. I do not propose to speculate. I have been in post now for a year. I hope coroners and you tonight will be a little bit more generous about me than the MP, Alun Michael, a former Minister, was in the passage of the Coroners and Justice Bill when, looking at the administrative role, which is largely my role, the central part of my role you could say, of the Chief Coroner’s job, he said: “The chief coroner is a judge, so he is not necessarily competent to run anything.” (Laughter) Very helpful! I make no comment about that. I am a judge and perhaps in my defence I can say that the Broderick Committee, which reported in 1971 into death certification and coroners, was chaired by Norman Broderick, also a judge at the Old Bailey.

So it is my purpose as Chief Coroner to provide leadership for the coroner system, to implement and develop reform, to create a more co-ordinated and accountable system, all with a national consistency in quality of standards and approach. Not a national service, unfortunately; we haven’t taken that step; so a local service but nationally monitored and brought together, I hope. I am accountable to the Lord Chief Justice and I have to report annually to the Lord Chancellor. I have statutory functions and duties, some particular ones, particularly in relation to service deaths, those who die on active service or training for active service. Fortunately, there has only been one and that was very recently, in the last six months, so the numbers are reduced, but I have special duties to provide properly trained, fully trained coroners for that particular purpose. I work with Government, but I, like coroners, am an independent judicial office holder and I am therefore independent of Government, central and local.

So how do I propose to carry out my duties and make reforms? What is the way forward, the positive way forward? Let me set out my four main strands of reform, which, if implemented, effectively should mean fewer inquests, earlier release of bodies for burial and cremation, inquests with dates set earlier, and hopefully completed in the main within six months, and if not completed within 12 months I will investigate, all with a view to providing bereaved families, at the heart of the process, with a more efficient, effective and modern coroner service. My role is to facilitate change.

So, first, the statutory reforms, the 2009 Act and this year’s rules and regulations which go with it, all in place in July. I have worked closely with the Ministry of Justice over the last year in developing many of these rules. There is quite a lot of change there and it will take time to bed in, but I believe excellent progress is already being made. The old Act, the 1988 Act, focused very much upon the inquest. So the coroner takes a box, puts everything into the box; that is, medical evidence, witnesses, hospital notes, other witnesses, police enquiries, whatever is necessary; and we get to the inquest date and the box is opened – “Let’s see what is there.” So the focus is really upon the inquest; that is the central point. Now the focus is much earlier, on the investigation, and, even before that, on preliminary enquiries before the investigation, with a view to seeing whether an investigation may not be needed, and this shift of emphasis should have a big impact. As a result, there will be fewer “natural causes” inquests, and that will reduce the number of inquests by as much as up to 20%. Coroners will focus on early enquiries and if the case can be resolved early, with or without a post-mortem examination, and signed off as “natural causes”, so much the better for families; no inquest needed, no delay, less distress.

And another immediate product of the rules is that bodies can now be released earlier without the need for an inquest to be opened. In the past, the opening of the inquest was the moment in the process when the coroner was permitted to release the body, and not before. There was therefore pressure to open an inquest and, once opened, it had to be completed. Now the body can be released, where the coroner thinks appropriate, at an earlier stage without the need to open an inquest, and this should be particularly welcomed by faith groups, Muslim/Jewish, who want early burial.

Along with these key changes there comes a whole raft of procedural provisions, framed with a view to providing a better coroner service, and at the top of the list, following on from earlier scrutiny of cases, are measures to make the inquest process more transparent and accessible and to reduce delays. This involves opening inquests in public, not in an office, recording all hearings, setting a date for the next hearing at an early stage, giving directions to experts to provide reports and statements within a short period of time and generally putting in place case management structures to check on the progress of cases on a monthly basis, which with new computer software is easily done. This means completing the vast majority of inquests within six months, and if they go over 12 months, as I said, I will investigate; that is my statutory duty. One coroner told me that his usual pathologist took a year to provide a report. That is not good enough. That is not a report that is a guess; that is a guess what her notes, 12 months old, mean. Many coroners already, on the other hand, discuss with their local hospitals and GPs what is required and when it is required and how that can properly work. That is good practice and I want to encourage that. Coroners have got to work collaboratively, and many do, not just with the police and local authority, which is vital, but with all those whose work touches on the coroner process. Gone are the days when coroners sat alone in their offices dictating diktats into their dictaphones.

So fewer “natural causes” inquests, reduced delays, inquests held earlier, bodies released earlier and families will receive information earlier and have greater access to documents and evidence, and greater collaboration with the stakeholders, and I am going to run a competition for a new word to replace “stakeholders” – it reminds me of those who used to carry heads around the streets of London after an execution.

Secondly, training. I have developed compulsory training courses for coroners and coroners’ officers. Under the auspices of the Judicial College, which trains all judges, there have been regionally based courses in the new laws for all coroners, and others have been invited to take part; for example, local authority and police representatives; Police and Crime Commissioners came, pathologists, prosecutors, lawyers, health and safety, the Defence Inquests Unit from the Ministry of Defence, charities and others with interest in the coroner service. So all the coroners have been trained and we have invited others to come in and join the training so that we can lead the way with the training, explaining what the new procedures are, what the new laws are and hoping that everybody will work together with those reforms. I have just come back today from Loughborough from the first new three-day induction programme, which was extremely positive, and this is for new coroners, assistant coroners, and some of these, at least, are the senior coroners of the future, and they were good. Continuation training is already being planned, as is a new starter course for coroners’ officers. Senior coroners are going to get trained in leadership and management in February and there will be specialist training next month for my newly created cadre of coroners to investigate deaths of personnel on active service, as I have myself been with a number of coroners, on the MoD training course at the Warminster Garrison, which is a big area where soldiers train and go out into the Wiltshire countryside. They show you all manner of procedures and equipment; you get to learn how to use an AK47, which may well come in useful in my job over the next year or so.

Thirdly, I am working to overhaul the appointments process. Previously local authorities made some coroner appointments, and coroners made the rest. Now, under the Act, all appointments will be made by local authorities, all coroner appointments, whatever rank, but only with my consent and that of the Lord Chancellor. So that means, in order to consent, where it is a senior post, I will make sure that I am involved. I may be there at the time of interviews; I may help them with the process, to see that they are not making a mess of the sift, whether they are asking the right questions, whether they know the answers to the technical questions which they should be asking; but in order to exercise my consent and to make sure that the process (which it hasn’t always been in the past) is public and open and well advertised. Recently a local post was advertised. They put it on the website for five minutes and invited everybody to reply within six minutes and were surprised when nobody applied for the job. Nobody knew about it. So that kind of thing has to be avoided. So the appointments process will be much more open now, and I hope fairer, and coroners will no longer appoint their spouses and partners as assistant coroners. Coroners had no retirement age; now it is the age of 70, for new appointments not the old ones. I will also want to encourage a bit of crossover in the judicial world, encouraged by the Lord Chief Justice and Senior President of Tribunals. For example, I have recently achieved agreement with the Chief Magistrate that full-time District Judges can be part-time coroners, and coming free of charge, fully paid District Judges becoming free of charge for a short time, maybe three weeks a year, into the coroner service, like Crown Prosecution employees, who can also come free of charge into the coroner service. So a part-time coroner and part-time District Judge became a full-time District Judge and he wanted to continue his coroner work and so we have been able to allow that to happen. So a bit of judicial crossover using expertise from one field in another, and vice-versa, and I want to build up this pool of free expertise gradually and possibly use it in certain areas to help reduce some of the serious backlogs.

Fourthly, I have begun to provide written guidance to coroners on a number of topics, with a view to achieving greater consistency across the country. So far they include (what I have just been talking about) the appointment of coroners, the location of inquests, which is now much more flexible; you can, exceptionally, move out of your own coroner area; recording hearings, which is new for all coroners, a cadre for service deaths, reports to prevent future deaths, post-mortem imaging and oaths and robes. So much more is in the pipeline. I also give legal advice and guidance through “law sheets”, I call them, and decisions which I give in the High Court on inquest cases where I sit in the Divisional Court with a High Court Judge. For example, I sat on the Hillsborough decision with the Lord Chief Justice when we quashed the original inquests and ordered fresh hearings to take place. So all this is now posted publicly and is available for the public on the open judiciary website, www.judiciary.gov.uk, so the lawyers have no excuse when they turn up at inquests and they don’t know what the Chief Coroner’s guidance is, and coroners have all of that and much more on the private judiciary internet. So the information is there and available and hopefully being spread.

Of those guidance topics, I would like to just pick out one of my statutory duties, which is to encourage coroners to make reports to prevent future deaths, formerly known as Rule 43 reports, but Rule 43 was repealed, so they had to be called something else, so they are struggling for recognition as PFDs (Preventing Future Deaths reports); I suppose PFDs in PDF format would be the way forward. But they have already increased, with my encouragement, and they are over 400 a year. A lot of coroners were not writing any reports at all, but I think that has changed, or is changing, and I am about to publish the majority of reports on the open judiciary website, which can be used to read them, to search them and to do what you like with them, and from some of those reports I will extract issues; it may be from a single report or it may be from a number of reports on a particular topic which I believe needs to be taken up and moved on into practical or legal action. Obviously, deaths in custody is a particularly important area for that kind of work, although, as Lord Ramsbotham, formerly a Chief Inspector of Prisons, always says, “The recommendations have all been made. They have been made, and made, and made, and often repeated over and over again. It is the implementation that matters.” However, there is no harm in saying something. I believe that these reports are a crucial function of coroner work. It is important for bereaved families to know that some good may yet come from their tragic loss, and it is an important part of coroner public service that unnecessary deaths may be avoided in the future. At the Warminster course, just coming back to that for a moment, where coroners were shown a lot of equipment, what is being used in Helmand Province, in Afghanistan, where most of our military is, what sort of procedures were being used, what sort of equipment had to be carried, how much double their body weight and beyond they had to carry in 40–50°C. It was very interesting, but what was impressive, or what impressed me, was that from time to time a senior officer would say “See that piece of equipment there; we have changed that to this one as a result of a coroner’s report. That procedure which we used to adopt, we have changed that now as a result of a coroner’s report.” So it is important work, and it was recognised by the military at Warminster.

So this is just a snapshot of the work I am doing and the way forward, the positive way forward as I see it, and there is certainly much more to be done. For example, as part of the bigger picture, I am working with the Lord Chancellor towards reducing the number of coroner areas from 96, which is the present number, to about 75, as Tom Luce proposed in 2003. So that will create a more or less standard size of coroner area, with a relatively standard number of reported deaths to the coroner, with a senior coroner in charge of a coroner area, assisted by a number, maybe about four assistant coroners, mostly local, as well as a more standardised number of coroners’ officers, identifying the scope of their functions, as nobody quite seems to know what their functions should be, and what administrative staff is needed in support. So, for example, I want each coroner area to have a team, a senior coroner working with the assistants, working together as part of a team, part of a package, and then having that awkward but necessary tripartite relationship with the police, who often provide coroners’ officers, and coroners’ officers are line managed by the police, and with the local authority, who often supply the administrative staff, and they are line managed by the local authority, and the senior coroner is not line managed by anybody. So that is not a wonderfully happy relationship, unless the senior coroner and the team work on it, and where it works well, it works extremely well, but it works by talking, collaboration and co-operation.

I have been at the training today of assistant coroners, and the arrangements are incredibly varied for assistant coroners. They are the secondary ones, they are the support coroners, fee paid usually, a day here, or a week here. Some teams work well. There is a senior coroner; they have assistant coroners, a small team together; they have a standard amount of work, which is all agreed; they have team meetings on a regular basis, social events. I think of Durham. I have been talking to assistant coroners from there today; a good example. Then I have been talking to other assistant coroners. Some work, do coroner work and are paid nothing for it. Some work, but all the work is treated as training, even though it has been going on for a year and a half, and are not paid for it. Some are appointed, qualified, trained and are given no work at all. So it is a very varied picture and that is why I want to create this more or less standard size of the area, a senior coroner and a team of assistants working together, and then between them they can sort out the collaboration with the local authority and the police, and outside that sort of triangle they can work with the hospitals. They can agree at a senior level that reports should be produced within six weeks. So it’s “Might as well get on with it”; you know, once he’s started it and done it, it’s done and dusted. Why leave it? It is much more difficult to write a report six months afterwards.

But all of this is a longer term task. In a very supportive speech (supportive to me) to the Coroners’ Society earlier this month the Lord Chief Justice, Lord Thomas, called for a cultural change. Just as civil and criminal and family justice is having to adapt to modern times, with no more money, probably less, so too must coroners, and it can be done. I feel that as reform progresses and coroners, many of them, are positive about it, they deserve a greater recognition and understanding of their work in the administration of justice, because it is justice work. Only those unfortunate enough to have a family member die a violent or unnatural death, or where the cause is unknown or the death was in custody or state detention, come into contact with the coroner service. The police have their own word they sometimes use in the early stages of an investigation; they say the death is “unexplained”. Stated simply, coroners are there to provide the explanation. Unlike some of you, they do not wield the knife as pathologists, nor are they forensic scientists, as some television programmes would lead viewers to believe. They investigate in order to find out how somebody has come by their death, so that the family know, the public know and the record can be kept, and, importantly, coroners can report to a person, organisation or Government agency when they believe action should be taken to prevent future deaths.

As the President of the Supreme Court said recently citizens should be aware of what their courts and judges are doing. He is right, and in some respects a coroner is much more important than the judge, who simply decides a private issue between two parties. Each coroner in each case is making a public finding, a conclusion that matters, of course to the family but also to the health and welfare of the country; that is an important public function. I want to show that it is a good service, a valuable service and that it is improving through the reforms. Coroners are no longer, as Chaucer wrote, “… lord and sire; ful often tyme he was knyght of the shire … .a shreve hadde he been, and a corouner,” but, as I wrote in The Times recently, they are hard-working judicial office holders, proud of their independence, acting for the public good and, with a fair wind, these reforms will bring back public pride in their work.

Thank you. (Applause)

Discussion

The President: I am going to ask the first question; it is my privilege as President. I have been to a number of inquests, either as an independent medical expert at the request of the coroner if it is a difficult renal case and I have prepared reports on behalf of the next of kin who may be thinking about clinical negligence. My understanding is that there are going to be fewer doctors who are coroners and more lawyers. So question one: am I going to get busier in the future? And question two: can you comment on this move away from doctors as coroners?

Judge Thornton: I can certainly comment on it. It was not my decision, it was the decision of Parliament, and Parliament decided that, although there have been, and still are, some medically only trained coroners, not legally qualified – there aren’t many of them now – Parliament decided that all coroners should have the same qualifications for appointment as all judges, which is the five-year judicial legal qualification, including five years practice as a lawyer. So that does mean that, except for the medics who have survived the process and continue to work, as long as they don’t try and change their job, because if they want a step up, say, from being an assistant coroner part-time to a full-time job, they will have to get a legal qualification, lawyers only from now on. So there is a change and it means that you are going to have more lawyers, more legally qualified obviously, all legally qualified, but more lawyers, more to that side of things, and it is becoming quite a legal business being a coroner, not on an everyday basis but with difficult inquests. On the other hand, they do have to have good medical knowledge. You would be training today, for example, in aspects of pathology and causes of death.

So what is going to happen? I think those who are more lawyers are going to need more advice from doctors; that is definitely going to be the case. Whether they will be better coroners or not so good coroners we shall have to wait and see. But the idea is that coroners are definitely becoming more like judges; they take the judicial oath, they are trained by the Judicial College, which trains all judges; they are subject to the same complaints procedure now as all judges; more like judges.

The President: Now, we don’t have a microphone, so I want speakers to introduce themselves and to speak up for the record. Linda Lee.

Ms Lee: Hello. My name is Linda Lee; I am a solicitor. I have represented families at inquests for about 20 years. I am still a member of Bedford Road Victims Trust, representing families pro bono, which I have been since it started. I have worn many hats in the process of lobbying Government and in the consultation process that led to this point, and I have represented Action Against Medical Accidents, a patient safety charity, Victims’ Voice, for victims of crime, and I was President of the Law Society from 2010 to 2011, and we wanted lots of quangos burned, but we lobbied very hard for you to be appointed, so I am delighted you were and I am very pleased to hear tonight the progress you have made so far. It is certainly in our wish list, and particularly relating to Rule 43, or PFDs as I have got to learn to call them….

Judge Thornton: Very good.

Ms Lee: … because we particularly wanted lessons to be learned there, because representing families and knowing that I have represented a similar family with a similar death, whether it was industrial or medical, the week before with the same people, it is heart-breaking, and it is heart-breaking for the family. There is just one aspect that I am troubled by, and that relates….

Judge Thornton: Only one?

Ms Lee: Only one; only one … and that really relates to the decision about natural deaths, because in the medical field that is a difficult area and I have had many years’ experience of coroners not wanting to look at the medical aspects of the death and saying it’s a natural cause; it can be fudged that way; and there is an important lesson to be learned for patient safety purposes, a public interest in dealing with that, and one of the public interest points we had when dealing with deaths related to medical assessment units, where, to beat the targets of A&E, people were shunted off into wards with no medical care, or minimal medical care, and deaths occurred, and that was the result of something driven by a target, and what I am worried about with the natural death aspect is that you will put pressure on people to do things quickly and to have less inquests, and that might have an unintended consequence of not dealing with those deaths where there are real patient safety issues to be learned. Am I right to be concerned?

Judge Thornton: Yes. Thank you very much. That is a very good point. The question of natural causes does not mean that merely because it is a “natural causes” death there will be no investigation. If there is no need for an investigation because it is clear that it is natural causes and there is nothing else, there is no evidence or suspicion or information of something else, but if the family had a particular complaint about something the coroner would have a duty to investigate and to make at least preliminary enquiries, if not to go further into an investigation, and once an investigation has started there must be an inquest. So the mere label of “natural causes” does not mean that the coroner will not look further if there is something there, and there are no targets. I can reassure you that it is not a question of saying to coroners up and down the coroner “I’ve got to see 20% in your reduction.” That is just what we believe may be the outcome of this change. We shall see. It may be less. In some parts of the country, it is already a bit less, which may mean that they are investigating further in the way that you suggest is necessary for patient safety and care.

Ms Lee: Is it possible that you could have some sort of monitoring system just to consider that as the programme is rolled out?

Judge Thornton: Well, if I had the resources for it maybe. But I would also like to say that there are many volunteers in the coroner service world, people who act pro bono, lots of lawyers. The legal representation is very, very low. There is this ridiculous position that if you have an Article 2 inquest then the Legal Services Commission may well fund it for the family, but if it is not an Article 2 inquest they usually say “No, we won’t fund it. It is not sufficiently special; it is not Article 2,” whereas they may both be equally complex and difficult and important.

Ms Lee: They don’t fund many Article 2 deaths either, only a tiny percentage.

Judge Thornton: But they are more likely to than if it’s not. There are a lot of volunteers working and there is also (and I want to mention it) the Coroners’ Courts Support Service, who work in about 20–30 court centres up and down the country, all volunteers, but properly trained. They look after the families, they look after witnesses; they are like Victim Support; they are specially trained in relation to coroner work; and that kind of volunteer service works fantastically well. So if you want to give any money anywhere or find any money that can be given to the Coroners’ Courts Support Service, then they can train more people in different parts of the country. The Government provided a little bit of money this year, which I am not supposed to say really. But there are a huge number of excellent volunteers and pro bono lawyers (and I have spoken certainly at the AVMA conference earlier this year) who do very good work.

If I can just come back to one point you have mentioned, which just comes across my mind, about the new legal qualification. The best sort of background now for a coroner might be somebody…. Well, one of the new coroners that was recently appointed, she was a nurse originally, which is good, but, even if she hadn’t been a nurse, her recent work had been as a solicitor doing clinical negligence work, so a mixture of law and medicine, a good mixture. So that is the sort of coroner we may be looking for, to come forward with a legal qualification.

The President: I am reminded that one of the important criticisms against the GMC in past years is that it has been run by doctors who have no experience of judicial process, how to run a committee, how to take evidence, so I am neutral on the subject. Eleanor Platt.

Ms Platt: Eleanor Platt, lawyer. Thank you very much, your honour. The current Act, the 2009 Act, deals with medical examiners.

Judge Thornton: Yes.

Ms Platt: You haven’t mentioned them.

Judge Thornton: No.

Ms Platt: Can you please tell us about them? Are we going to have any? If not, why not? I suspect it is just resources.

Judge Thornton: Yes. Well, what would you like me to say? I could probably say that, and it might well be true or it might not be true. At the moment there are no medical examiners. They are in the Act.

Ms Platt: And they are an important part of the Act.

Judge Thornton: And they are an important part. If you look at the Francis Report, a number of his recommendations are dealing with coroners. Nearly all of them, in fact, relate to the medical examiner scheme. At the moment it is said to be coming into force in October 2014. There are some difficulties with it. One of the problems is who is going to pay for it. Having an extra medical layer locally checking on deaths, deaths which are to be reported or not reported to the coroner, who is going to pay for that service. Originally it was going to be the family of the deceased, and of course it was labelled the “death tax”. Well, you are not going to have a death tax shortly before a General Election, which is May 2015. So they are talking about something else now. I went to a meeting with a Department of Health Minister and she said: we were talking about collection: “Who is going to collect this money? Is it going to be paid for by the family? Are they going to just pay the funeral director? If they don’t pay, who is going to collect, and what happens if they don’t pay? Are you going to lock them up?”

Anyway, her suggestion was that the Registrars could collect the money. They already collect a little bit for the payment of the certificates. I said “Well, yes, that is very interesting.” There were a number of people round the table and I just said it was slightly unfortunate there wasn’t anybody here from the registration office. The Registrar General wasn’t there. Nobody was there to sort of talk about it. So that didn’t go very far. There is some talk at the moment about having something half-way. I don’t know the detail. It has been talked about a little bit, it’s called “medical examiner light”, slightly derogatorily, and there was supposed to be, and is still supposed to be, a consultation process about the system. It was due in March; it was due in June; it is due now; it has not come. They have appointed a – well, it is not quite clear actually whether he is temporary or provisional; there isn’t a word which goes with it – National Medical Examiner. Somebody has been appointed, but there was absolutely no fanfare about it. You couldn’t find it on the Department of Health website, you couldn’t find it anywhere, but I received a letter from him. So it is all very uncertain. Six months ago I would have said it’s going to die the death. Sorry, that is an unfortunate phrase to use in my line of work, but it was fading away. Then the Francis Report really kick-started it again, I think, and so there is a feeling that there should be something, but money is a problem. The latest I heard was maybe the Treasury might pay. It seems unlikely, but… (Laughter)

The President: Okay. Bertie; last question.

Mr Leigh: Bertie Leigh. Following on from what you have just said, isn’t the real problem with all of the services you are trying to introduce the question of resources and the failure of the Treasury to pick up the tab?

Judge Thornton: Yes.

Mr Leigh: Because you have got the medical examiner scheme, which apparently looks like it is still there; you have talked about how you want a more professional service and you are trying to bring in a more professional and more effective service; you talk about a pathologist taking a year to produce a report. A coroner’s pathologist is paid less than £100 for doing a coroner’s post-mortem report.

Judge Thornton: Yes.

Mr Leigh: It’s absurd. Going to another town, doing an operation, giving in writing a detailed report, all for less than £100, it is just not realistic; and, above all, your coroners – I’ve spent some time representing coroners – one of the problems is that they don’t employ their own staff; they can’t direct them; they’re employed either by the police or the local authority. How can you expect a coroner to be at the centre and the person with the real authority to control a system as long as it is totally unresourced and financed out of other people’s back pockets?

Judge Thornton: You are absolutely right, I entirely agree with everything you have said, but it can be done; I have seen it done. I can think of one particular area. I won’t name that area: there are coroners here. There is one particular area where, with no extra money, the senior coroner in that area has gradually put together, working with the local authority year in, year out – he says it has taken him 10 years – with no extra money, an office, a place where people work together, a team, a good team of assistant coroners with very good close working relationships with the local authority. He doesn’t pay the staff, and actually I am really against coroners paying staff. There are one or two who still pay staff and I don’t think it is a good thing. I think it is better that the local authority pays for that, because it is very complicated when it comes out of the senior coroner’s pay, which was the old system. In the old system, there would be one coroner and he would be given a lump sum. “That’s your sum for the year. Do what you like with it. I don’t expect you to go on any training, or anything like that, but if you want to employ somebody, if you want to have a secretary or a clerk, fine; you do it and you sort it out”.

I don’t think that is the best way, not any more. So it can be done, but it is difficult with the lack of resources, it is difficult without a national scheme, but with good senior coroners working to build up a team it can be done, and effectively, and I can show you parts of the country where it does really work well, and that is what I am working towards.

The President: Okay, I am going to wind the discussion up. It can continue over drinks next door. It occurred to me that Dr Harold Shipman, who you mentioned – we don’t think he was a member of this Society; we are a bit nervous but we don’t think he was – he left two legacies for the doctors; he’s left appraisal and revalidation, about which I am personally a little bit cool. But I think the coronial system is a very important part of everyday life and I think everyone here recognises you have taken on what I think is a terrible task and we wish you every success with it. So I want to say thank you. Here is a little gift from the Society.

You are an honorary member for the next year – we won’t ask you for a subscription – so, if you have time, we would be very happy to see you here. Thank you very much.

Judge Thornton: Thank you. That is very kind. (Applause)