Reflections

This is my last year as a Senior Coroner serving the denizens of the city of Sunderland and being one of the Deputy Chief Coroners of England and Wales (a role which I’ve held since 2019).
When I was appointed Senior Coroner in 2003, there was an open competition and an interview.

This was in stark contrast with days gone by, when the position would have been inherited by the next in line within a firm of solicitors.

I was relieved that the daily task of the Coroner viewing the deceased at a mortuary had been abolished before my appointment.

As a Judge I swore the Judicial Oath on my first day in court. It would now read:

“I, Derek Winter, do swear by Almighty God that I shall well and truly serve our Sovereign King Charles the Third in the Office of Senior Coroner, and I shall do right to all manner of people after the laws and usages of this realm, without fear or favour, affection or ill will.”

However, what did strike me in the days following my appointment was, that the coronial forms all had different colours - blue, yellow, pink, peach and white, some with serrated edges and counterparts, and all requiring a wet signature.

Then there were the formal proclamations for opening, adjourning, resuming, and closing Court with or without a Jury:

“Oyez oyez oyez! All manner of persons who have anything to do at this court before the King's Coroner for this corner area touching the death of X draw near and give your attendance and, if anyone can give evidence on behalf of our sovereign Lord the King when, how and by what means X came to his death, let them come forth, and they shall be heard.”

My Local Authority wanted to modernise the Coroner Service. This was going to be a challenging journey, given that the first clear evidence of the Office of Coroner dated to the reign of Richard I in 1194, possibly earlier.

Local reforms evolved:

• my warranted Police Officers, who acted as my Coroners Officers, were ‘civilianised’;
• I established continuity of Coroner’s Officers for families;
• every effort would be made not to retraumatise the participants of an Inquest;
• I brought in IT;
• I developed a website;
• timely disclosure was to be given in every case;
• I brought in The Coroners’ Court Support Service volunteers, who do amazing work.

It would be a decade before national reforms took place.

The Coroners and Justice Act 2009 came into force in 2013, and there were significant changes for the better. For example, we have had three – soon to be four - Chief Coroners, each with their own vision for the Coroner Service and, above all, providing leadership and endeavouring to promote consistency amongst the 77 Coroner Areas.

Some practices were thankfully no more:

• pre-signed forms were forbidden;
• robing up in court with a horsehair wig, tabs and blue gown were ruled out (save for ceremonial occasions);
• hearings could not be conducted out of the public or media gaze.

But it was not all about consigning some practices to history, but making things better and relevant for everyone who encountered the Coroner Service and the new concept of the Coroner’s Investigation. There have been benefits from:

• 46 x Chief Coroner’s Guidance Notes, including ones on disclosure and pen portraits;
• Coroner Bench Book;
• 5 x Law Sheets;
• Chief Coroner’s Newsletters;
• Chief Coroner’s reports and lectures;
• mandatory Coroners’ Continuation Training and Coroners’ Officers’ Training under the auspices of the Judicial College who also support Assistant Coroners’ Induction and Medical Training events;
• established Disaster Victim Identification (DVI) processes and training; I am a member of the DVI Cadre of Coroners.
• Chief Coroner’s conferences for Senior and Area Coroners;
• Chief Coroner’s conferences for Local Authorities and Police Forces;
• a Model Coroner Area addressing operational issues and infrastructure, so that Local Authorities and Police Forces, who provide staff and accommodation, are better informed.
• increased transparency, including through: -
  • the provision of Inquest audio recordings (rather than expensive transcripts);
  • remote observation of hearings;
  • publication of Coroners’ salaries;
  • publication of the numbers of Inquest cases over 12 months old.

Coroners now have sophisticated IT systems with death referrals being made via a portal. The systems allocate the information to a specific death report, and forms are generated on request with electronic signatures being the norm. This IT with remote working arrangements in place and our business continuity plans helped Coroners manage the challenges of the covid-19 pandemic.

Accommodation for Coroners can be challenging. Personally, I have sat in court at a variety of locations including a Magistrates’ court, my solicitors’ office, an art gallery, a serviced office in the ownership of the local authority, a committee room and serviced offices rented from a private provider. Now I am based at City Hall co-located with my Coroner’s Officers, Assistant Coroners, support staff and Local Authority’s Registration Service. I am fortunate to have the unwavering support of my Local Authority and benefit from two courtrooms with the most up to date IT facilities.

I continue to engage with many agencies, stakeholders and organisations to promote and demystify the Coroner Service.

Once sworn in as one of the two Deputy Chief Coroners, it became apparent to me that there was a great deal of work to be done within a small team. This included work with Coroners and many others during the Covid-19 pandemic. I was involved with the implementation of the Notification of Deaths Regulations 2019 to ensure consistency of reporting to Coroners, rather than local reporting criteria. I assisted the professional legal regulators to develop competences to recalibrate the tone of Inquests from increasingly adversarial to their intended inquisitorial purpose. I have appeared twice before the Parliamentary Justice Select Committee.

It can be a lonely job being a Coroner. It would be remiss of me not to mention The Coroners’ Society of England and Wales - the judicial association for Coroners - which has been an invaluable source of legal and pastoral support and friendship.

There are lots of further opportunities for improvements. This is not an exhaustive list, but perhaps some of the following may be worth considering:

• a feasibility study to consider a model for a national Coroner Service and its resourcing, including a review of the mergers of Coroner Areas;
• Coroners to be cross appointed across all Coroner Areas and deployed as may be required;
• How to improve coroners' access to pathology and scanning services, including the feasibility of creating a national service.
• Senior Coroners to become eligible to be appointed as Chief Coroner;
• making better use of Prevention of Future Death Reports;
• improved welfare support for Coroners;
• an oversight mechanism to ensure that local coroner areas are resourced and structured in a way that enables them to provide an effective service.

It is over 20 years since two key Reports relating to the coroner service were published in 2003:

• Death Certification and the Investigation of Deaths by Coroners, the Third Report of The Shipman Inquiry under Dame Janet Smith DBE (the “Shipman Inquiry”); and
• Death Certification and Investigation in England, Wales and Northern Ireland: The Report of a Fundamental Review 2003 under Tom Luce (the “Luce Review”).

Both Reports found the systems for the certification and investigation of deaths in England and Wales to be unfit for modern society.

Change can be challenging but there can be no looking back. The changes since 2013 have been for the better with further changes to come. Coroners are modern judges, well able to adapt.

I shall miss the work of the Coroner with its daily challenges and, most of all, its rewards. As well as contributing to the greater public good, we can make a real difference to those in our local communities by helping people and being kind in all we do.