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1 June 2021 | Comment | Article by Lynda Reynolds

House of Commons Justice Committee report on inquests calls for changes

The House of Commons Justice Committee has released its report on the Coroner Service. The report comments on many issues that we at Hugh James experience representing families at inquests.

For us at Hugh James the most important reflection in the report is that families should be at the heart of the process. There is a recommendation that the Coroner’s Service should provide better advice for families in written format however, there is acknowledgement that families do benefit from specialist legal support.

Giving evidence to the committee, Assistant Coroner, Andrew Bridgman, said:

‘As an independent judicial officer conducting my own inquiry, how can I possibly represent the views of the family? They may have completely different issues. I invite them to tell me what those issues and concerns are. But they may miss the point. I find it far easier for me as a Coroner to conduct my inquiry more thoroughly and without fear of bias if the family is represented.’

Lynda Reynolds, Head of the Hugh James inquest team said:

‘We put families at the heart of the Inquest process, ensuring they have seen all the relevant disclosure, can question the relevant witnesses and make submissions to the Coroner. It is always important to families that there is an opportunity to explore all the facts leading to their loved one’s death, and that, if necessary, lessons are learned and changes are made.’

One of the barriers to specialist representation is a lack of non means tested Legal Aid Funding. The report identifies there were 531,000 deaths in 2019, of these 211,000 were reported to the Coroner and approximately 30,000 inquests were held. When discussing access to Legal Aid the figures provided by the Ministry of Justice were that 420 applications for Exceptional Funding were made and 280 granted. This confirms what those of us representing families already know: that Legal Aid funding is not really available for families, they must either pursue a successful civil claim or rely on charities and pro bono legal support.

The recommendation is that where the state has legal representation, such as Hospital Trusts, then Legal Aid should be made available for families. However, this has been recommended before and has yet to be implemented.

Rose Harvey-Sullivan, a barrister at 7BR, fully supported this recommendation, saying that:

“When one party is represented and another – usually the family – is not, it can often result in injustice. Family members should be at the heart of an inquest, yet without lawyers, many are unable to fully participate and are left feeling that they have not been provided with the answers and accountability they deserve. This disparity is sometimes mitigated by lawyers who are willing to give their time to represent families pro bono, but the system should not be set up to be reliant upon this.”

The report has also highlighted that Prevention of Future Deaths (PFD) reports are not adequately followed up. With missed opportunities to learn and improve safety. There is a suggestion that a new body be established called the Coroners Service Inspectorate which will review and follow up on PFD reports.

The report also highlights that there is a postcode lottery in the standard of service provided by Coroners. This is a result of the fact that each Coroner’s area is funded by the Local Authority and there is no national provision for England and Wales. Consideration to establish the Coroners Service Inspectorate is supported by some Coroners. However, others feel it may be used as an opportunity to ‘level downwards’ and reduce the service provided in areas of excellence. Such a change will be expensive to implement and may cause disruption to the service which is still dealing with a backlog form the Covid pandemic.

The report also commented that the review into whether stillbirths should be investigated by Coroner’s remains outstanding since October 2019. Hugh James participated in this consultation and fully supports expanding the Coroners jurisdiction to include stillbirths. There are often opportunities to learn lessons and prevent future deaths that are not investigated when they should be.

Lynda said:

‘I truly hope that families will be able to access legal advice, be supported through the inquest process and that a new inspectorate is established to properly consider PFD reports and ensure that lessons are learned. The hardest part of my job is seeing the same failings repeated and sitting explaining these repeated failures to families that cling onto the fact a death has not been in vain and lessons can be learned.’

The full report can be found here.

Author bio

Lynda Reynolds


Lynda is a Partner and Head of the Inquest Team that forms part of the Clinical Negligence Department in the London office. She has considerable experience in assisting families with inquests that relate to deaths in hospital or care homes, where medical negligence is suspected.

She has been instructed on Article 2 inquests, inquests with juries and complicated medical inquests where numerous experts have been instructed. Where necessary she will make submissions on the Coroner’s power to issue Prevention of Future Deaths reports. Her inquest role combined with subsequent civil claims ensures that she is a specialist on Fatal Accident Act Claims. She is recognised in both UK Chambers & Partners and Legal 500.

In addition to her role in the Inquest team Lynda has a caseload of complex clinical negligence matters which include cerebral palsy, brain injuries, spinal injuries and cauda equina claims.

Disclaimer: The information on the Hugh James website is for general information only and reflects the position at the date of publication. It does not constitute legal advice and should not be treated as such. If you would like to ensure the commentary reflects current legislation, case law or best practice, please contact the blog author.


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