15 November 2021

“To prevent further avoidable deaths, and protect the bereaved, this report must be acted on.”

- Andy McCulloch, witness to the Justice Committee inquiry

An important Westminster Hall debate to discuss the government’s commitment to reforming the Coroners’ Service has taken place.

MPs put questions to Justice Minister James Cartlidge MP at the debate, which was organised to discuss the government’s lacklustre response to the Justice Committee’s recent report on their inquiry into the Coroner Service.

INQUEST submitted written and oral evidence to the Justice Committee inquiry. We also worked with over 50 bereaved families to inform the inquiry and make their voices heard.

The Government responded to their report in September. While the response contained positive commitments to remove means testing of legal support for some bereaved families, actions being taken on other key issues were far less clear.

The Westminster Hall debate, on 28 October, provided an opportunity for new government ministers to demonstrate their understanding and commitment to putting bereaved families at the heart of the inquest process. Despite strong questions from MPs, the government’s response was disappointing.

INQUEST shared a briefing for MPs ahead of the debate. Our policy team and Andy McCulloch, a bereaved family member and witness to the inquiry, attended the debate in person. Chair of the Justice Committee, Sir Bob Neill MP, welcomed our presence and thanked us for the evidence we had inputted to the inquiry.

The need for “major reform” to the Coroner Service

The Justice Committee’s report set out the need for several key reforms, including:

  • A clear deadline by which the Government should introduce non-means tested legal aid or other public funding for bereaved people in all inquests where public authorities are legally represented. This deadline has already passed.
  • The introduction of a duty of candour to all public bodies at inquests.
  • A system for appealing a coroner’s decision, and a complaints process.
  • The establishment of a national coroner service and inspectorate.
  • An independent office to report and follow up on issues and recommendations emerging from inquests.
  • Better signposting and support for bereaved families and strengthened guidance on disclosure.
  • A call for the 2015 post-implementation review of the Coroners and Justice Act to be made public and strong criticism of the reasons cited by ministers for failing to publish.

There were many helpful interventions made by MPs at the debate which emphasised the urgent need to implement these recommendations and finally strengthen the inquest system to ensure bereaved families’ needs are met. INQUEST’s evidence was regularly referred to.

Sir Bob Neil MP, speaking in Westminster Hall

Inequality of arms

MPs Sir Bob Neill, Maria Eagle, Tim Loughton and Andy Slaughter all highlighted the ongoing injustice and inequality of arms in the inquest system, not least the fact that bereaved families do not have access to automatic, non-means tested public funding for their legal representation, except in exceptional circumstances.

While countless recommendations have been made for the Government to establish equality of arms at inquests (see timeline), the Government continue to argue that funding is not necessary as inquests are “inquisitorial, fact-finding” processes.

However, MPs at the debate strongly contested this argument. As INQUEST has evidenced time and again, lawyers acting for the state very often make the inquest process adversarial.

The truth is, in these types of inquest, it is not the purely old-fashioned inquisitorial system any more. The reality is that an adversarial and defensive nature has inevitably been brought into the legal proceedings by the legal representatives —acting on the instructions, of course, of the public bodies concerned.

- Sir Bob Neill MP, Westminster Hall, October 2021

“I have had constituents who have had to deal with coroners’ inquests at the worst time in their lives—after they have lost a loved one, often in traumatic, unexplained or contentious circumstances. They have had to face a public authority that is being defensive, that is lawyered up to the eyeballs and that seemingly has an unlimited budget to spend on avoiding the blame and minimising its responsibility.”

- Maria Eagle MP, Westminster Hall, October 2021

Maria Eagle MP, speaking in Westminster Hall

Failure to publish the 2015 review into the Coroners and Justice Act

MPs also challenged the continued refusal from government to publish its own review into the implementation of the Coroners and Justice Act 2009, on the basis that it is out of date.

Notably, Sir Bob Neill strongly questioned the Government on why a public review into the implementation of the Act, which concluded in 2015, has still not been published.

 “This simple question is: why was the review never published? What on earth was the reason, even back in 2015? We ask it has not been published and are told that it is now out of date. We might ask whether this is a blatant cover-up, but if it is not a cover-up why not publish the review?”

- Sir Bob Neill MP, Westminster Hall, October 2021

INQUEST believe the Government’s justifications for not publishing the report (by saying that it is out of date) lack transparency and are disingenuous.

The Judicial Review and Courts Bill: a missed opportunity

The Government’s Judicial Review and Courts Bill introduces a series of changes to the coroner service. Yet it is INQUEST’s view that these changes are largely out of step with the Justice Committee’s recommendations for change.

“Unfortunately, the current proposals in the Bill are pretty minimalist and, if they do anything, they tend to restrict transparency and accessibility”

- Andy Slaughter MP, Westminster Hall, October 2021

One crucial step that we hope to see is for the government to amend this Bill to introduce equality of arms for bereaved families. You can read INQUEST’s briefing on the Bill here.

More must be done

This debate was the opportunity to commit to implementing the Justice Committee’s recommendations to improve the inquest system for bereaved families. Instead the Minister doubled down on the Government’s rejections and continued to defer on clear actions.

While this is extremely disappointing for many of the families we work with, INQUEST will continue to advocate for critical changes to be made.

More information: