Lord Filkin CBE
Parliamentary Secretary at the
Department for Constitutional
Affairs and Minister for the
Northern Ireland Court Service
The existing coroners service in Northern Ireland has been essentially unchanged since the enactment of the Coroners Act (Northern Ireland) 1959. I am grateful for the dedication and hard work of those who have worked within the system.
However, limitations in the inquest systems across England, Wales and Northern Ireland have been recognized for some time. The Government is aware, in particular, of the concerns held by many stakeholders in Northern Ireland about the number of cases which remain outstanding due, in part, to unresolved legal proceedings. As a result, the Government is committed to modernising the service to ensure that it meets the needs of bereaved families and the wide range of agencies with which the coroners service interfaces.
As an interim measure, the Northern Ireland Court Service has, following consultation with key stakeholders, produced proposals for improving the inquest system in Northern Ireland through administrative redesign, in advance of the introduction of new legislation.
I am pleased to introduce this consultation document, which seeks your views on our proposals.
Lord Filkin
1. The coroners service in Northern Ireland is managed by the Northern Ireland Court Service, which is the Lord Chancellor’s department in Northern Ireland.
2. The existing coroners service has a long history and parts of its practice have not been reviewed or updated for many years.
3. The Government is aware of the limitations of the current service and is keen to improve the service provided to families of people who have died and also to ensure that public confidence in the system is high.
4. For that reason the Government commissioned an independent review of the coronial and death certification systems in England, Wales and Northern Ireland chaired by Mr Tom Luce CB. The Review appointed a Northern Ireland Reference Group. The report, “Death Certification and Investigation in England, Wales and Northern Ireland” was published in June 2003. The report’s principal recommendations are detailed at Annex A.
5. The Court Service issued the Luce Report to relevant interest groups in Northern Ireland, including the political Parties, the Northern Ireland Human Rights Commission and others. The report was also made available on the Court Service and Home Office websites.
6. In addition, the Court Service undertook a series of consultation meetings with political Parties and other stakeholders.
7. As well as the Luce Review, the Government asked Dame Janet Smith to hold an inquiry into the deaths caused by Harold Shipman. Dame Janet’s third report “Death Certification and the Investigation of Deaths by Coroners”, published in July 2003, did not cover Northern Ireland specifically. A summary of the report’s conclusions is at Annex B.
8. Although the two reports contain a broadly common analysis of the defects of the present system, there are some important points of divergence, mainly concerning the scope of the death certification process.
9. Proposals outlining the Government's plans for reform of the coroners service are expected to be issued by the Home Office later this year.
10. In the interim, the Court Service intends to proceed with improvements to a number of areas of the coroners service in Northern Ireland through administrative redesign, including:
This consultation document seeks your views on each of the proposals.
11. The consultation period is open until 30 April 2004.
12. A form for submitting your views is at Annex F. It is also available electronically on the Court Service website www.courtsni.gov.uk.
Please send the completed form to:
The Consultation Co-ordinator
The Northern Ireland Court Service
Windsor House
9-15 Bedford Street
Belfast BT2 7LT
Fax No: (028) 9041 2390
E-mail: informationcentre@courtsni.gov.uk
1. Coroners in Northern Ireland are independent judicial officers appointed by the Lord Chancellor. To be eligible for appointment they must have practised for not less than five years either as a member of the Bar of Northern Ireland or as a solicitor.
2. Coroners derive the legislative authority to carry out their function from the Coroners Act (NI) 1959 and the Coroners (Practice and Procedure) Rules (NI) 1963. 3. The coroner’s role is to seek to establish the cause of deaths in cases reported to the Coroner that appear to be:
4. In Northern Ireland there are approximately 3,500 deaths reported to coroners each year and approximately 230 inquests are held. Annual statistics for 2002 showing deaths reported and cases dealt with is at Annex C. 5. When a death is reported to a coroner, there are normally four courses of action open to him or her:
6. Coroners’ investigations are supported by information from the police or Police Ombudsman’s investigation into the death and from families, the bereaved, witnesses and reports from pathologists and forensic scientists.
1. Northern Ireland is currently divided into seven coroners’ districts:
2. There is a full-time coroner and two deputy coroners in the Greater Belfast district. Six part-time coroners and four deputy coroners provide a service to the other districts. What we are proposing
3. It is proposed that the seven coroners’ districts should be amalgamated into a single district covering the whole of Northern Ireland. Inquests will continue to be held throughout Northern Ireland as required. The coroners service will have its administrative headquarters in Belfast.
4. Creating a single coroners jurisdiction will entail revising the current resource arrangements, accommodation and IT provision. Further information on each of these aspects is given later in this consultation document. Why we are proposing this change
5. The Luce Review recommended “the introduction of a consistent professional service based on full-time leadership, reformed into a single Northern Ireland jurisdiction”.
6. The current structure of seven coroners’ districts under one full-time and six part-time coroners is based on historical arrangements, rather than an analysis of service requirements and the needs of users.
7. Creating a single jurisdiction supported by an administrative headquarters will help to achieve uniformity of practice and a more effective and consistent service to bereaved families and other users.
8. It will also enable more effective collation and analysis of management information, which will facilitate the detection of patterns or trends. page
1. The coroners service currently comprises one full-time coroner, six part-time coroners and six deputy coroners.
2. It is proposed that, when the single Northern Ireland coroners jurisdiction has been created, it should be headed by a senior presiding judge at High Court level. There should also be a full-time coroner and two full-time deputy coroners.
3. The senior presiding judge will be appointed as a coroner following consultation with the Lord Chief Justice of Northern Ireland.
4. The current full-time coroner will assume day-to-day responsibility for the new single jurisdiction. Two full-time deputy coroners will be appointed through open competition.
5. We are proposing the appointment of a senior presiding judge in response to the recommendation in the Luce Review, which recommended that “Each of the new national coronial jurisdictions should be headed by a member of the permanent or senior judiciary and should include arrangements for enabling exceptionally complex inquests to be heard at higher judicial levels”.
6. It is envisaged that the presiding judge would provide guidance and leadership for the coroners service and hear complex cases. It is also anticipated that the appointment of a presiding judge will help to alleviate the current backlog of cases. It will also provide a means of ensuring that the coroners service becomes more fully integrated into mainstream judicial services.
7. The Luce Review also recommended that “the service should become a service of predominantly full-time, legally qualified professionals appointed, trained and supported to modern judicial and public service standards”.
8. A coroners service comprised of full-time coroners will aid the delivery of a more modern and effective service to the public by creating a team of appropriately trained and specialist coroners, focused on one area of expertise. It will also create more opportunities for the sharing of best practice and communication within the profession.
1. The Government is committed to providing an efficient and responsive coroners service in which the public can have confidence. The review of the coroners service and our consultations with the Northern Ireland political Parties and other key stakeholders, identified a number of ways in which the service provided to bereaved families and others could be improved.
2. Significantly, there is a general lack of knowledge about the role of the coroners service and how it interfaces with other agencies engaged in death certification and investigation. Also, the information given to bereaved families about their individual cases could be provided more appropriately.
3. It is proposed that the service to the public could be improved in the following ways:
4. Providing a professional service to families who have been bereaved is an important responsibility of the coroners service. The changes we are proposing will help improve the service we give to the public and other users including witnesses.
1. The coroners service deals with a wide range of other agencies involved in death certification and investigation. Work has already progressed on developing inter-agency protocols including:
2. It is proposed that the coroners service should establish a working group with the relevant agencies to develop protocols in relation to child deaths.
3. A protocol with the Police Ombudsman will be formalised.
4. The current informal arrangements with other agencies should be formalised with the production of written protocols.
5. The Luce Report identified that “In some coroner districts there are standing protocols between the coroner and the various children’s services and the child protection agencies setting out how the children’s agencies should be involved in death investigation and how the coroner and his staff should work with them”.
The review recommended that, “There should be such protocols in all areas, taking into account the characteristics of the areas and the configuration of the relevant children’s health and social services and the child protection networks”.
6. Establishing protocols with other agencies will set the standard of investigation expected. It will enable the departments to agree on areas of responsibility and the co-ordination of investigation.
7. The information gathered as a result of a coroner’s investigation, and any report made by the coroner during an inquest, may lead agencies to review their procedures. It is essential that any lessons learnt from a death are passed onto, and used by, agencies to prevent any further deaths.
1. In most cases the police are responsible for investigating deaths on behalf of the coroner. The investigations currently undertaken by the police are into the factual circumstances surrounding a death. The primary purpose of these investigations is to ascertain whether there is any evidence of criminal conduct associated with the death. The evidence gathered by the police in the course of an investigation will be made available to the coroner in order to assist his own inquiry into the death. The coroner may also require additional investigations to be carried out, such as ordering a post-mortem report on the medical cause of death.
2. In some cases it may not be appropriate for the police to investigate a death, for example, when it is apparent that the police may themselves have been involved in the death. In these circumstances, the Police Ombudsman will investigate the death and the coroner will be provided with copies of witness statements and other relevant information concerning the death.
3. Other cases where police involvement may not be necessary include deaths in nursing homes and hospitals where there is no suspicion of neglect, malpractice or misconduct.
4. Support to coroners in the death investigation process is provided by Coroners Officers in England and Wales. In Northern Ireland, the PSNI presently carry out this role on behalf of coroners.
5. We would like to hear the views of consultees on whether certain categories of death should be investigated by someone other than by the police or the Police Ombudsman.
6. One option would be to develop an investigative capacity within the coroners service. This might involve appointing suitably trained personnel who would assume responsibility for investigating the deaths and, if appropriate, refer cases to the police or other agencies. However, this could possibly result in investigative duplication and it would take significant time and resources to develop a comparable level of investigative expertise to that currently provided by the police.
7. It is important to establish whether there is a need for an investigative capability other than that currently provided for coroners by the police and the office of the Police Ombudsman and, if so, the best means of providing that capability. Our provisional view is that the police (and in appropriate cases the Police Ombudsman) are best placed, and have the necessary expertise and resources, to undertake the investigation of the majority of deaths reported to coroners. There may however be scope to develop improved liaison arrangements between the coroners service and other investigative agencies.
8. We would welcome views on the adequacy of the current arrangements for investigating deaths reported to coroners, and whether improved liaison arrangements should be put in place between coroners and other agencies.
1. A significant amount of statistical information about coroners’ cases is already collected such as, the number of cases reported, the number of cases completed, numbers of outstanding cases etc. See Annex C.
2. However, the current structure of the coroners service in Northern Ireland means that the collection of information on the progress of cases is not as efficient as it might be and it does not always meet the requirements of service users.
3. Information systems will be enhanced to enable more effective management of data.
4. Additional information collected will include:
5. Data collection arrangements will be formalised in Coroners Rules.
6. Improving our management information systems will enable us to analyse the handling of cases, identify where delays are being caused, help us to make further improvements to the service and respond to queries from elected representatives and others more efficiently.
1. Most criminal justice agencies are subject to oversight by an independent inspectorate. For most agencies this activity is co-ordinated by the Chief Inspector for Criminal Justice in Northern Ireland. The Northern Ireland courts are inspected by the Magistrates’ Courts Service Inspectorate (soon to become the Independent Inspectorate of Courts Administration) for England and Wales.
2. The Magistrates’ Courts Service Inspectorate will be responsible for inspecting the performance of the coroners service in Northern Ireland.
3. Following the devolution of justice to the Northern Ireland Assembly, this inspectorate function may become the responsibility of the Chief Inspector of Criminal Justice for Northern Ireland.
4. The Luce Review recommended that, “There should be a small Coroner Service Inspectorate to monitor standards of interaction with families and the standards of the service’s physical environment”.
5. The Inspectorate will monitor the performance of the coroners service and provide feedback, in a published Annual Report, on performance and the quality and effectiveness of the service provided to the public.
6. The Inspectorate will pay particular attention to reports made by coroners to other agencies to help prevent future loss of life. It is important that where a coroner makes such reports these are followed-up and acted upon. The Inspectorate will ensure that this happens.
1. At present there is no independent body with a strategic, reporting and guidance role in respect of the coroners service in England, Wales and Northern Ireland. However, the establishment of such a body – a Coronial Council – is currently being considered.
2. If a Coronial Council for England, Wales and Northern Ireland is established it will help take forward further improvements that can be made, but do not require new legislation. Nominated representatives from Northern Ireland should sit on this Council.
3. Alternatively, or in addition to Northern Ireland participation in a national Coronial Council consideration will be given to the desirability of establishing a separate Coronial Council for Northern Ireland to advise on the operation of the coroners service.
4. The Luce Review recommended that, “There should be a Statutory Coronial Council with powers to monitor the general performance of the new structure in death certification and investigation, and to give statutory guidance on issues of policy and process”.
5. It is important that agencies involved in any aspect of the death investigation and certification process have the opportunity to agree the best methods of implementing the Government’s reforms.
6. Furthermore, any new system will benefit from scrutiny by an independent council to monitor the general performance of the new structures on death investigation and certification.
7. Participation in the England, Wales and Northern Ireland Coronial Council would ensure that Northern Ireland is represented at national level and lead to uniformity of practice.
| Activity | Date range |
|---|---|
| Public consultation period | February 2004 – April 2004 |
| Publication of a response to the consultation exercise | May 2004 – June 2004 |
| Implementation of agreed recommendations | May 2004 – March 2005 |
In respect of England, Wales and Northern Ireland:
1. The Death Certification and Investigation in England, Wales and Northern Ireland review was set up by the Home Secretary on 26 July 2001 to undertake a root and branch review of the existing coroner system including post mortems and inquests. It also examined the case for the introduction of medical examiners to supervise the certification of deaths by natural causes.
2. The review covered the death certification and coroner system in England, Wales and Northern Ireland.
3. Tom Luce, former Head of Social Care Policy at the Department of Health, was appointed chair of the team. Other review team appointees were: Mr Anthony Heaton-Armstrong, a barrister; Professor Sir Colin Berry, Professor Emeritus of Morbid Anatomy at the University of London; Mrs Elizabeth Hodder, formerly Commissioner for the Equal Opportunities Commission; Mrs Deidre McAuley, formerly a Citizens Advice Bureau advisor in Ballymena and chair of the local Peace and Reconciliation Partnership; and Mr Iqbal A.K.M Sacranie OBE, Secretary General of the Muslim Council of Britain.
4. The Review appointed a Northern Ireland Reference Group. The report, ‘Death Certification and Investigation in England, Wales and Northern Ireland’ ‘The Report of a Fundamental Review 2003’ which followed an extensive period of research and investigation during which the review team consulted widely not only with coroners and other professionals within the system, but the families and the bereaved who use it, was published by the Home Office Minister Paul Goggins on 4 June 2003.
5. A synopsis of the six major changes envisaged by the review are:
1. Harold Shipman was convicted at Preston Crown Court on 31 January 2000 of the murder of 15 of his patients while he was a general practitioner at Market Street, Hyde, and on one count of forging a will. He was sentenced to life imprisonment. On 1 February 2000 the then Secretary of State for Health announced that an independent private inquiry would take place to establish what changes to current systems should be made to safeguard patients in the future. The inquiry would be held in private but its report made public. The private inquiry began work on 10 March 2000 and was to report its findings and recommendations to the Secretary of State for Health and the Home Secretary by September 2000.
2. Many of the families and sections of the British media sought a judicial review in the High Court, which found in their favour and recommended that the Secretary of State for Health reconsider his decision that the Inquiry should be held in private. In September 2000, the Secretary of State for Health announced that the Inquiry would be held in public under the terms of the Tribunals of Inquiry (Evidence) Act 1921. Both Houses of Parliament ratified this decision in January 2001.
3. Dame Janet Smith DBE was appointed Chairman of the Shipman Inquiry and the work of the independent public inquiry began in February 2001. The Inquiry has been divided into two separate phases. In Phase I the Inquiry considered how many patients Shipman killed, the means employed and the period over which the killings took place. The public hearings into Phase I began on 20 June 2001 and the Inquiry’s First Report was published on 19 July 2002.
4. The public hearings into Phase 2 began on 7 May 2002. Phase 2 is in four stages. The first stage dealt with the police investigation of March 1998 (Dame Janet Smith’s Second Report). The second stage dealt with death and cremation certification. The issues included in this stage were: the roles of the informant, medical practitioners, medical referees, the registrar and coroner; custom and practice generally, and in Hyde; the role of funeral directors; good practice and the practices followed in the Shipman cases; and proposals for change.
5. The Second and Third Reports were published to the House of Commons on 14 July 2003. The Third Report covers death and cremation certification and makes specific recommendations on the future of the coronial system.
6. The main recommendations in the Third Report with reference to the coronial system and death certification and registration are:
| Coroners’ caseload | Cases disposed of | ||||||
|---|---|---|---|---|---|---|---|
| Outstanding at end of 2001 | Deaths Reported | Inquest Held (Form 21) | No Inquest with Post-Mortem (Form 17) | No Inquest and No Post-Mortem | Other Disposals of Registered Entries | Outstanding at end of 2002 | |
| Londonderry [see Note1 below] | 122 | 206 | 38 | 75 | 70 | 0 | 145 |
| North Antrim | 131 | 233 | 92 | 92 | 81 | 65 | 117 |
| Greater Belfast | 771 | 2,430 | 142 | 912 | 888 | 495 | 764 |
| East Tyrone & Magherafelt | 222 | 147 | 0 | 18 | 66 | 0 | 285 |
| Fermanagh & Omagh | 120 | 144 | 21 | 55 | 59 | 0 | 129 |
| Armagh | 103 | 262 | 14 | 74 | 129 | 56 | 92 |
| South Down | 100 | 141 | 6 | 69 | 62 | 3 | 101 |
| Northern Ireland Totals | 1,569 | 3,563 | 230 | 1,295 | 1,355 | 619 | 1,633 |
[Note 1] Londonderry have recalculated their number of outstanding cases at the end of 2001 (previously 450)
1. This policy has been submitted for equality screening in accordance with the obligations contained in Section 75 of the Northern Ireland Act 1999, as detailed in the Northern Ireland Court Service Equality Scheme.
2. No potential differential adverse impact on persons of different religious belief, political opinion, racial group, age, marital status, sexual orientation, men and women generally, persons with a disability and persons without and persons with dependants and persons without was identified.
This form is published as separate document Response Form - Annex F (PDF format).