The appointment last year of a Chief Coroner, HHJ Peter Thornton QC, was expected to be followed by changes to coronial practice and procedure, and so it turns out. I have not yet seen the final rules and regulations which are expected to be published this month but, together with the (belated) implementation of the Coroners and Justice Act 2009 they will introduce some important changes to the Coroners' court.
Coroners will be engaged in three stages - an enquiry, which may or may not lead to an investigation, which may or may not lead to an inquest.
As publicised by the Ministry of Justice today it is required that investigations (which includes the inquest if required) should be completed within six months or as soon as practicable thereafter. Any investigation not completed within 12 months must be reported to the Chief Coroner (as provided for by the 2009 Act).
HM Coroner for Manchester has forewarned local "stakeholders" that the new regime will necessitate compliance by all parties, including NHS Trusts, with directions for providing documents, witness statements and witness availability. There are sanctions available to the Coroner in the event of non-compliance.
As a clinical negligence practitioner I am primarily concerned about the effect of these changes on cases involving deaths in a healthcare setting.
The first and most obvious benefit could be that bereaved families have an investigation into the death of their loved-ones at an early stage. There is a general benefit in not being kept waiting and a specific legal benefit in some cases. Under the Human Rights Act there is a one year time limit for bringing a claim: a coronial investigation completed within a year of death will help families know, in time, whether there a grounds for such a claim.
It is laudable to seek to conclude coronial investigations within these time limits, but it will be interesting to see how many cases do get reported to the Chief Coroner for having overrun. Some investigations require the attendance of a large number of witnesses including busy medical professionals. The administrative systems of some NHS Trusts are not geared to the prompt disclosure of documentation. These changes will place further demands on the already stretched NHS.
It would also be of considerable concern if the desire to meet targets for completing investigations interfered with the need for a thorough investigation.
Bereaved families need to be aware to ask the right questions at the right time. Some families whom I have represented, did not start raising questions about the death of their loved-one until several months after the death. They often have other priorities or are not emotionally ready to assert themselves with the huge organisation that is the NHS. Coroners should be alert to those cases where certain difficult questions need to be addressed but often they need the family to alert them to shortcomings, concerns or unanswered questions.
Helen Grant, Justice Minister, says that "we are making absolutely sure that the needs of bereaved people are put first and foremost". A simple way of doing that would be to fund representation of bereaved people for inquests. However the government has made it pretty clear that it does not encourage representation of families at inquests save in a very few cases. That is its position even though it pays for representation for NHS trusts as a matter of course.
Families may benefit from representation if there is a possible civil claim for clinical negligence or where a lawyer is prepared to act pro bono. Useful advice to families can be found on the AvMA website here.