Chief Coroner’s Guidance for Coroners on the Bench
Foreword
In June 2015, the then Chief Coroner, His Honour Judge Peter Thornton KC issued a Coroner’s bench book. The intention was that a comprehensive bench book addressing all coronial work would be issued section by section. He started with jury inquests. In 2019, the then Chief Coroner, His Honour Judge Mark Lucraft KC asked me to lead a team of practitioner editors to produce a “Bench Book” covering all aspects of court inquest work.
A team of experienced coroners was selected. They were led by Christopher Dorries OBE and Bridget Dolan KC who between them edit or contribute to the two main legal textbooks on coronial law. They were to lead the writers, drawing on their joint publishing experience and would edit the final publication. I acknowledge that without them this publication would never have been produced.
They were joined by the late Kally Cheema (Senior Coroner for Cumbria), Andrew Cox (Senior Coroner for Cornwall), Louise Hunt (Senior Coroner for Birmingham), Penelope Schofield (Senior Coroner for West Sussex, Brighton and Hove) and Catherine McKenna (Area Coroner for Manchester North). They each wrote and reviewed the chapters that make up this guidance.
Gradually chapters were written, reviewed, amended and perfected. The writing teams discovered consistency and inconsistency in coronial practice. Discussions were had to agree the best practice.
As the writing ended a team of reviewers were identified to check that what had been written was accurate and provided practical assistance. These included Derek Winter (Deputy Chief Coroner), Andre Rebello (Honorary Secretary Coroner’s Society of England and Wales) and Adam Hodson and Vanessa McKinlay (Assistant Coroners from Birmingham).
Finally the draft guidance was reviewed by the then Chief Coroner, HHJ Thomas Teague KC and Catherine Yallop, legal adviser to the Chief Coroner. This final review involved considerable work in reviewing existing published guidance to see if the new guidance incorporated all aspects of the original guidance.
This final review was completed by myself, when I took up office, with the continued assistance of Catherine Yallop.
I set out the genesis of the publication that is issued today to highlight the work of all those named and to emphasise what a significant task it has proved to be.
I have stood up at many training events promising that this work would be published by Easter and Christmas of successive years. I am delighted to finally launch this guidance and I offer my profound and sincere thanks to all who have contributed, especially to the writers and editorial team.
This publication is intended to be a “live” document. It will be regularly reviewed. Can I gently discourage you from printing it and putting it into a file but encourage you each time you need to consult it to check the online version.
HHJ Alexia Durran,
Chief Coroner
24 January 2025
Introduction
This guidance for coroners on the bench (which will generally be referred to as the ‘Bench Guidance’) has been produced as a resource for coroners to help them locate key principles, practical information and precedents when dealing with inquests. It is not legally binding and does not replace the need for coroners to conduct their own legal research. It holds the same status as the Chief Coroner’s existing guidance notes and law sheets, and has been issued to promote consistency and encourage best practice.
Within this Bench Guidance there are chapters which include, update and expand upon previous Chief Coroner guidance notes. Until the existing guidance notes are withdrawn or updated, there may be inconsistencies between them and some aspects of the Bench Guidance. Where such inconsistencies exist, the Bench Guidance will prevail.
As expressed by the Chief Coroner in her foreword, this is intended to be a “live” document. It will be regularly reviewed. Future chapters will include Article 2.
Please direct all enquires to chiefcoronerguidance@judiciary.uk
| Chapter – click the links below | Sub-sections | Appendix |
| 1. Opening the Inquest | Introduction Discontinuing an investigation Continuing to an inquest Opening in private Matters to consider prior to opening an inquest At the opening Evidence to be admitted How evidence is admitted Directions on opening an inquest | Appendix 1.1 Appendix 1.2 |
| 2. Interested Persons | Introduction Family members and partners: s.47(2)(a) A personal representative of the deceased: s.47(2)(b) A medical examiner: s.47(2)(c) Insurers and beneficiaries of insurance: s.47(2)(d-e) Those whose actions contributed to the death: s.47(2)(f) A trade union representative: s.47(2)(g) A representative of an enforcing authority or government department: s.47(2)(h) and s.47(2)(l) A Chief Constable or Provost Marshal section 47(2)(i) and (j) Any other person with sufficient interest: s.47(2)(m) Giving consideration to who should be an IP Individual IPs employed by corporate IPs The rights of an IP Questioning and legal submissions by those who are not IPs | |
| 3. Pre-inquest review hearings | Introduction Timing of a PIR PIR agenda Submissions to the court Service of written submissions on other IPs The PIR hearing Rulings and minutes of the PIR Court attire | |
| 4. Documentary inquests and inquests in writing | Introduction Summary inquest procedures Pre-conditions for holding an inquest in writing Pre-conditions for holding a documentary inquest Cases suitable for documentary inquests and inquests in writing Considerations before holding a documentary inquest or an inquest in writing Single hearing inquests Disclosure in advance of a documentary inquest Conducting an inquest in writing Open justice in inquests in writing Conducting a documentary inquest hearing Final letters from the deceased | Appendix 4.1 – Letter to bereaved before IIW Appendix 4.2 – a standard witness statement template Appendix 4.3 – Example of a ruling in an inquest in writing |
| 5. The Inquest Hearing | Introduction Accessibility and location of inquests Age limits on attending Court An inquest script Pen portraits The content of pen portraits Photographs displayed in court Language in court and equal treatment Signing the Record of Inquest Translators and interpreters Inquest recordings Copies of recordings Use of inquest recordings Inquest transcripts | |
| 6. Remote hearings | Introduction The law regarding remote observation Equal treatment considerations Offering a video link to participants Remote witness evidence Considering an application to observe remotely Practicalities for partially remote hearings Matters to address in advance of a partially remote hearing Matters to address before a partially remote hearing begins At the outset of a partially remote hearing Matters during a partially remote hearing Matters to address at the conclusion of a partially remote hearing Other matters to consider | |
| 7. Scope of the inquest | Introduction The meaning of ‘scope’ The extent of an inquest’s scope The discretion as to scope Article 2 ECHR and scope Reports to prevent future deaths and scope Determining the scope of the inquest Recording the inquest’s scope Questioning on issues that are outside of scope | Appendix 7.1 – example scope of the inquiry document |
| 8. Open Justice | Introduction General principles Publication of hearing dates Closed hearings Media requests for disclosure of documents The approach to requests for disclosure Media requests for recordings Live text-based communications | |
| 9. Anonymity of witnesses and reporting restrictions | Introduction What do we mean by anonymity and reporting restrictions? Anonymity applications Tests to be applied Reporting restrictions orders A child who is a witness A child who is not a witness Anonymity of victims of certain sexual offences Reporting restrictions under s.4(2) Contempt of Court Act 1981 Considerations on making an anonymity order or reporting restriction order Press notification Reporting Restrictions Orders under CCA 1981: the considerations | Appendix 9.1 – Anonymity s.39 CYPA 1933 Appendix 9.2 – Template Order s4(2) COCA 1981 (Reporting restrictions) Appendix 9.3 – Template Order s11 COCA 1981 (Anonymity) |
| 10. Contempt of Court | Introduction Types of contempt Contempt in the face of the court Immediate response to a disturbance in court Contempt by a witness refusing to answer a question Disobedience to a Schedule 5 notice Contempt by jurors Contempt related to audio recordings of proceedings Contempt related to images from court Breach of reporting restrictions Dealing with contempt from the bench General approach to potentially contemptuous behaviour Approach where contempt is admitted Approach where contempt is denied Enforcement of financial penalty imposed Appeal from the coroner’s court following a finding of contempt of court | Appendix 10.1 – Schedule 5 notice: Requiring evidence to be given Appendix 10.2 – Schedule 5 notice: Requiring evidence to be given or produced Appendix 10.3 – Certificate of fine imposed under Schedule 6 part 2(6) CJA 2009 Appendix 10.4 – Warrant to Commit for Contempt of Court Appendix 10.5 – Certificate of fine imposed for contempt of court Appendix 10.6 – Inquest fine process map |
| 11. Jury inquests | Introduction Inquests requiring a jury Notifiable accidents Railway deaths and reports to the Office of Rail Regulation (ORR) Summoning the jury pool Jury Bundle The morning of the inquest Selecting jurors from the jury pool Coroner’s opening remarks and jury warnings Jury warnings Jury questions of witnesses Directions to the jury Summing up to the jury Retirement of the jury Jury questions during their deliberation Eliciting jury conclusions Article 2 cases: list of issues or questions? Majority direction Watson direction Finality of the jury’s decision Signing the Record of Inquest Jury irregularities Thanking the jury | Appendix 11.1 – Jury Warnings Appendix 11.2 – Summing up and legal directions |
| 12. Disclosure of documents | Introduction Disclosure to the coroner The Worcestershire Coroner case Disclosure by the coroner to IPs The timing of disclosure The format of disclosure Redactions Health Records The post-mortem examination report Disclosure of other material Refusal of disclosure – legally prohibited or privileged documents Sensitive or upsetting material Correspondence from MPs and others General discretion to disclose documents Use of disclosed documents | Appendix 12.1 – Undertaking to the court as to their confidentiality |
| 13. Witnesses | The legal position Identifying witnesses Calling of witnesses Oaths Admitting written evidence Examination of witnesses Questioning by non-IPs Self-incrimination Special measures for vulnerable witnesses Ground Rules Hearings Screening a witness Evidence by live link Taking evidence from abroad How to seek permission to take evidence from abroad | Appendix 13.1 ‘bench warrant’ |
| 14. Expert evidence | Introduction Whether to instruct an expert Identifying an appropriate expert Experts previously instructed by an IP How to instruct the expert Format of the expert report Dealing with conflicting expert evidence in advance of the inquest Concurrent expert evidence Experts as an assessor Fees payable | Appendix 14.1 – Letter of Instruction to an Expert (without a letterhead) |
| 15. Conclusions | Introduction The Record of Inquest Completing the Record of Inquest Three stage process for reaching a conclusion Level of confidence / standard of proof Causation Accidental death or misadventure Alcohol / Drug related death Industrial Disease Lawful / Unlawful killing Natural causes Road traffic collision Stillbirth Suicide Alternative conclusions after fatal self-harm Open conclusion Neglect Narrative Conclusion Dealing with admitted failings Submissions regarding conclusions Applying the Galbraith test Naming individuals on a Record of Inquest | |
| 16. Reports to prevent future deaths (PFDs) | The Law The extent of the obligation The circumstances in which the duty arises Hearing evidence relevant to the duty under paragraph 7(1) of Schedule 5 Consideration before making a PFD report Structure and content of PFD reports Sending the PFD report Response to a PFD report Requests to withdraw a PFD report Where action has already been taken to reduce the risks to other lives Absent or inadequate reply to a PFD report Letter instead of a PFD report | Appendix 16.1 – Templates for PFD reports |
| 17. Overturning inquests | Introduction Decisions before an inquest has concluded After an inquest has concluded Quashing an inquest under s.13 Coroners Act 1988 The grounds for quashing an inquest under s.13(1)(b) The procedure for seeking a fiat Procedure following the grant of a fiat | Appendix 17.1 ‘s.13 Consent order’ |
| 18. Counsel to the inquest | Introduction Choice of CTI Instruction and Funding of CTI Delegation of functions Practical Benefits of CTI Privileged advice from CTI |