The Parliamentary Under-Secretary of State for Justice (Alex Davies-Jones)
My condolences to you on your loss, Madam Deputy Speaker.
I congratulate the hon. Member for Birmingham Perry Barr (Ayoub Khan) on securing this important debate. I thank him for his emotive speech, and all hon. Members who contributed, representing the views of bereaved families, sometimes including their own. It is appreciated and they have done so dutifully.
The House will be aware that although the Ministry of Justice is responsible for coronial law and policy in England and Wales, it does not have operational oversight of the coronial system. Coroner services are not centralised as part of His Majesty’s Courts and Tribunals Service, and are instead administered and funded through the relevant local authorities for each coroner area. The chief coroner provides judicial leadership for coroners. I take this opportunity, as other Members have, to express my thanks to all coroners, their officers and their staff, as well as the chief coroner and her team for their tireless and expert commitment to their work. We are all extremely grateful to them for the vital service they provide to the bereaved and to the justice system.
Coroners are independent judicial office holders. They are specialist death investigation judges and part of the wider death investigation, certification and registration system. Their statutory duty is to investigate any death of which they become aware if they suspect that it was violent or unnatural in its cause, its cause was unknown, or it occurred in custody or other state detention. They also have an ancillary duty to ensure that, in appropriate cases, action to prevent future death is identified via prevention of future deaths reports.
The needs of the bereaved, particularly where there are faith concerns in respect of a death, should remain central to the coroner process. Both the Lord Chancellor, as a west midlands MP, and I are very aware of local concerns about coroner provision for communities that require swift burial or cremation. Clearly, decisions about the release of the body, including whether to hold a post-mortem examination, are independent judicial decisions for the coroner. However, I know that in many jurisdictions, including in the west midlands, families have experienced real delays. Sometimes, that is because the coroner needed to gather further evidence to support the investigation. I fully understand that, regardless of the reason, delays can cause real distress for bereaved families, particularly when faith requirements are dependent on the timely release of a loved one’s body.
We are working hard to cut delays wherever possible and to ensure that families are properly communicated with and supported throughout the process, particularly so that we can ensure that any religious ceremonies or faith requirements can be met, as they should. There are already a range of measures in place to help guide coroners as to best practice in terms of early decision making once a death has been reported, in order to ensure that families can be given certainty as soon as possible.
The chief coroner has issued detailed practical guidance for coroners in dealing with requests for urgent consideration of a death and early release of a deceased body, including on religious grounds. The guidance sets out that legal framework and states:
“Coroners should pay appropriate respect to those wishes, within the framework of their legal duties and in the context of other responsibilities.”
In addition, the chief coroner has issued guidance on the use of post-mortem imaging, including CT scanning, and on pathology more generally, which emphasises that the family should be kept fully informed throughout. I regularly meet the chief coroner to ensure that we have a shared understanding of the issues with the coroner system, including this one. I am also happy to engage with representatives of faith communities to understand their concerns and to meet hon. Members to discuss the matter further.
As the House will know, the Justice Committee undertook an inquiry into the coroner service in 2021, with a follow-up in 2023-24. The Government responded to the Committee’s letter of May 2024, summarising their findings in December 2024. That letter has been published by the Committee. It is right that our focus should be on ensuring that the bereaved are at the heart of the process. I hope the House will find it helpful if I set out a number of steps that the Government are taking to address the issues raised by the Justice Committee, other stakeholders and hon. Members.
After just a few months in office, in September 2024 this Government implemented the statutory medical examiner system in England and Wales. It represents the most fundamental change to the end-to-end process of death certification and registration in recent times. The new system means that every death is subject either to the scrutiny of a medical examiner or to a coroner’s investigation, thereby fulfilling the long-standing ambition of successive Governments to introduce a robust system whereby all deaths, without exception, are subject to an independent review.
Medical examiners and coroners have distinct roles. The new arrangements will ensure that cases are managed in the right part of the system and that only those deaths that require a judicial investigation are referred to the coroner. That will enable better focusing of coronial resource, which in turn is expected to support the reduction of inquest backlogs and delays. I hope we are already seeing the evidence of that. Just last week, the Ministry of Justice’s coroner statistics were published: 174,900 deaths were reported to coroners in 2024—the lowest level since 1995 and down 10% compared to 2023. That is because, following the creation of the new system, only those who genuinely need to go to the coroner will do so. In addition, 81,200 post-mortem examinations were ordered by coroners in 2024—a 6% fall compared to 2023.
Iqbal Mohamed
To reduce the burden and time it takes for post-mortems, does the Minister agree that we should use technology, and MRI and CT scans, wherever possible, which will also speed up the release of the body?
Alex Davies-Jones
I appreciate the hon. Member’s contribution. As I have said, that guidance is there and that equipment is available to coroners if they deem it necessary. Of course, we want to see anything that will help speed up the process for families.
Although we want to wait a full year for the proper data next May, the early evidence is encouraging that the new arrangements are working as intended. Reducing the number of unnecessary cases being referred to coroners means that coronial resources can be focused on the most complex deaths, while reducing the impact and burden on families. It also means that the number of post-mortem examinations that subsequently reveal a natural cause of death may also be reduced, since those cases may be identified by better surveillance and scrutiny much earlier in the process.
More widely, we recognise the concerns expressed by the Justice Committee and hon. Members present about the shortage of pathologists, particularly child pathologists, available to undertake coronial post-mortem examinations. That is a long-standing and complex problem, and its resolution requires a cross-Government approach. I am happy to reassure hon. Members that such an approach is taking place. I am meeting my counterparts in the Department of Health and Social Care to look at how we can fix the issue in the long term. Coroners rely on the pool of pathologists working in the wider medical system, including the NHS, to perform those examinations. We are carefully considering the views of the Justice Committee in its report, as well as the data we have gathered from our call for evidence on coronial pathology, which was issued in late 2023, with a view to publishing a new strategy for improving coronial pathology in due course.
We recognise the impact that inquest hearings are having and are doing all we can to process that backlog as quickly as possible. We will work with the chief coroner to continue to build on the foundation that has been put in place to reduce the time. I know that coroners in the west midlands are well below the national average, as we have already heard. The Black Country coroner area completes inquests in an average of 11 weeks, and Birmingham and Solihull, and Coventry, complete inquests in an average time of 17 and 18 weeks respectively. Bereaved families should not be left waiting longer than is necessary for inquests to be completed.
We are working on a number of areas, including on a guide to make coroner services more accessible. We are considering all we can do and all the recommendations, and I am happy to come back to the House in due course. We will work with the chief coroner on the content of all material, and to reinforce the use and dissemination of these guidance documents.
The hon. Member for Birmingham Perry Barr spoke about MPs making representations, MPs are elected to this House to represent their constituents, and they should be able to do so. I will raise his point with the chief coroner when I meet her soon.
I recognise the concerns expressed today, as well as the wider concerns expressed by the Justice Committee and other stakeholders, about the importance of an effective coroner service. We will continue to do all we can to ensure that the system continues to put its focus on finding answers on behalf of the deceased, that bereaved families are always at the heart of the process, that lessons are learned from any death and that this learning is disseminated as quickly and as widely as possible to protect the public.
Question put and agreed to.