Faultlines in the Welsh coroner system?

Dr Huw Evans

A recent Nation.Cymru article reported that the Gwent Coroner’s service has seen a significant increase in workload leading to long delays before cases are concluded. This article discusses the coroner service in Wales.

Coroners must investigate a death where that death is violent or unnatural, its cause is unknown, or it occurs in custody or other state detention. The Coroners and Justice Act 2009 (CJA) sets this out.

The coroner system is part of the justice system and so is not devolved.  Yet under the CJA, the coroner service is delivered through local authorities. Local authority areas are designated by the Lord Chancellor for a coroner service. There are seven coroner service areas for Wales: Carmarthenshire and Pembrokeshire, Ceredigion, Gwent, North Wales East and Central, North Wales West,  South Wales Central, and Swansea and Neath Port Talbot.

Coroners are appointed by local authorities with approval from the Lord Chancellor and Chief Coroner for England and Wales. The Chief Coroner oversees standards and issues guidance but does not manage coroners directly. Coroners are independent judicial officials, not local authority employees.

The CPA requires sufficient resources for coroners to perform their duties. Each coroner area must have a senior coroner, and the Lord Chancellor may order local authorities to appoint additional coroners to support the senior coroner. Local authorities must also provide adequate staff and suitable accommodation for coroners.

Gwent Coroner’s Service covers five local authority areas and is managed by Newport City Council. Currently, only 27.3% of new cases are being listed for an inquest within six months after being opened, compared with 90% of new cases in the previous three years. 

The stated reason was that, since September 2024, a law change requiring an independent medical examiner for death certifications has resulted in longer delays due to more cases and increased case complexity.

The Gwent situation suggests that the coroner service there is not sufficiently resourced despite the law requiring sufficient resourcing by local authorities for coroners to do their job. The appointment of an additional two coroners begins to deal with the issue.

Gwent has been honest about its challenges. As far as I know, there are no similar reports on other Welsh coroner services.   

Coroner service challenges

It would be wrong to link current challenges to just the recent law change.  There was a 2021 House of Commons Justice Select Committee report  on the coroner service in England and Wales. Among its recommendations was that a national coroner service be established as it found ‘an unacceptable variation in the standard of service between Coroner areas’.  Evidence heard from the Coroners’ Society of England and Wales stated that:

in some areas lack of resources, lack of engagement, reluctance to recognise funding responsibility and poor communication mean the service is not as effective as it should be. Too many Local Authorities do not engage with the coroner’s service nor do they understand their statutory funding responsibilities.

It recommended a unified service under the Ministry of Justice but it was rejected by the UK Government as ‘the cost of the creating a national coroner service could be disproportionate to the benefits’.  

A follow-up enquiry by the same committee ended prematurely in 2024 due to the general election. Although no report was issued, the committee chair wrote a letter in May 2024 outlining the enquiry’s progress, including evidence from the Chief Coroner that:

‘the coroner service in England and Wales is, with very few exceptions, chronically under-resourced and underfunded… If… you get to a situation where a coroner’s decisions are partly dictated by economic necessity, judicial independence no longer exists, and that imperils the rule of law…  a point which we have already reached in some areas.’

Competing public interests

Two competing public interests were mentioned in an article I wrote about the death certification law change. Those same interests are relevant here: that causes of death are identified and explained; and that the those affected by death are shown dignity and respect free from unnecessary aggravations. 

Those public interests are important for many reasons, but sometimes they may conflict. The justifiable need to establish a cause of death may delay a burial or cremation, with attendant upset for family and friends. Even where a burial or cremation can take place, that same upset can arise if there is an outstanding inquest.     

Overview

The Gwent coroner service currently has its challenges but is facing up to them. Meanwhile, satisfactorily meeting the two public interests is more difficult. These challenges are attributed to the September 2024 death certification law change. Yet evidence from the House of Commons Justice Select Committee points to challenges before then: under-resourcing threatening the rule of law because judicial independence is undermined by economic necessity.

There has been a report on the Gwent Coroner’s Service but no equivalent reports for other Welsh areas. It might reasonably be assumed that other coroner areas also have challenges. But that is just that: an assumption, not an established fact.  

What next?

Immediately, the complete picture about the coroners in Wales must be established to enable an informed assessment about what needs to be done and how to do it.  Notably, the Gwent position has been made public because of Newport Council scrutiny arrangements. If not already planned, other councils managing coroner services could carry out their own scrutiny.  

In the longer term there must be a debate about the best way for the coroner service to be delivered – especially, with a view to meeting the two public interests. As part of the justice system, the coroner system is not devolved but, as part of the local authority architecture, the coroner system has a devolved connection throughout Wales. 

Given this connection, establishing an independent coroner service for Wales is worth considering. Although justice is not currently devolved, the transfer of certain justice functions has a precedent, see: Welsh Tribunals.