Sarah Henderson
Department for Constitutional Affairs
Coroners Division
Seacote House
2 Marsham Street
London
SW1 4DF

16 September 2005

Dear Sarah

Family Charter Consultation

Thank you for giving us the opportunity to comment on the draft Family Charter. We have expressed our concerns to Government on the subject of Coroners both in writing and at meetings over the years. One very useful meeting was with Lord Williams of Mostyn. We also took part in the Review of the Coroners' Service and a paper that we provided in connection with the Review will be of interest to you and your colleagues. A copy is enclosed with the hard copy of this letter, which is posted.

Our comments relate to situations where a road death occurred, where there is always an Inquest and should not be taken to apply to other situations, which are outside the experience of this charity.

Charter

A major concern is that the word Charter implies that rights are given or existing rights stated but this document does not give any rights or even impose an obligation to inform the bereaved of their existing legal rights. This is effectively a fraud on the bereaved, who may assume that they have no rights.

As an absolute minimum, there must be an obligation to inform bereaved families of their legal rights and of organisations who can help them within 24 hours of the death.

It must be made absolutely clear that some of these rights have to be exercised in the immediate aftermath of the death eg in relation to the Post Mortem and viewing the body and that if such rights are not exercised at that stage, the opportunity is gone forever.

There must be specific duties on Coroners included in the Charter, for example, a commitment to hold an Inquest before any Magistrates Court Hearing in relation to the death (re Beresford rule), to hold the Inquest within 4 months of the death.

There is no obligation on Coroners or their staff to meet the bereaved face to face except to explain Inquest procedures and court layout. A bereaved family's primary concern is to find out what happened not where they can sit in court and they should be entitled to at least one meeting face to face for the evidence to be explained before an Inquest and any questions asked and answered. Again, it is important for them to have access to the Coroner and his staff not just physical access to a building.

General, Objectives and Values
Note: your numbering and headings are used

The first two sections of the Charter are written in very general terms and express concepts, which it would be hard to fault but they do not give any rights, which could be enforced nor do they give any idea to bereaved families of what they can expect in terms of the actual service provided.

The document expresses good intentions, it does not set national standards except in very limited ways, We have set out, in an Appendix, a list of existing rights and a separate list of best practice matters which we would recommend be enforceable as national standards

Standards of Service

4.Will the information be provided be written or oral? How is 'full' defined? Who has primary responsibility: the Coroner or his staff? How will the bereaved know if the information is 'full ' what can they do if it is not full?

5.What does 'nearest' mean, geographically or next of kin ? There can be problems over eg divorce or separation of parents or where there is a partner of the deceased.

6.Information is also needed on national services and organisations. The information must be provided at the first meeting within 24 hours of the death and must include Home Office funded literature on Coroners and Inquests and the Work and Pensions literature 'What to do after a death in England and Wales '.

8. At what stage will the report be provided before or after the Inquest? Families need information in order to prepare for the Inquest, which is their only opportunity to ask questions and find out what happened. Unless they have sufficient information to prepare, this opportunity is wasted. Families should also be entitled to Inquest transcripts free or for the price of photo copying only.

10.How much notice of the Inquest date? It must be at least 4 weeks; families need to take time off work and make arrangements for the care of children or the elderly or disabled. Written information must be provided including Home Office funded literature on Inquests and Coroners.

11.Specific material must be provided to the family in every case eg list of witnesses, copy of PM report and any evidence likely to cause distress to them plus all other evidence unless good cause can be shown for not providing it. The requirement must be to provide information unless there is good cause for withholding it. The process must be transparent and not discretionary.

12.and 14. Bereaved families must also be told within 24 hours of the death of their right to be represented at the Post Mortem and that any possible defendant has the same right. They must also be told of the procedure to exercise this right and why it may be important to their understanding of how death occurred. Most people never give these matters any thought until it is too late and in many cases, the deceased has been cremated.

A careful Post Mortem by a Home Office pathologist can reveal vital information, which may not be found by a routine hospital Post Mortem, carried out largely by unqualified staff and it is a matter of where someone died which will decide which type of pathologist is used and the quality of the Post Mortem. If some families did send their own medical representative, Post Mortems would be carried out more carefully, as they would be open to scrutiny by a qualified observer. At present most families simply do not know that they have this right so that it is rarely exercised.

13. The Coroner must provide reasons for withholding such information. These reasons should be open to challenge. No information should be released to third parties unless it is also released to the bereaved family.

16.There is no obligation on Coroners or their staff to meet the bereaved face to face except to explain Inquest procedures and court layout. A bereaved family's primary concern is to find out what happened not where they can sit. There must be at least one meeting before an Inquest, for the evidence to be explained and any questions asked and answered.

18.Families must be informed of their rights and given time to consider and decide what they wish to do. It may be that they feel that further investigation is needed although their religious beliefs tend towards an early burial.

It is their choice and it is not for Coroners or their staff to anticipate the '' religious views or requirements but to find out and be sympathetic and responsive to the individual families' actual beliefs and requirements. We know of a case where a Muslim family would have preferred to have had a Post Mortem which could have yielded important information about what happened but officials released the body in the mistaken belief that they were acting sensitively towards the family's religion.

19.Please note comments at 12 and 14 above.

20 Families must be told exactly what is removed and retained and why. The reason given must be reasonable or capable of being challenged. Horrific though this may be, it is preferable to being offered, without any warning, a heart or brain for a second burial, months or years after the funeral, as many of our members have experienced.

22. This information must be offered within 24 hours of the death.

25. Physical access is vital but actual access to the Coroner and his staff is more important. Can all bereaved visit the Coroner's office, make an appointment to do so or only disabled bereaved ? Can anyone?

26. We need a precise list of what is to be monitored and how and for it to be available to the public free of charge.

29. Who do we comment to and what will they do as a result ? I and many of our members have written to the Home Office Coroners Department and individual Coroners without any action resulting.

Conclusion

It is a worthy idea to have a Charter but after so much work has been done on reviewing the inquest system, we are entitled to something, which gives families rights, informs them of their existing rights and imposes duties on Coroners not just expressing worthy objectives in very general and unenforceable terminology.

Yours sincerely
Mrs Zoe Stow
Chair
RoadPeace

APPENDIX

Existing Rights

1.Right to be represented at the Post Mortem, provided notification is given to the Coroner.

2.Right to be represented at the Inquest.

3.Right to ask questions at the Inquest.

Good Practice which we recommend as National Standards

1.To see the body as soon as possible.

2.To be informed in advance of Inquest proceedings (4 WEEKS before a full inquest )

3.Inquest to be held in advance of any summary legal proceedings

4.Inquest to be held within 4 months of the death whenever possible

5.To be informed of relevant training by Coroner

6.To receive in advance of the Inquest, copies of the Post Mortem Report and any evidence which may be distressing to the family and all other evidence unless reasonable cause can be shown for withholding it.

7.To review witness list

8.To have an Inquest at a public location in a purpose built Coroners Court with adequate facilities and separate seating in court and separate waiting rooms for the bereaved and anyone who may have been responsible for the death.

9.A pre Inquest meeting to discuss evidence and inquest procedures

10. Any driver who may be involved in the incident to be required to attend, subpoenaed, if necessary

11. To receive a copy of Coroner's Report /Transcript at cost of photocopying

12. Coroner's Recommendations to be monitored and collated and available to the public with comment from any appropriate authority as to when and why they are or are not to be implemented.