Report of the Chief Coroner to the Lord Chancellor 202005/11/2020

Report of the Chief Coroner to the Lord Chancellor
Sixth Annual Report: 2018–2019
Seventh Annual Report: 2019–2020


  1. This is the Chief Coroner’s annual report to the Lord Chancellor. It combines both the sixth and seventh such reports. It is the third and fourth reports from His Honour Judge Mark Lucraft QC, who is the second holder of the post of Chief Coroner. In these combined reports, the Chief Coroner will provide an assessment of the current state of the coroner service over the last two years and make recommendations for the future direction and progress of the service.
  2. Section 36 of the Coroners and Justice Act 2009 (the 2009 Act) provides that the Chief Coroner must give the Lord Chancellor a report for each year. Although a report for 2018-19 had been provided to the Lord Chancellor, the Model Coroner Area blueprint had not been finalised and the report with its annexes had not been published before the outbreak of the COVID-19 pandemic; the report for 2019-20 is provided with the plan that both be published in this joint report.


Contents  of report

  1. As required by section 36(2) of the 2009 Act the Chief Coroner wishes to bring a number of matters to the attention of the Lord Chancellor. These include the development of the statutory reforms which came into force in July 2013, the additional reforms which the first Chief Coroner devised and which the second Chief Coroner continues to develop, and actions taken by the Chief Coroner under his powers and duties in the 2009 Act.


The Chief Coroner

  1. The post of Chief Coroner of England and Wales was created by section 35 and Schedule 8 of the 2009 Act which came into force for appointment purposes on 1 February 2010.
  2. The Chief Coroner is the judicial head of the coroner system, providing national leadership for coroners in England and Wales.
  3. His Honour Sir Peter Thornton QC took up the post with effect from September 2012. Sir Peter completed his term as Chief Coroner on 30 September 2016 and retired as a Senior Circuit Judge on 18 October 2016.
  4. His Honour Judge Mark Lucraft QC, The Recorder of London, was appointed as the second Chief Coroner of England and Wales with effect from 1 October 2016 for a three-year term. In June 2019, his term of office was extended for up to two years, to 30 September 2021. On 8 April 2020, it was announced that following the election by the Court of Aldermen of the City of London, Her Majesty The Queen had appointed the Chief Coroner as the next Recorder of London, the lead judge at the Central Criminal Court. It was stated that Judge Lucraft QC would take on some of the responsibilities of leadership  at  the  Central  Criminal  Court  with  immediate  effect.   However,  in  the light of pressures on the coronial system as a result of the COVID-19 pandemic, it     was agreed that Judge Lucraft QC would remain in post as the Chief Coroner. An exercise to recruit a new Chief Coroner has been launched and appointment will be made in due  course.
  1. The extent of the Chief Coroner’s jurisdiction is England and Wales.
  2. The Chief Coroner sits in the Divisional Court of the High Court on coroner cases, either applications for judicial review or applications for a fresh inquest (brought with permission of the Attorney General) under section 13 of the Coroners Act 1988 (as amended). He divides his time between his duties as Chief Coroner and sitting as a judge at the Central Criminal Court and in the Court of Appeal (Criminal Division).  He also hears some high-profile inquests at first instance.


The coroner service in 2018-19 and 2019-20

  1. The coroner service of England and Wales remains essentially a local service. There is no national structure. Coroners are appointed and paid locally, the service is funded locally including the provision of courts and other accommodation and IT systems and coroners’ officers and support staff are employed locally by police and or local authorities.
  2. There have been numerous calls for a national service, with coroners appointed and the service funded and run centrally, like other judicial services. This has     not happened. The Chief Coroner supports calls for a national service. There is much to be gained from such a move in terms of standardisation, consistency   and implementation of reform. The operational infrastructure provided by a national service would address, over time, many of the issues about inconsistency  of experience by bereaved families; that experience can occur in many situations outside the formality of the court room – for example in the interaction with the processes that follow immediately after a death is reported to the coroner.
  3. However, in the absence of a national service the Chief Coroner, working with coroners, local authorities, the police and other stakeholders, continues to make progress on reducing inconsistency through training, guidance and other interventions. In addition, he held a further Local Authority conference in early 2019 in which many of these issues were discussed.
  4. Many of the topics raised ...

The Full report can be downloaded here: chief-coroner s-annual-report-1920

178. This is the combined sixth and seventh annual report of the Chief Coroner to the Lord 
Chancellor. In the opinion of the Chief Coroner, significant progress has continued to be made in 
this period. The statutory reforms and the first Chief Coroner’s reforms have been effective and 
positive and in the public interest.
179. The Chief Coroner continues to acknowledge the enormous contribution made by his predecessor 
His Honour Sir Peter Thornton QC, in setting in place many systems, guidance and training that have 
continued long after his retirement.
180. The Chief Coroner is sincerely grateful to all coroners in post in the course of his tenure, 
for all of their hard work and support. Many coroners work with limited resources in the most 
difficult of situations and often their work goes unacknowledged. As with any other area of human 
life, we do not always get
everything right, and we need to acknowledge that and work to learn and improve.
181. There is still much to be done. The Chief Coroner is confident that the system will develop 
and improve further for the benefit of all who come into contact with the coroner system. The Chief 
Coroner looks forward to working further with all
coroners and other stakeholders on the plans set out in this report in the course of the remainder 
of his time in post and to observing the further developments in the hands of his successors.

His Honour Judge Mark Lucraft QC, Chief Coroner
1 July 2020


The report includes

Annex A – A Model Coroner Area, 2nd Edition July 2020
Annex B – Table of cases over 12 months 
Annex C – Senior and area coroner salaries as of July 2020