Agenda item

To receive a presentation on the Berkshire Coroner’s Service.

Members received a presentation on the Berkshire Coroner’s Service from Matthew Golledge, Public Protection Manager, Reading Borough Council and James Crosbie, AD Planning Transport and Public Protection, Reading Borough Council.

During the discussion of this item, the following points were made:

·       Reading Borough Council hosted the Coroners Service on behalf of all of the Berkshire authorities.  The service was operated under a joint arrangement.

·       The Coroners Service was located in the Town Hall in Reading.  There were two courts, a jury room and office facilities.

·       Matthew Golledge outlined the staffing structure within the service.

·       Under the Coroners and Justice Act 2009, local authorities were required to fund a coroner service. 

·       The primary purpose of the Coroners Service was to investigate deaths that were violent, unnatural, unexplained or that had occurred in custody or otherwise in state detention.

·       The role of the Coroner included –

Ø  providing bereaved families with answers as to how their loved ones died with the assurance that an independent judicial process has investigated any relevant concerns.

Ø  contributing to the accurate registration of deaths, thereby enabling more secure analysis of trends in public health

Ø  carrying out an enhanced investigation where the state’s responsibilities under Article 2 of the European Convention on Human Rights (‘ECHR’) (the right to life) were engaged.

Ø  considering whether any circumstances revealed by an investigation give rise to a risk of future deaths and alerting those who might be able to mitigate or eliminate such risks.

Ø  investigating treasure finds, allowing museums to acquire treasure and appropriate rewards to be paid.

·       In 2022 there had been 7096 deaths in Berkshire, 2257 of which had been reported to the Coroner.  871 postmortems had been carried out.  75 Histology and 222 Toxicology investigations had been carried out.  23 noninvasive postmortems (CT scanning) had been carried out.  438 inquests had been undertaken.

·       Matthew Golledge highlighted performance in different areas, against England and Wales. 

·       The number of less invasive postmortems (CT scanning) carried out was low nationally and lower again in Berkshire.  CT scanning was starting to become more widely used across the country but was dependent on availability of a scanner and cost.  The service was looking to develop in this area.

·       The mortuaries used were based in Royal Berkshire Hospital and Wexham Park Hospital and were run by Berkshire and Surrey Pathology Services.  The contract was in place until 2027.

·       Across Thames Valley consideration was being given to a regional mortuary, which would potentially be a Centre of Excellence, serving a number of authorities.  An options appraisal around possible locations was in process.  Consideration would need to be given to the benefits of a regional mortuary against local mortuaries and vice versa.  Local mortuaries were already under pressure. 

·       Members were informed that postmortems cost approximately £500, not including pathologist fees.

·       Local authorities were required to fund the removal and transportation of the deceased to the coroner.  There had previously been some difficulties in procuring this service.  Traditionally this service had been provided by funeral directors but more recently there had been less desire to undertake this service from this area.  The contract was a short time service, and additional funding had been sought for this from the partner local authorities.  It was anticipated that the procurement process would be resolved in the next few months.

·       The Committee was advised that there was a national shortage of autopsy trained pathologists.  Coroners work was not part of pathologists’ NHS contracts.  The fees for pathologists had not been reviewed since 2013.  Matthew Golledge indicated that in practice most local authorities had to pay over and above the fees to ensure that the work was carried out.  The Ministry of Justice was undertaking a review of fees, but it was a slow process. 

·       Consideration was being given to how pathologists could be encouraged to undertake the necessary work, for example the establishment of a teaching facility.

·       Inquests were becoming more complex and legal costs increasing as challenge and family expectations increased.

·       Following a review in September 2022, the Berkshire local authorities had agreed to provide additional funding.  The number of Coroners Officers had increased from 5 to 7, and the appointment of an Area Coroner, and 5 Assistant Coroners had been agreed.  A Bereavement Nurse, part funded with the NHS, had been recommended but was yet to be implemented.  Additional funding had been agreed for the increased costs of removals.

·       Matthew Golledge outlined service improvements that were underway and future developments.

·       The joint arrangement was now 10 years old and due to be reviewed.  Apportionment of costs would be looked at as part of this review.

·       It was noted that from April 2024 the Medical Examiners service would be moved onto a statutory footing.  All deaths in the community would be referred to the Medical Examiner before a death certificate was issued.  It was likely that this may reduce the number of referrals to the Coroner.

·       In response to a Member question, Matthew Golledge indicated that the length of an inquest varied according to the complexity of the case.

·       A Member questioned whether a breakdown of deaths by area was possible. 

·       A Member queried whether the funding was split equally amongst the Berkshire authorities. Matthew Golledge explained how the apportionment was set. 

·       With regards to the coroner’s involvement in the prevention of future deaths, a Member asked whether this would be in a leading role or a consultative role.  Matthew Golledge commented that this was a matter for the Senior Coroner but the intention would be to engage with the relevant review groups so that when deaths came in, learning could be undertaken to help form prevention policies.

·       A Member commented that in some cultures and religions, burial had to take place as soon as possible after death.  He questioned whether inquests were expedited in such case.  Matthew Golledge responded that the service was aware of cultural and faith aspects and worked hard to expedite the process as much as possible.  They worked closely with Islamic funeral services for example.  However, there were some cases where further analysis was required.

·       A Member went on to ask whether families could request a non-invasive postmortem, and if so, whether they would be required to pay, and was informed that availability was key.  Scanners were very expensive.  Cases could be referred for CT scanning and families could choose to pay for these to take place in the case of elective scans.  The cost of a scan varied on a case by case basis.  The Member commented that it would be helpful to make families aware that they could choose to pay for a CT scan should they wish.  Matthew Golledge stated this was an option but emphasised that currently CT scans tended to be offered in exceptional circumstances due to availability and had to be agreed by the Senior Coroner.

·       With regards to the mortuary at the Royal Berkshire Hospital, a Member questioned what impact the possible hospital move would have on the plans to expand the footprint of the mortuary.  James Crosbie commented that they were cognisant of the New Hospital programme.  Options around a regional function were being explored and if a regional approach was taken, facilities may be less accessible than currently for families.

·       In response to a Member question Matthew Golledge explained that not all in hospital deaths were referred to the Coroner.

·       A Member questioned whether the pathologist fees were set locally or nationally and was informed that whilst they were set nationally, some local negotiation was required such was the shortage of the required workforce.

·       Matthew Golledge indicated that there were no costs to the bereaved family for inquests unless they wished to have their own legal advice.

·       Should an incident resulting in a large loss of life occur, Members were informed that the Coroner would play a central role in the response.  Planning took place at national and regional level and a Thames Valley wide mass fatality planning unit was in place.

·       The Committee requested to be kept informed of the outcomes of the service review.

RESOLVED:  That the update on the Berkshire Coroner’s Service be noted and Matthew Golledge and James Crosbie be thanked for their presentation.