A Report on Coroners’ Restrictions, Systemic Failures, and Suicide Prevention in the UK

Prepared by STOPSuicides UK Campaign Group

Introduction

This comprehensive report examines the historical evolution of coroners’ duties in the UK, the legislative and judicial changes restricting their ability to address systemic failures, the limitations of the Prevention of Future Deaths (PFD) reporting mechanism, and the potential implications of the Joy Dove Appeal. Furthermore, it incorporates references to public PFD reports and other relevant documents to provide a comprehensive understanding of the issues.

Historical Development of the Coroner System in the UK

Medieval Origins

The office of the coroner dates back to the 12th century, established under King Richard I in 1194. Originally, coroners were tasked with investigating deaths to ensure proper records for the Crown, primarily focusing on financial implications like fines and forfeitures.

The Coroners Act 1887

The Coroners Act 1887 marked the first comprehensive legislative framework for coronial duties. It formalised the role of the coroner in determining the cause of death and emphasised public accountability, allowing coroners significant discretion to comment on contributory factors, including institutional failures.

The Coroners Act 1988

This act updated the legislative framework, retaining much of the 1887 Act’s provisions but placing a greater emphasis on procedural efficiency. While still allowing broad discretion, it laid the groundwork for future restrictions by prioritising administrative clarity over exploratory inquests.

The Coroners and Justice Act 2009

The 2009 Act introduced significant reforms, replacing traditional verdicts such as “neglect” and “unlawful killing” with short-form conclusions like “suicide” or “accident.” It also limited coroners’ ability to assign blame or comment on systemic issues, reflecting judicial guidance that inquests should avoid prejudicing civil or criminal proceedings. Critics argue that these changes effectively “gagged” coroners and reduced the preventive value of inquests.

Legislative and Judicial Constraints

Judicial Guidance on Coroners’ Roles

Case law following the 2009 Act has reinforced the restrictive approach. Courts have emphasised that coroners must focus on establishing “how” a person died rather than “why,” limiting inquiries into broader societal or institutional factors. This guidance has been criticised for discouraging coroners from addressing systemic failures.

Restriction on Narrative Verdicts

Narrative verdicts, which allow coroners to provide detailed accounts of death circumstances, have become constrained under these interpretations. Coroners are now cautioned against using language that could imply liability, further curbing their ability to highlight systemic failings.

The Joy Dove Appeal: A Case Study

Background

Joy Dove’s daughter, Jodey Whiting, died by suicide in 2017 after her benefits were terminated by the Department for Work and Pensions (DWP). The initial inquest lasted only 37 minutes, failing to consider the DWP’s potential role in her death. Joy Dove campaigned for a second inquest to address this omission.

Court of Appeal Decision (2023)

In March 2023, the Court of Appeal ruled in favour of holding a second inquest, citing new evidence of systemic failings by the DWP. This decision highlights the limitations of the original inquest and underscores the need for coroners to have greater latitude in exploring institutional factors.

Implications

The Joy Dove Appeal has the potential to set a precedent for more comprehensive inquests, challenging the constraints imposed by the Coroners and Justice Act 2009 and subsequent judicial interpretations.

The Prevention of Future Deaths (PFD) Reporting Mechanism

Purpose and Process

Introduced under the 2009 Act, the PFD system allows coroners to identify risks and make recommendations to prevent similar deaths. Organizations receiving a PFD report are required to respond but are not legally bound to implement the recommendations.

Limitations

Non-Binding Nature: PFD recommendations are advisory, and there is no enforcement mechanism to ensure compliance.
Fragmented Oversight: There is no centralized system for analysing PFD reports to identify recurring systemic issues.
Limited Public Engagement: Many PFD reports receive little media attention, and their technical language can hinder public understanding.

Relevant Public PFD Reports

Case of Natasha Abrahart (2018): A student who died by suicide following inadequate support from her university. The coroner’s PFD report identified failures in mental health support systems but did not lead to substantive policy changes.
Case of Emma Day (2017): Emma Day was murdered by her ex-partner following systemic failures in addressing domestic abuse. The coroner’s PFD report highlighted failures by the Metropolitan Police Service, the Department for Work and Pensions, and other agencies.
Case of Molly Russell (2017): The coroner issued a PFD report addressing the role of social media in Molly’s death. Despite widespread media coverage, systemic changes in regulating harmful online content remain limited.

Implications for Press Reporting

Restricted Access to Systemic Analysis

The limitations on coroners’ commentary and the non-binding nature of PFD reports have reduced the media’s ability to report on systemic causes of suicides. This restricts public awareness and hinders advocacy efforts.

Impact on Accountability

Without detailed coronial findings, institutions are less likely to face scrutiny or be compelled to implement meaningful reforms.

Recommendations for Reform

Expand Coroners’ Mandate: Allow coroners to investigate and comment on systemic factors contributing to deaths.
Strengthen PFD Mechanisms: Make recommendations binding and establish a centralised oversight body to monitor compliance.
Enhance Public Engagement: Simplify the language of PFD reports and increase their accessibility to the general public.
Support Judicial Reforms: Encourage courts to interpret coronial duties in a manner that prioritises transparency and systemic accountability.
Promote Legislative Changes: Amend the Coroners and Justice Act 2009 to restore the ability of coroners to assign blame where warranted.

Conclusion

The historical evolution of coroners’ duties and the restrictions imposed by the Coroners and Justice Act 2009 have significantly curtailed their ability to address systemic failures. The limitations of the PFD mechanism further compound these issues, reducing the transparency and accountability necessary to prevent future deaths.

The Joy Dove Appeal and other high-profile cases highlight the urgent need for reform. By empowering coroners and strengthening the PFD system, the UK can better address preventable deaths, enhance public trust, and support advocacy efforts to improve mental health and suicide prevention.

This report is submitted on behalf of the STOPSuicides UK Campaign Group to advocate for these critical changes.