A programme of reform to the coroner and death certification service was established in 2003. Proposals on how to take it forward were announced in a position paper in March 2004. On 6 February 2006, further plans were announced in an oral ministerial statement and a briefing note was published. . A draft Bill was published on 12 June 2006 and consultation responses published on 27 February 2007.
The reform programme was established in response to a report of the fundamental review of death certification and coroner services, published in 2003; and to recommendations made in the third report of the Shipman Inquiry. When the reform programme was established, the Home Office was responsible for coroners. In May 2005, we took over responsibility for coroners.
The draft Coroners Bill aims to modernise the coroner system so that it provides a more effective response to bereaved families and others who are touched by the service. It was published on 12 June 2006. The consultation period on the draft Bill closed on 8 September 2006.
The government is committed to reforming the coroner service and Harriet Harman announced the way forward in an oral statement in the House of Commons on 6 February 2006. A briefing note was also published. The note gives further details of the reform plans. The main aims of reform are to improve the service provided to bereaved people, to introduce national standards and national leadership, and to improve the efficiency and effectiveness of coroner investigations
Report 4 June 2003
A fundamental review of death certification and coroner services was set up in July 2001. The review group undertook a considerable programme of consultation. On 4 June 2003, they published the Report of a Fundamental Review 2003 Death Certification and Investigation in England Wales and Northern Ireland. The report calls for a number of changes to improve efficiency and increase public confidence in death certification and the coroner service. The review was commissioned by the government but independent and chaired by Tom Luce CB, former Head of Social Care Policy at the Department of Health.
The full report is available to download from the Stationary Office website.
The case of Harold Shipman, a general practitioner who was convicted, in 2000, of murdering 15 of his patients, prompted further reform of the coroners' system. There were six reports after the inquiry into the Shipman case. The third report considered the work of coroners and the death certification system, and how they might be reformed to minimise the chance of another professional operating unnoticed, as Harold Shipman did. The third report of the Shipman Inquiry was chaired by Dame (now Lady Justice) Janet Smith, an Appeal Court judge, and was published in July 2003.
All six reports of the Inquiry are available at on the Shipman Inquiry website.
The government drew on recommendations from the fundamental review of coroner and death certification systems and the third report of the Shipman Inquiry to produce the position paper "Reforming the coroner and death certification service". The paper proposes a system with oversight of all deaths based around full time independent coroners with legal qualifications who will be closely supported by appropriate medical expertise. It also proposes tightening up the death certification process by increasing medical scrutiny in the system.
You can download the paper from the Stationery Office website.