On 24 January 2025, HHJ Alexia Durran, Chief Coroner, released the Chief Coroner’s Guidance for Coroner’s on the Bench (more commonly and previously known as “the Bench Book”). This guidance replaces (and expands upon) a large number of the Chief Coroner’s Guidance Notes and is intended  to form a resource to assist Coroners with inquests. Practitioners are encouraged to refer to new guidance as the Bench Guidance, but invariably it will be referred to as the Bench Book.

Crucially, the Bench Guidance is not legally binding. Rather the new Bench Guidance holds the same status as existing guidance notes and law sheets and is described as a tool to “promote consistency and encourage best practice.”

The Bench Guidance provides a comprehensive guide to the inquest process and will be of great assistance both to Trusts, in house legal teams and lawyers in ensuring that there is consistency through the inquest process.

The Chief Coroner has encouraged practitioners not to print the Bench Guidance as the intention is for the guidance to be updated regularly. We are also informed that a Chapter on Article 2 is to be published, which we eagerly await.

Key Updates

The Bench Guidance includes clarification and guidance around:

• Disclosure, including:
  • managing disclosure, including the provision of disclosure to Interested Persons (“IP”s) – it is reasonable for the Coroner to disclose documents in batches, as the investigation process proceeds, but that IP’s are to be provided with sufficient information at an early enough stage to allow them to fully participate (para 6.19 and 20).
  • disclosure of sensitive material -  where documents contain very sensitive information (whether written or photographic) consideration of the circumstances is needed before disclosure to the family or other IP’s and that such material should be identified to the Court and discussed with the IP’s (para 5.15).
  • disclosure of health records and any redactions needed - inquests necessitating the deceased’s full health records, rather than those records relevant to the circumstances of death will be rare (para 5.38). The private addresses, email addresses and phone numbers of third parties, such as family members of the deceased, ought to be redacted prior to disclosure to the Court (para 5.33). It is reasonable for the Coroner to direct lawyers representing public bodies to assist in producing indexed, paginated and bookmarked PDF bundles (para 5.30). 

• Pre-Inquest Review (“PIR”) hearings, including:
  • when to hold a PIR (rarely, as per paragraph 3.1);
  • issues around cross-disclosure of submissions – the guidance makes it clear that all submissions (and indeed any communication to the Court on a matter of substance or procedure), should be cross-disclosed to all parties (paragraphs 3.14 and 15);
  • remote attendance at PIRs, which should now be offered where appropriate and practicable (paragraph 3.18);
  • the provision of an agenda and disclosure in advance of a PIR, which should be provided at least two weeks in advance of the hearing (paragraph 3.4);  and
  • the instruction of experts, which remains at the wide discretion of the Coroner, but is noted to not be required in every case and largely where a lack of expert evidence would result in an insufficiency of investigation (paragraph 14.6).

• The management of jury directions and evidence that should be heard by the jury - of note, paragraph 16.14, notes that it would be “unusual” not to hear all evidence before the jury, and that if evidence is heard in the absence of the jury, it must be limited to post-death improvements and changes. We consider it likely that the Guidance will trigger an increase in Coroner’s hearing PFD evidence before the jury;
• Guidance on the considerations taken before issuing Prevention of Future Deaths Reports – the Coroner is required to consider all the documents, evidence and information that is relevant to the investigation and available at the time in making any decisions (paragraphs 16.17 and 18);
• Taking evidence from abroad – this must be managed on a case by case basis and there is no list of countries where witnesses can give evidence from (paragraph 13.57);
• Available conclusions and when they can be appropriately used. Chapter 15 provides guidance around the name of the deceased where the deceased may have changed their name, the various short form conclusions available and their definition, and helpful examples of appropriate narrative conclusions; and
• In respect of obtaining post-mortem reports – paragraph 12.46 indicates that, where an organisation is not yet an IP, a doctor who treated the deceased in a hospital, will usually be considered a proper person to be given disclosure of a post-mortem report. This is often an issue we encounter, where clinicians are asked to provide evidence on the cause of death, but are not provided with the post-mortem report as the Trust has not yet been granted IP status.  As such, this will be useful to refer Coroner’s Officers to if disclosure of post mortem reports is not forthcoming.

What do these Changes Mean?

Organisations involved in inquests should:

• ensure that they have carefully reviewed the Bench Guidance and that their own practices, particularly in relation to disclosure, are in accordance with it;
• be prepared to receive an increase in requests for paginated and bookmarked bundles of records and statements;
• ensure that clinicians are aware of the guidance around the summonsing of witnesses and giving of oral evidence

We hope that this guidance will increase consistency across Coronial jurisdictions and between interested parties and lawyers acting on behalf of interested parties at inquests.

It must be noted that the Bench Guidance is not binding and does not replace Coronial directions.

How Capsticks can help

Capsticks can support your organisation following the implementation of the new Bench Guidance.  Where you have been informed an inquest has been opened, Capsticks can help to protect your organisation’s reputation and give your staff the support they need in the lead-up to, and during, an inquest, as well as assisting with disclosure requests. We have one of the largest inquest teams in the country, representing all types of service providers at around 1,400 inquests a year.

If you have any queries around this Insight, and the impact on your organisation, please contact Georgia Ford or Martha Froy to find out more about how Capsticks can help.