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Coroners and Justice Act 2009

Part 1 - Coroners etc

16.The legislative changes in the Act are part of an overall package of reform aimed at addressing the weaknesses in the previous coroner and death certification systems, identified in the reports of the Fundamental Review of Death Certification and Investigation and the Shipman Inquiry, both published in 2003 ( and, respectively).

17.A draft Coroners Bill was published in June 2006 ( and the public consultation on it ran until September 2006. This consultation took a number of different forms, including inviting written representations – more than 150 responses were received from a range of organisations and individuals. A summary report of the responses was published in February 2007 ( A document setting out the changes to the proposals made in response to consultation was published in March 2008 (

18.The draft Coroners Bill was subject to pre-legislative scrutiny by the then Constitutional Affairs Select Committee (CASC – now the Justice Committee). CASC’s report on the draft Bill was published in August 2006 ( pdf). The Government responded to the CASC report in November 2006 (

19.In 2008, a consultation paper on the introduction of a statutory duty for medical practitioners to report deaths to coroners was published ( The Government decided that the statutory duty to report would be placed on registered medical practitioners only, and a draft list of the type of death to be reported was included in the response document (

20.A further consultation was carried out in April 2008 regarding sensitive reporting in coroner’s courts ( The Government concluded that the Press Complaints Commission Code would not be amended and that instead consideration would be given to finding ways of drawing the Code to the attention of the bereaved families. The response to the consultation was published on 14 January 2009 (

21.A consultation was carried out on a draft Charter for bereaved people who come into contact with the coroner service in June 2008 ( The consultation resulted in the Charter being revised, and the revised draft Charter was published on 14 January 2009 (

22.A consultation on Improving the Process of Death Certification was published by the Department of Health in July 2007 ( Consultations/Closedconsultations/DH_076971). The public consultation ran until October 2007 and a summary of responses was published in May 2008 ( The Department of Health received 157 written responses to the consultation and additional feedback through meetings with national stakeholder organisations and with councillors and representatives from local communities.

23.The majority of respondents and participants in the consultative meetings recognised and acknowledged the problems with the previous process of death certification described in the consultation paper and supported the proposed improvements. The main concerns raised by respondents and participants were that the new scrutiny process should not cause significant delays to funerals and that medical examiners should be able to carry out their duties with the necessary degree of independence from the NHS and other public authorities. These two concerns have been critical factors in designing the improved process and will remain so in development of regulations and guidance.

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