ReportoftheChiefCoronertotheLordChancellor

CombinedAnnualReportsfor2021and2022

December2023

HisHonourJudgeThomasTeagueKC,ChiefCoroner

ofEnglandandWales

ReportoftheChiefCoroner

totheLordChancellor

CombinedAnnualReportsfor2021and2022

PresentedtoParliamentPursuanttosection36(6)oftheCoronersandJusticeAct2009

December2023

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Contents

Contents

1.Introduction7

2.Coronerstatistics2021and202211

MOJ/ONSdata11

Casesover12monthsold12

Servicedeaths13

PreventionofFutureDeathReports13

3.Training15

4.Appointments17

5.Thecoronersystemin2021and202218

COVID-19andtherecovery18

Welfareandmoraleandthe‘tour’19

NewlegislationandrevisionstoChiefCoronerguidance20

MedicalExaminersystem21

Widerworkingwiththejudicialfamily22

Pathologyservices22

WorkwiththeBarStandardsBoard(BSB)andtheSolicitors

RegulationAuthority(SRA)23

DisasterVictimIdentification(DVI)andMassFatality

investigations23

Stakeholders24

6.Conclusion25

5

ReportoftheChiefCoronertotheLordChancellor

6

Introduction

1.Introduction

1.1Thisannualreportisacombinedannualreportwhichcoverstheyears

2021and2022.Inpart,thisapproachisbeingtakeninorderproperlyto

alignthepublicationscheduleoftheAnnualReportoftheChiefCoroner

withtheprecisestatutorywordingoftheCoronersandJusticeAct2009

(the2009Act),whichrequirestheproductionofanannualreportby1Julyeachyear,tocoverthepreviouscalendaryear.Since2014,whenthefirst

ChiefCoronerAnnualReportwaspublished,legacypracticehasbeen

foreachreporttocovertheperiod1Julyto31June.Thisapproachwas

initiallyimplementedtoenablethefirstChiefCoronertorapidlyissuehisfirstreport.However,asthereportingframeworkisnowwellestablished,itisappropriatethattheprocessforpublicationshouldbealignedwiththeprecisestatutoryrequirement.

1.2Secondly,theJuly–JuneapproachputtheAnnualReportoutof

synchronisationwithotherimportantpublicationsinthedeath

managementsystem,includingtheannualMOJcoronerstatistics,whicharepublishedeachMaycoveringthepreviouscalendaryear.Goingforward,therefore,Ihopethatthisnewschedulewillprovideinformationwhichis

clearertounderstandandeasiertoassessandplaceincontext.

1.3TheofficeofChiefCoronerwascreatedbythe2009Actaspartofthe

far-reachingstatutoryreformstothecoronialsystemcontainedinthatActandimplementedinJuly2013.TheChiefCoroner,whomustbeaHigh

CourtorCircuitJudgeundertheageof70,isappointedbytheLordChiefJusticeinconsultationwiththeLordChancellor.TheappointeeisrequiredtocombinetheirresponsibilitiesasChiefCoronerwiththeirexistingjudicialduties.Inmycase,IspendpartofmytimesittingasaCircuitJudgeintheCrownCourtatLiverpool.

1.4IamsupportedbymyprivateofficeandbytwoDeputyChiefCoroners–HHJAlexiaDurran(whoisaseniorCircuitJudgeattheCentralCriminalCourt)andDerekWinterDL(whoistheSunderlandSeniorCoroner).

1.5TheChiefCoroner’sjurisdictioncoversEnglandandWalesandincludesarangeofformalpowersandduties:

(a)approving(‘consentingto’inthelanguageofthe2009Act)the

appointmentsofallcoroners,alongsidetheLordChancellor;

(b)directinganinquesttobeheldintheabsenceofabody;

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ReportoftheChiefCoronertotheLordChancellor

(c)globalcasemanagementpowers,suchasdirectingtransfersofinquestsbetweencoronerareasandappointingjudgestodealwithcertain

high-profileorunusuallycomplexinquests;

(d)receivingnotificationsofinvestigationstakinglongerthanayearandmaintainingaregister;

(e)monitoringinvestigationsintoservicedeathsandensuringthatcoronersconductingsuchinvestigationsaresuitablytrained;and

(f)reportingannuallytotheLordChancellor,whomustlaythereportbeforeParliament.

1.6Byconvention,theChiefCoroneralsositsintheDivisionalCourthearing

judicialandstatutoryreviewcasesconcerningcoroners,andfromtimeto

timemayalsoconductinquestspersonally,eitherbyvirtueofhisofficeorasanominatedjudge.

1.7Abarerecitalofthoseformalfunctionscannotprovideacompletepicture

oftheChiefCoroner’srole,fortheyrepresentonlythetipofalargeiceberg.Muchoftheworkinvolvesleadershipofaninformalkind.TheChiefCoronerseekstopromoteconsistencyandgoodpracticeincoroners’courtsby

organisingtrainingforcoronersandcoroners’officers(deliveredthroughtheJudicialCollege),encouragingconstructivecollaborationbetweencoronersandtheirrelevantauthorities(i.e.theleadlocalauthorityineachcoroner

area),workingcloselywiththeMinistryofJustice(MOJ)andlocalauthoritiestofacilitatecoronerareamergers,issuingwrittenguidanceoncoroniallawandpractice,andprovidingjudicialleadershipandpastoralsupervision.

TheChiefCoroneralsohasanimportantco-ordinatingroleintheevent

ofamassfatality,terroristattackorotherincidenthavingDisasterVictim

Identification(DVI)aspectsinEnglandandWales(orasimilareventoverseasinvolvingUKnationals).Unsurprisingly,becauseofthedecentralised

natureofthecoronerservice,muchoftheChiefCoroner’sworktakes

placeintheintersticesbetweenthestatutoryprovisionsandday-to-dayoperationalpractice,andrequirestheexerciseofdiplomacy,patienceandgoodcommunication.

8

Introduction

1.8AsChiefCoroner,oneofmyfunctionsistocommunicatetheviewsand

interestsofcoronerstocentralgovernment.Inadditiontothereport

submittedannuallytotheLordChancellor,ImeetregularlywiththeJusticeMinisterresponsibleforthecoronerservice,aswellotherministers.MyofficeengageswiththeMOJandothergovernmentdepartmentsonmybehalf

(andonbehalfofcoroners)onarangeofissues,includingnewlegislation,governmentconsultationsandpolicyinitiatives,andsuchoperational

mattersasmayhaveapracticalimpactontheadministrationofjustice.Myofficialsalsositoncommitteesandworkinggroupswhereatechnicalperspectiveonthecoronersystemisneeded.

1.9Insummary,myroleistoprovidejudicialleadershiptocoronersin

promotingandsustainingaconsistentlyefficientandproportionatesystemofdeathinvestigationthatkeepsthedeceasedandbereavedfamiliesat

theheartoftheprocess.InnosenseamIa‘ChiefExecutive’ofthecoronerservice–thebricksandmortarandmostotheroperationalaspects(such

asstaff,ITsystems,courtroomsandsoon)areprovidedbylocalauthorities.Andsinceeverycoronerisanindependentjudicialdecision-maker,itis

quiterightthatIhavenopowertoissuebindingedictsorinstructionsin

individualcases.Instead,Iseektoprovideleadershipthroughacombinationofguidance,training,informaladviceandpastoralgovernance.

1.10BycontrasttotheChiefCoroner’spost,theofficeofcoronerisofgreat

antiquity,datingbackatleastasfarasthe12thcentury.Overthecourseof

itslonghistory,ithasdevelopedacharacterandethosofitsown.TothisdaythereremaintworespectsinwhichcoronersdifferconspicuouslyfromotherjudgesinEnglandandWales.Inthefirstplace,thespecialistjurisdiction

theyexerciseisinquisitorialratherthanadversarial;inotherwords,their

functionisnotsomuchtoadjudicateastoinvestigate.Second,theydo

notformpartoftheunifiednationalsystemofcourtsandtribunalsnow

administeredbyHMCourtsandTribunalsService.Theyare,andalwayshavebeen,locallyappointedandresourcedjudges,dividedinto83independentcoronerareasasattheendof2022.

1.11Althoughtheofficeofcoronerisanancientone,itretainsconsiderable

contemporarysignificance.Itsproperfunctionofinvestigatingdeathsservesthewelfareofthebereavedandtheinterestsofsocietyatlarge.Acoroner

mustinvestigateareporteddeathifheorshehasreasontosuspectthatthedeceasedpersondiedaviolentorunnaturaldeath,orthecauseofdeathisunknown,orthedeceaseddiedwhileincustodyorotherstatedetention.

Inmanycases,thecoroner’sinvestigationwillculminateinacourthearingknownasaninquest.

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ReportoftheChiefCoronertotheLordChancellor

1.12Acoronialinvestigationisaformofefficientsummaryjusticethatprovides

answerstofourstatutoryquestions,namelywhothedeceasedwasand

when,whereandhow(usuallyconfinedtomeaning“bywhatmeans”)

thedeceasedcamebyhisorherdeath.Theinvestigationmustbeaswift

one.Thecoroner,whomustconducthisorherinvestigation“assoonas

practicable”,1isunderadutytoopenaninquest“assoonasreasonably

practicable”2and,ifpossible,tocompleteanyinquestwithinsixmonthsofthedateonwhichthedeathisreported.3Theinvestigationmust,ofcourse,besufficientbutitisnotmeanttobeexhaustive.EvenwheretheenhanceddutyofinvestigationarisesunderArticle2oftheEuropeanConventiononHumanRights,thecoronerorjuryisnotpermittedtoexpressanopinion

onanytopicotherthanthefourstatutorymatterstobeascertained.Nor

mayaninquest’sdeterminationbeframedinsuchawayastoappearto

determineanyquestionofcivilliabilityoranyquestionofcriminalliabilityonthepartofanamedperson.

1.13ThesearethecharacteristicsIhaveinmindwhenIdescribethecoroner’s

investigationas“aformofefficientsummaryjustice”.ItisaprocessthathasitsrootsintheinquisitorialmethodandmakesaninvaluablecontributiontotheadministrationofjusticeinEnglandandWales.Itcombinesaprocessoffact-finding,incollaborationwithinterestedpersonsandwitnesses,withthelegalrigourthatcomesfromexposuretoscrutinyandchallengebywayofJudicialReviewproceedings.

1.14Mypredecessorsrepeatedlyemphasisedthatthedeceased,andby

extensionthebereaved,shouldbeattheveryheartofthecoronialprocess.ThatisacoreprinciplethatIfullyendorse.Butweshouldnotforgetthat

itispreciselytheinquisitorialnatureofthecoroner’sinvestigationthat

guaranteesthecentralityofthebereaved.Whereproceedingsacquirea

moreadversarialcharacter,thefocusisliabletobedivertedawayfromthebereaved,whereitproperlybelongs,andchannelledinsteadintoadebatebetweencompetingdisputants,whowillnotnecessarilyincludethefamilyofthedeceased.Intheprocess,theimportantdistinctioninprinciple

betweentheroleofaninterestedpersonandapartytoproceedingscan

becomeblurredtothepointwhereacoronermayevenfindthatheorshehas,withoutintendingto,cededameasureofcontroloftheinvestigationtointerestedpersonsortheirlawyers.Inshort,thereisariskthattheinquestmightendupasyetanotherformoflitigation,withthecoronerbecomingcomplicit,albeitunwittingly,inthemarginalisationofthebereaved.

1

CoronersandJusticeAct2009(.uk)

2

Coroners(Inquests)Rules2013,rule5(1)(.uk)

3

Coroners(Inquests)Rules2013,rule8(.uk)

10

Introduction

1.15Ofcourse,someinquestsareunavoidablyhigh-profileorcontentious.

Butevenacontentiousinquestshouldnotdescendintoanadversarialconfrontation.Itisnotthefunctionofacoronialinvestigationto

resolvedisputesortoserveasavehicleforthosewhowishtoairextraneousgrievances.

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ReportoftheChiefCoronertotheLordChancellor

2.Coronerstatistics2021and2022

2.1AlldeathsinEnglandandWalesmustberegisteredwiththeRegistrar

ofBirthsandDeaths.Fromtheinformationprovidedforregistration,the

OfficeforNationalStatistics(ONS)collatesandpublishesstatisticsonall

deaths–itsmortalitystatisticsreportthetotalnumberofdeathsregisteredinEnglandandWalesinaparticularyear,irrespectiveofwhethercoronershaveinvestigatedthem.

2.2TheMOJpublishesseparatecoronerstatisticsannuallyinMay.Thelatestfigures(forthecalendaryear2022)andthoseforprecedingyearscan

befoundat

.uk/government/collections/coroners-and-burials

-

statistics

.Thesestatisticsprovidedetailonarangeofmetricsincluding

inquestconclusionsbrokendownbytype,thenumberofdeathsinstate

detention,thenumberandtypeofpost-mortemexaminationsundertaken,anddataontimeliness.Thisdatacanalsobebrokendownbyindividual

coronerarea.Idonotproposetorepeatallthatdata,butIwillprovideasummaryofhigh-levelinformationhereonthetotalnumberofreporteddeathsinEnglandandWales,aswellasontimeliness.

2.3Inaddition,Iprovidemyownfigures(whichrelatetomystatutory

responsibilitiesasChiefCoroner)oncasesover12monthsold,servicedeathsandPreventionofFutureDeathReports.

MOJ/ONSdata

2.4195,200deathswerereportedtocoronersin2021,thelowestamount

since1995.Thisfigurerepresents33%ofthe586,334deathsregisteredinEnglandandWalesin2021.4

2.5Therelativelylowproportionofdeathsreportedtoacoroner(asopposedtothesumtotalofallregistereddeathsin2021)islikelytobeafunctionofthenumberofexcessdeathscausedbyCOVID-19infection.AsCOVID-19isanaturallyoccurringdisease,itwillhavemeantthatagreaterproportionthanusualofalldeathsinEnglandandWaleswouldhavearisenfromnatural

causesandthereforedidnotrequireareporttothecoroner.

4Itisimportanttomakeclearthatthenumberofdeathsregisteredinacalendaryearandthenumberofdeathsreportedtoacoronerineachcalendaryeararenotnecessarilycomposedofthesamecohortofdeaths.Aminorityofdeathsregisteredin2021willhaveoccurredin

2020orinearlieryears;typicallythesearedeathswhichwillhaverequiredaninquestandforanumberofreasonstheinquestwillnothavebeenheldinthesameyearasthedeath.

12

Coronerstatistics2021and2022

2.6In2022,208,400deathswerereportedtothecoroner–a7%increase

comparedwith2021,and36%ofthe577,160deathsregisteredinEnglandandWalesin2022.

2.7Theaveragetimetakentocompleteaninquestincreasedfrom27weeksin2020to31weeksin2021.In2022,theaveragetimetocompleteaninquestwas30weeks;amodestbutencouragingimprovement.

2.8Thesharpincreaseintimetakentocompleteaninquestin2021(andits

after-effectsinto2022)areamatterofrealconcerntome,andtackling

delayisapriorityformeandmyoffice.Aprimarycauseofdelayin2021

wastheCOVID-19pandemic.Duringtheinitialperiodoflockdownfrom

MarchtoJune2020,manyjuryandnon-jurycomplexinquestswerehalted.Ofcourse,manycoronerscontinuedtohearroutineinquests,eitheronthepapersorincourtusingaudioandvideoconferencing.

2.9Theeffectoflockdownontimelinesswasnotinstantaneous.Thesignificantbacklogcreatedbylockdownfedforwardinto2021,becausemost

coroners’courtsdidnothavethecapacitytoclearthebacklogcreated

duringtheremainderof2020(notleastbecausesocialdistancingandotherfactorscontinuedtoslowthethroughputofcasesafterthereturntohearingcasesincourtfromJune2020onwards).Ofcourse,newdeathscontinuetobereportedtocoronersallthetime.AsIwillsetoutlaterinthisreport,Iamtakingforwardseveralmeasurestotackledelay.

Casesover12monthsold

2.10AsChiefCoroner,IhaveastatutorydutytoreporttotheLordChancelloron

casesover12monthsold.SetoutinAnnexAisatablefor2021and2022(aswellasprecedingyears),brokendownbycoronerarea,showingthe

numberofcasesthathavebeeninthesystemforover12months,andthepercentagetheserepresentofthenumberofcasesreportedineacharea.Thisdatarepresentsasnapshot,inAprileachyear,ofthenumberofcasesolderthan12monthsoldinthesystem.ItisimportanttomakeclearthatthisdataiscollectedseparatelyfromtheMOJandONSstatistics.

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ReportoftheChiefCoronertotheLordChancellor

2.11Inanynormalyear,therearegoodreasonswhysomecasesareoutstanding

beyond12months–forexample,wherethereareongoingpoliceenquiries,criminalinvestigationsandprosecutions,orinvestigationsbyotherstate

bodies.Thecoroner’sinquestwillbeadjournedpendingtheoutcomeoftheseenquiriesorinvestigationswhichcan,insomecircumstances,be

verylengthy.Incertainareas,therehavealsobeenproblemswithcoronerresources.SeniorCoronersintheseareashaveworkedwiththeirlocal

authoritiestoensurethatadequateresourcesareprovidedtoenablecasestobedealtwithasexpeditiouslyaspossible.

2.12However,itisconcerningthatthenumberofcasesover12months

withinthesystemhasincreasedduringtheperiodcoveredbythisreport.InApril2021,therewere5,013casesinEnglandandWalesthatwere

notcompletedwithin12monthsofbeingreportedtothecoroner.Forcomparison,in2019(incompletedataexistsfor2020),therewere2,278suchcases.Theimpactofthepandemiconcaseprogressionisthereforeclearlyvisible.

2.13InApril2022,therewasareductioninthenumberofcasesover12months

old,downto4,568,whichisawelcomeimprovement,althoughthereismuchstilltodo.

2.14ThispictureissymptomaticofthebacklogofcasescreatedbytheCOVID-19

pandemic,notleastbecauseofthewholesaleadjournmentofcaseswhichoccurredacrossthejusticesystemduringthefirstlockdowninMarch–June2020whichIrefertoabove.Idiscusstheresponsetoandrecoveryfrom

thepandemicbelow;oneofmyprioritiesasChiefCoroneristotackleandeliminatebacklogswhereverpossible.IworkwithSeniorCoronersandlocalauthoritiestodealwithanyparticularlocalbacklogs,andtoconcentrate

effortsandlocalresourcesontherecovery.

Servicedeaths

2.15Inthewholeperiodcovering2021and2022,Ireceivedreportsofthree

deathsofservicepersonnelwithinthemeaningofsection17ofthe2009Act.IamsatisfiedthatthesecoronerinvestigationsandinquestsarebeingprogressedbytherelevantSeniorCoronersinanentirelysatisfactoryway.

14

Coronerstatistics2021and2022

PreventionofFutureDeathReports

2.16Duringacoronerinvestigationandinquest,thecoroner’sprimaryfocus

willbeonidentifyingandformulatingtheanswerstothefourstatutory

questions,butcoronersalsohaveaduty,incertaincircumstances,tomakeareporttopreventfuturedeaths(a‘PFD’report).

2.17However,althoughthedutytomakeareportmaybeanimportantaspect

oftheoutcomeofaninvestigation,itisancillarytotheprimarypurposeofaninquestwhichistomakethestatutorydeterminations,findingsandconclusionsrelatingtothedeath.

2.18ThestatutoryobligationtomakeaPFDreportariseswheretheevidence

obtainedduringaninvestigationorinquestgivesrisetoaconcernthat

futuredeathswilloccur,andtheinvestigatingcoronerisoftheopinionthatactionshouldbetakentoreducetheriskofdeath.

2.19ChiefCoronerGuidanceonPFDReportsispublishedonthe

judiciarywebsite.5

2.20440and403PFDReportswereissuedbycoronersin2021and2022

respectively.MuchmoreinformationcanbefoundatthejudiciarywebsitewherethereisasectiondedicatedtothepublicationofPFDReports.6Usefulinformationcanalsobefoundintheacademiccommunity,especiallyatthePreventableDeathTrackerledbyDrGeorgiaRichardsatOxfordUniversity.7

5

RevisedChiefCoroner’sGuidanceNo.5ReportstoPreventFutureDeaths[i]–Courtsand

TribunalsJudiciary

6

ReportstoPreventFutureDeaths–CourtsandTribunalsJudiciary

7

TheDatabase–PreventableDeathsTracker

15

ReportoftheChiefCoronertotheLordChancellor

3.Training

3.1AsChiefCoroner,IexercisemyresponsibilitiesfortrainingSeniorCoroners,

AreaCoroners,AssistantCoronersandcoroners’officersundertheauspicesoftheJudicialCollege.Iremainverygratefultoallthecoursedirectors,

syndicateleadersandthecollege(particularlyHHJJeremyRichards)fortheirsupportindevisingandprovidingourprogrammeoftraining.

3.2ThejudicialtrainingyearrunsfromApriltoMarchsothisreport(covering

both2021and2022)includesinformationrelatingtothreetrainingcycles.8

3.3Duetothesevererestrictionsanddisruptionimposedbythepandemic,coronercontinuationandcoronerofficertraininghadtobesuspendedinthetrainingyearMarch2020–21.Coronerinductiontrainingwent

aheaddigitally.

3.4ForthetrainingyearApril2021toMarch2022,coronercontinuation

trainingwasdelivereddigitallyasaone-daycourse,focusingonanumberofissuesforcoronersarisingfromtheexperienceofthepandemic.Coronerinductiontrainingwasalsodelivereddigitally,asitwasin2020–21.In

addition,one-daymedicaltrainingwaspausedin2021–22.

3.5Bearinginmindthedisproportionatelyintenselevelsofpressuretowhichcoroners’officersweresubjectedduringthepandemic,trainingwas

pausedforthe2021–22cycle(althoughsomedesktoplearningmaterialwasprovided).

3.6Duringlate2021andearly2022,pursuanttoajointarrangementbetweentheJudicialCollege,ChiefCoroner’sOfficeandRoyalCollegeofPathologists,allcoronersandmedicalexaminerswereofferedthechancetoattend

aone-daydigitalcourseontheinterfacebetweenMedicalExaminers

andcoroners.Feedbackconfirmsthatthiswasaverysuccessfulcourse,designedtoensurethatcoronersandMedicalExaminersgainedabroadunderstandingofeachother’srolesandresponsibilities.Itwasdeliveredtodelegatesviaanumberofonlinesessions.Iamverygratefulforthe

supportoftheNationalMedicalExaminer,DrAlanFletcher,andtheRoyalCollegeofPathologists,includingDrSuzyLishman,indevelopingthis

importanttraining.

3.7FromApril2022onwards,trainingreturnedto‘in-person’residentialorone-daytrainingforallcoronerandcoroners’officerscourses.

8April2020–March2021,April2021–March2022andApril2022–March2023.

16

Training

3.8Finally,workonthenewcoroners’benchbook,whichhasbeendevelopedundertheleadershipofDeputyChiefCoronerHHJAlexiaDurran,isnowsubstantiallycompleteandthetextisundergoingathoroughreview

processpriortopublication,whichisexpectedbeforetheendof2023.

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ReportoftheChiefCoronertotheLordChancellor

4.Appointments

4.1Whilecoronerappointmentsaremadebytherelevantlocalauthorityfor

therespectivecoronerarea,asChiefCoronerIhaveastatutoryresponsibilitytoconsent,alongwiththeLordChancellor,toallcoronerappointments

inEnglandandWales.Inpractice,myinvolvementgoesfurther;Iprovidedetailedguidancetocoronersandlocalauthoritiesandoverseeindividualcompetitions.9

4.2IamparticularlypleasedtoseethegrowthintheappointmentofArea

Coronerswhichhastakenplaceduringtheperiodofthisreport.

4.3Asof1July2023,10thenumberofcoronialappointments11are:

?SeniorCoroners–77

?AreaCoroners–46

?AssistantCoroners–391

4.4Atanyonetime,anumberofjudge-ledinquestsareinprogresswithinthe

coronersystem.Furtherinformationaboutjudge-ledinquestscanbefound

at

www.judiciary.uk/related-offices-and-bodies/office-chief-coroner/

9

ChiefCoroner’sGuidanceNo.6Theappointmentofcoroners–CourtsandTribunalsJudiciary

10Althoughthisreportcoverstheperioduntiltheendofthecalendaryear2022,Ihopeitwillbe

consideredmoreusefulforthemost-up-to-datefiguretobeprovided.

11Thatisthenumberofextantjudicialpostscurrentlyheld.

18

Thecoronersystemin2021and2022

5.Thecoronersystemin2021

and2022

COVID-19andtherecovery

5.1AlthoughtheCOVID-19pandemicisrecedingintothedistance,ithashadasignificanteffectontheadministrationofjusticeacrossalljurisdictions,anditseffectsremain.Mypredecessor,HHJMarkLucraftKC,setouttheimpactoftheinitialstagesofthepandemiconthecoronerserviceinEnglandandWalesintheprevio