PARLIAMENTARY DEBATE
Coroner Services: West Midlands - 15 May 2025 (Commons/Commons Chamber)

I am extremely grateful for the opportunity to address an issue that continues to cause deep pain and disruption to our communities across Birmingham and the west midlands, and to speak about an under-appreciated service that we will all turn to at some point in our life. The amount of time that passes between death and burial is not a matter of mere procedure or bureaucracy; it is, first and foremost, a matter of dignity, faith, and human decency, so we must afford our coroner services the urgent and serious attention that they deserve. For many, the news of a loved one passing brings not only sorrow, but an immediate sense of duty. In both the Muslim and Jewish traditions, burial cannot be postponed without consequence. It is a religious imperative to bury the deceased as soon as possible, ideally within 24 hours. That is a fundamental and non-negotiable feature of those faiths. When that process is delayed—not for hours, but for days and sometimes weeks—it causes a deep wound. These families are not just dealing with a loss, but being kept in suspense, both spiritually and emotionally, unable to complete the final rites that bring the peace, closure and healing that we all deserve when we lose a loved one.

What is worse is that these delays have become commonplace. They are no longer the exception; increasingly, they are the norm. Every week, I hear from grieving families in my constituency—

Every week, I hear from grieving families who are tired, frustrated and often feel helpless. Their stories are heartbreaking. Many do not know where to turn. They call their councillors and their MPs, and they are right to do so. When the system fails them, it is our job to listen, to act and to advocate.

On coroner services in the west midlands, I call Jim Shannon.

I spoke to the hon. Member for Birmingham Perry Barr (Ayoub Khan) before the debate, Madam Deputy Speaker; he and I were in a debate in Westminster Hall just this afternoon. Coroner services, whether it be in the west midlands or anywhere else in the United Kingdom, are an issue. I told the hon. Gentleman what my intervention was going to be, by the way, and he okayed it; I was happy to do so.

The hon. Gentleman may be aware that there are only three full-time coroners in Northern Ireland. With the historic legacy of the troubles taking up time and the coroner stepping outside his remit, does the hon. Gentleman not agree that, in both his constituency and mine, the need for the coroner must be focused on and that they should be available to those who need them most? Furthermore, does he agree that there is a need to increase the number of coroners in order to allow families to have the facts of the case when they need them, to allow the healing to begin?

I really appreciate the intervention from the hon. Gentleman, who makes a poignant point. The service does require modernisation. In Birmingham and Solihull we have one senior coroner, two area coroners and seven assistant coroners to look after a population of approximately 1.5 million, according to the 2021 census. In comparison, in the hon. Gentleman’s patch, there are four coroners for 1.9 million people, which is simply not enough.

As I said, these families are not just dealing with the loss of a family member, but being kept in suspense, both spiritually and emotionally.

In May 2024, more than 6,000 inquests in this country had been delayed by more than a year. As the hon. Gentleman appreciates, each of those inquests represents a grieving family unable to find closure, plan funerals or settle estates. Does he agree that this Government should now act to clear the backlog and to provide extra funding? This situation is nothing short of a crisis.

I thank the hon. Gentleman for his intervention; I was going to quote those figures in my speech. He is absolutely right that those 6,000 delays have a direct impact on not just families who want closure, but current cases that need to be worked on. The time spent by the coroner on inquests will naturally impact the basic sign-off of documents in other cases, and where the coroner is not available to sign off, families will have to wait to effect burial. We need modernisation, of course, and I seek support from the Minister on how we can modernise the service.

As I said, I hear of grieving families every week. They are tired, frustrated and often feel helpless, and turn to elected representatives for intervention. I want to share a story from my constituency that highlights the human impacts of these delays. A prominent brain surgeon had lost his father. The funeral, which should have taken place within a day, was delayed for over a week due to coroner backlogs. That surgeon, bound by faith and family duty, remained in mourning and could not return to work until the burial had taken place. His father’s death was more than a personal loss; it had a professional consequence, too. Appointments were cancelled and surgeries were delayed. There are countless examples of where family members, and extended family members, have to remain in mourning, which means that they are not able to do the work that they would ordinarily do.

I had not actually thought about the loss of a child, but, of course, that must be extremely distressing, especially if the family have to wait for a child’s body to be sent to another part of the country for examinations to take place. In raising this matter in the Chamber today, I hope the Minister will take on board the points that I have made and understand why we believe that there is a desperate need for modernisation, which deals with the issues felt by communities up and down this country.

Let me return to my personal experience. Patients were left waiting because the brain surgeon was unable to attend to them while he was still in mourning. This is what happens when we allow systemic inefficiencies to go unaddressed. They begin to erode the very services on which we all rely and impose hidden costs that cannot be measured, but are there none the less.

This brings us to the heart of the issue: what is causing these delays. There are several factors at play here. Among them is the state of our coroners service. Quite frankly, it is under-resourced, understaffed and overstretched. The people working in this sector are not to blame. They are doing incredible work under immense pressure, but the system is in desperate need of transformation. Let us look at the facts across England and Wales.

Of course, it is important that all communities form a bond with their local coroner, but, ultimately, if the coroner and their staff are limited in numbers, there is always going to be a backlog and delay in processing the very important work of identifying the cause of death and then releasing the deceased.

Let us look at the facts. Across England and Wales, more than 6,000 coroner cases were pending for more than a year—four times higher than in 2017. Birmingham and the west midlands were among the worst affected. Our population is growing. Our communities are increasingly diverse, with more residents who require specific religious considerations, yet the infrastructure has not kept pace. The Government’s funding commitments have not matched rising everyday demand. We do not have enough pathologists and we do not have enough administrative support. We do not have the essential tools that could make a significant difference—tools such as MRI and CT scanning machines, which are used for the sole purpose of conducting non-invasive autopsies. However, we do have access to these facilities, but they are not dedicated to the coroner. It is by taking advantage of technological innovations such as those that we can make life easier for families whose faith prohibits invasive post-mortem procedures. With the right equipment, we can respect those beliefs and still get the data required by law.

Another major issue is the absence of weekend services. In most parts of the country, coroners offices operates Monday to Friday, but people do not stop dying on Fridays. Deaths occur every day. When services close for the weekend, a death that occurs on Friday night may not be processed until Monday or even Tuesday. For families who are religiously obligated to bury their loved ones immediately, the delay is deeply distressing. Introducing weekend operation for coroner and burial services is not a luxury but a necessity. In Birmingham we did have a coroner who would give up his time on weekends, but that has stopped.

To speak plainly about another area of concern, MPs are increasingly being told not to contact a coroner’s office on behalf of constituents. We are told that it constitutes interference. In fact, that is set out in the code of conduct for parliamentarians. I reject that completely. MPs are not asking coroners to change their findings or trying to influence investigations. We are not questioning their professionalism or their judgment. We are simply asking for speed, efficiency and compassion. To suggest that this is interference misunderstands both the role of an MP and the seriousness of the issue. We must be allowed to advocate for our constituents.

I commend the hon. Gentleman for his wise words. We are all of different faiths, whether Christian or other faiths, and some people have no faith. A person’s religion must be paramount when it comes to the coroner’s work, and the coroner must ensure that a burial can take place within the period of time that the person’s faith indicates. I would have thought that is something that cannot be ignored under human rights and equality. Perhaps there is another way of looking at that.

I thank the hon. Member for his intervention. There is significant case law that identifies this specific need, and coroners do abide by that and try their best to assist when expediency is required because of religion. Unfortunately, it comes back to the bottleneck, where coroners want to do the best they can within the structure in which they are working, but they are limited by resources. That comes down to issues such as staffing.

When families have nowhere to turn, it should not be inappropriate for parliamentarians to contact the coroner to assist the suffering or grieving family. Will the Minister please review the part of the code of conduct for parliamentarians that relates to communicating with a coroner?

One way that we in Dewsbury and Batley try to overcome this restriction—a rule I also could not understand—is by working with our not-for-profit and charitable funeral services, especially in religious communities. Organisations such as Fisabilillah and Sadaqah Jariyah build a relationship with the coroner to try to facilitate communication with families who reach out to MPs. Does the hon. Member agree that these organisations in communities should be congratulated and thanked for their service, and that the communication channel he speaks of should be formalised and made permissible?

I agree wholeheartedly with the hon. Member. Up and down the country many organisations such as undertakers provide that support mechanism. Unfortunately, from my personal experience—this is certainly the case in Birmingham, and I am confident it is in the west midlands region too—a family’s first port of call is their local councillor or parliamentarian, and there is an expectation from the community or the family that they will make representations to the coroner. If elected representatives are unable to have that communication because of the code of conduct, our very function is undermined. It is important that organisations maintain the relationships that they have with coroners, but it is also important to give parliamentarians the ability to communicate with the coroner directly. To ensure that the services meet the demand of their communities, they need additional funding. Coroner services require transformation, but resourcing for that transformation is important. That means hiring more pathologists.

I am grateful to the hon. Member for allowing me to intervene again. Apart from him, I think I am the only Member from the west midlands in the Chamber; my constituency is Wolverhampton West. Does he agree that there appears to be a postcode lottery, as the time it takes to process an inquest ranges from 10 weeks to 76 weeks depending on where a person lives? If we do have a postcode lottery, does he agree that we must address that by having a national performance framework for our coroner services and targeting funding for underperforming areas?

Of course, if there is a disparity in the level of service received, there ought to be some mechanism for identifying where that is occurring and an understanding as to why. If it is because of resources and manpower, that must be addressed. I fully agree with the hon. Member’s analysis. It is a shame that we do not have other parliamentarians from the west midlands in the Chamber. I am confident that some will have received an enormous amount of contact and huge numbers of calls throughout their tenure, as I do.

One of the issues is resourcing, including those MRI and CT scan facilities available for post-mortems and dedicated to that purpose. Although our coroner in Birmingham and Solihull has access to those devices, unfortunately they are not dedicated to that task, and a deceased may lie in the coroner’s mortuary until a facility becomes available, which can take days, and sometimes even longer.

A transformation also means ensuring that services operate not just five but seven days a week, because death, grief and religious obligations do not adhere to the normal working week. We also need to develop a clear protocol across all local authorities that recognises the need for expedited burials in line with religious beliefs. There must be training, awareness and sensitivity in coroner services.

As I recently had the experience of bereavement in the family, may I ask the hon. Member to join me in recognising the exceptional service of the Blackburn coroner service and its vital contribution to our community?

I can say confidently that the coroners I have worked with work tirelessly, and often outside their working hours, to deliver the best possible service, but the limitations on them are of concern. Although coroners are doing their level best, they are limited—certainly in Birmingham—in what they can do if they do not have the resources. I hope that the Minister can take that issue away for review and support. I agree with my hon. Friend about the good work that coroners do up and down the country.

There must be training, awareness and sensitivity within coroner services, registrars and local councils. For example, in Birmingham we have a relationship whereby there is a rapid release system as hospitals understand the sensitivities and do their utmost to ensure that a body is released. Unfortunately, to give another example, one family were left grieving because a deceased’s body could not be given to the undertaker at Queen Elizabeth hospital because there was no individual who could do the handover. The family had to wait over the weekend just to get the deceased’s body. We need to look at how we can work across all sectors to ensure that they are properly resourced and we avoid any unnecessary delay.

The lack of resources and coroners across the country has a knock-on effect on the NHS. There is an additional administrative and logistical burden from holding bodies and dealing with families who are getting in contact every hour, many times. That takes staff away from frontline services. Does the hon. Member agree that having the right level of coroner services would reduce the burden of knock-on costs on the NHS?

I agree, but I am conscious of the time, so I will swiftly wrap up my speech.

This is not a partisan issue. It is not even a religious issue. This is a human issue. It affects people of faith and of no faith. No one deserves to wait weeks or longer to say goodbye to those they love. Let us act not just with policy, but with purpose. Let us fund, reform and rebuild a system that respects every community, honours every tradition and puts compassion first once more.

With my own father’s Islamic funeral taking place very recently in Birmingham, I too am very interested in the Minister’s response.

My condolences to you on your loss, Madam Deputy Speaker.

I congratulate the hon. Member for Birmingham Perry Barr (Ayoub Khan) on securing this important debate. I thank him for his emotive speech, and all hon. Members who contributed, representing the views of bereaved families, sometimes including their own. It is appreciated and they have done so dutifully.

The House will be aware that although the Ministry of Justice is responsible for coronial law and policy in England and Wales, it does not have operational oversight of the coronial system. Coroner services are not centralised as part of His Majesty’s Courts and Tribunals Service, and are instead administered and funded through the relevant local authorities for each coroner area. The chief coroner provides judicial leadership for coroners. I take this opportunity, as other Members have, to express my thanks to all coroners, their officers and their staff, as well as the chief coroner and her team for their tireless and expert commitment to their work. We are all extremely grateful to them for the vital service they provide to the bereaved and to the justice system.

Coroners are independent judicial office holders. They are specialist death investigation judges and part of the wider death investigation, certification and registration system. Their statutory duty is to investigate any death of which they become aware if they suspect that it was violent or unnatural in its cause, its cause was unknown, or it occurred in custody or other state detention. They also have an ancillary duty to ensure that, in appropriate cases, action to prevent future death is identified via prevention of future deaths reports.

The needs of the bereaved, particularly where there are faith concerns in respect of a death, should remain central to the coroner process. Both the Lord Chancellor, as a west midlands MP, and I are very aware of local concerns about coroner provision for communities that require swift burial or cremation. Clearly, decisions about the release of the body, including whether to hold a post-mortem examination, are independent judicial decisions for the coroner. However, I know that in many jurisdictions, including in the west midlands, families have experienced real delays. Sometimes, that is because the coroner needed to gather further evidence to support the investigation. I fully understand that, regardless of the reason, delays can cause real distress for bereaved families, particularly when faith requirements are dependent on the timely release of a loved one’s body.

We are working hard to cut delays wherever possible and to ensure that families are properly communicated with and supported throughout the process, particularly so that we can ensure that any religious ceremonies or faith requirements can be met, as they should. There are already a range of measures in place to help guide coroners as to best practice in terms of early decision making once a death has been reported, in order to ensure that families can be given certainty as soon as possible.

The chief coroner has issued detailed practical guidance for coroners in dealing with requests for urgent consideration of a death and early release of a deceased body, including on religious grounds. The guidance sets out that legal framework and states:

“Coroners should pay appropriate respect to those wishes, within the framework of their legal duties and in the context of other responsibilities.”

In addition, the chief coroner has issued guidance on the use of post-mortem imaging, including CT scanning, and on pathology more generally, which emphasises that the family should be kept fully informed throughout. I regularly meet the chief coroner to ensure that we have a shared understanding of the issues with the coroner system, including this one. I am also happy to engage with representatives of faith communities to understand their concerns and to meet hon. Members to discuss the matter further.

As the House will know, the Justice Committee undertook an inquiry into the coroner service in 2021, with a follow-up in 2023-24. The Government responded to the Committee’s letter of May 2024, summarising their findings in December 2024. That letter has been published by the Committee. It is right that our focus should be on ensuring that the bereaved are at the heart of the process. I hope the House will find it helpful if I set out a number of steps that the Government are taking to address the issues raised by the Justice Committee, other stakeholders and hon. Members.

After just a few months in office, in September 2024 this Government implemented the statutory medical examiner system in England and Wales. It represents the most fundamental change to the end-to-end process of death certification and registration in recent times. The new system means that every death is subject either to the scrutiny of a medical examiner or to a coroner’s investigation, thereby fulfilling the long-standing ambition of successive Governments to introduce a robust system whereby all deaths, without exception, are subject to an independent review.

Medical examiners and coroners have distinct roles. The new arrangements will ensure that cases are managed in the right part of the system and that only those deaths that require a judicial investigation are referred to the coroner. That will enable better focusing of coronial resource, which in turn is expected to support the reduction of inquest backlogs and delays. I hope we are already seeing the evidence of that. Just last week, the Ministry of Justice’s coroner statistics were published: 174,900 deaths were reported to coroners in 2024—the lowest level since 1995 and down 10% compared to 2023. That is because, following the creation of the new system, only those who genuinely need to go to the coroner will do so. In addition, 81,200 post-mortem examinations were ordered by coroners in 2024—a 6% fall compared to 2023.

To reduce the burden and time it takes for post-mortems, does the Minister agree that we should use technology, and MRI and CT scans, wherever possible, which will also speed up the release of the body?

I appreciate the hon. Member’s contribution. As I have said, that guidance is there and that equipment is available to coroners if they deem it necessary. Of course, we want to see anything that will help speed up the process for families.

Although we want to wait a full year for the proper data next May, the early evidence is encouraging that the new arrangements are working as intended. Reducing the number of unnecessary cases being referred to coroners means that coronial resources can be focused on the most complex deaths, while reducing the impact and burden on families. It also means that the number of post-mortem examinations that subsequently reveal a natural cause of death may also be reduced, since those cases may be identified by better surveillance and scrutiny much earlier in the process.

More widely, we recognise the concerns expressed by the Justice Committee and hon. Members present about the shortage of pathologists, particularly child pathologists, available to undertake coronial post-mortem examinations. That is a long-standing and complex problem, and its resolution requires a cross-Government approach. I am happy to reassure hon. Members that such an approach is taking place. I am meeting my counterparts in the Department of Health and Social Care to look at how we can fix the issue in the long term. Coroners rely on the pool of pathologists working in the wider medical system, including the NHS, to perform those examinations. We are carefully considering the views of the Justice Committee in its report, as well as the data we have gathered from our call for evidence on coronial pathology, which was issued in late 2023, with a view to publishing a new strategy for improving coronial pathology in due course.

We recognise the impact that inquest hearings are having and are doing all we can to process that backlog as quickly as possible. We will work with the chief coroner to continue to build on the foundation that has been put in place to reduce the time. I know that coroners in the west midlands are well below the national average, as we have already heard. The Black Country coroner area completes inquests in an average of 11 weeks, and Birmingham and Solihull, and Coventry, complete inquests in an average time of 17 and 18 weeks respectively. Bereaved families should not be left waiting longer than is necessary for inquests to be completed.

We are working on a number of areas, including on a guide to make coroner services more accessible. We are considering all we can do and all the recommendations, and I am happy to come back to the House in due course. We will work with the chief coroner on the content of all material, and to reinforce the use and dissemination of these guidance documents.

The hon. Member for Birmingham Perry Barr spoke about MPs making representations, MPs are elected to this House to represent their constituents, and they should be able to do so. I will raise his point with the chief coroner when I meet her soon.

I recognise the concerns expressed today, as well as the wider concerns expressed by the Justice Committee and other stakeholders, about the importance of an effective coroner service. We will continue to do all we can to ensure that the system continues to put its focus on finding answers on behalf of the deceased, that bereaved families are always at the heart of the process, that lessons are learned from any death and that this learning is disseminated as quickly and as widely as possible to protect the public.

Question put and agreed to.