Chief Coroners’ Guidance 49: New Guidance for Major Incidents

CHIEF CORONERS’ GUIDANCE 49: NEW GUIDANCE FOR MAJOR INCIDENTS

Inquests are by their very nature a time and resource intensive process.

There are many questions that the coroner must address ranging from scope, Article 2, disclosure, and the identification of interested persons to name a few. Reaching that final stage of holding the inquest itself requires an extensive investigation by the coroner including gathering evidence, identifying witnesses, and determining what will be relevant at the eventual inquest. The inquest itself may take several days, hearing from many witnesses, and providing sufficient opportunity for the interested persons to ask questions or make submissions.  

Compare that process with the tragic event of a major incident. This presents as a fast moving and ever-changing picture. The intense process required in even a single inquest is multiplied. There will be extensive multi-agency involvement up to a national level. The families of those who have died as well as the wider public will be seeking answers.

How can a balance be struck between the necessary need for a methodical process against that fast moving picture?

LESSONS FROM THE PAST

How the coroner’s courts have dealt with major incidents in the past have been subject to criticism.

In Her Majesty's Attorney General v Her Majesty's Coroner of South Yorkshire (West) and another [2012] EWHC 3783 (Admin), [2012] All ER (D) 175 (Dec) all the original inquests arising out of the tragedy of the Hillsborough disaster were quashed. There were a number of features of those inquests that concerned the Court such as the later revelations on the amendment of police witness statements as well as the decision to place an artificial cut off time on investigating the events on the day of the tragedy.

In R v HM Coroner for Inner West North London ex parte Lockwood Croft et al (1993) 157 JP 985, a judicial review raised allegations of apparent bias (which were rejected) for comments made by the coroner about one of the victim’s family members of The Marchioness disaster of 1989. Several of the coroner’s decisions in the inquests arising were also of concern to the families (whilst themselves not the issue in the judicial review proceedings). This included the decision to hold the inquest into two parts, the decision not to resume the adjourned inquests three years after their suspension for impending criminal matters, and the decision to remove the hands of a number of the victims for identification purposes.

In the later Thames Safety Inquiry conducted by Lord Justice Clarke, several issues relating to the conduct of major incident inquests were highlighted such as the need for families to be informed of their rights to attend or elect representatives to attend post mortems, the need to keep detailed and accurate records, and again the decision to authorise the removal of hands.

What these three examples show is that a major incident event will require a wide range of difficult decisions that need to be balanced against the transparency and desire for answers that the families of those victims of the major incident require.

Statute has since sought to ensure that there are appropriate constitutional functions in place to support the victims of major incidents. Section 35 of the Victims and Prisoners Act 2024 established the role of the ‘Standing Advocate/Independent Public Advocate’ for victims of major incidents whose role it is to advise the Secretary of State, on appointment by the Secretary of State under section 36, and to act as an advocate for victims of such a major incident as to the interests of victims of major incidents and their treatment by public bodies.  The role of an advocate appointed in respect of an incident may include, as defined in section 39, providing support in relation to an inquest or inquiry such as helping victims understand the actions of public authorities amongst other matters. This does not go as far as carrying on a legal activity (see section 39(8)). The effect of this on the inquest process is clear as section 47 of the Coroners and Justice Act 2009 now includes interested person status for a Standing Advocate and for each advocate that has been appointed under section 36(1) in respect of that incident.

How then does the new guidance reflect this renewed focus on managing a major incident in coroner’s courts effectively?

THE NEW GUIDANCE

Guidance number 49, released 04 June 2026, sets out a key framework within which a major incident is addressed. A major incident or a mass fatality incident is defined as:

• An incident involving mass fatalities which is likely to overwhelm existing local procedures for managing facilities and/or;

• An incident which occurs overseas involving the repatriation identification of multiple UK nationals;

• An act of terrorism in the UK where the number of fatalities may be relatively small in number.

On overarching matters, the guidance sets out a clear structure for addressing the major incident. This includes the following:

• Section 1 of the Coroners and Justice Act 2009 will be engaged from the start;

• The coroner with jurisdiction for the deaths shall be known as the ‘incident coroner’ who shall be provided with appropriate resources to manage the incident;

• In the event of an incident engaging multiple coroner areas, a lead coroner is appointed;

• Where necessary, the Chief Coroner will make directions under the 2009 Act for a coroner who is not the coroner under the statutory duty to investigate the deaths to conduct the investigation or for a judge to conduct such an investigation;

• Inquests need to be opened and adjourned as soon as reasonably practicable;

• Coroners will have access to relevant documents such as checklists, a Coroner action cards, and Mass Fatalities Co-ordinating Group (MFCG) agendas ensuring the coordination of the situation;

• The Chief Coroner will ensure that the incident coroner has access to appropriate advice and assistance from one or two members of the Chief Coroner’s Major Incident Cadre.

The incident coroner has several duties which include:

• Activating special arrangements for dealing with mass fatalities which include a Mass Fatalities Co-ordinating Group, chaired by the coroner, involving relevant organisations;

• Making key decisions for dealing with such an event, for example, initiating the establishment of emergency mortuary facilities;

• Taking all reasonable steps to identify the deceased and, where necessary, chairing an Identification Commission;

• Authorising the removal of bodies and ultimately their release or disposal;

• Appointing a supervising pathologist and agreeing a forensic strategy;

• Determining the approach for dealing with the event.

Of particular relevance in the context of the previous criticisms is the fact that the coroner needs to consider the prompt release of information to families and then the public about the identity of those who have passed away including to what extent an indication of identity can be given before the formal identification process is completed. It provides the option for the Chief Coroner and the coroner involved to speak to family members in order to explain the process. The recently established Standing Advocate/Independent Public Advocate also has a role where deployed. The Chief Coroner can liaise with them to provide family members or survivors with appropriate information.  

A CLARIFIED PROCESS

The new guidance sets clear and transparent processes in conjunction with existing legislation and lessons learned from the conduct of previous major incident inquests. It answers the challenge of such a fast moving process with core principles to assist in those difficult decisions for the coroner. It creates avenues to ensure the families remain informed. It reflects a positive step forward in addressing the difficult lessons learned in the past. It creates a clear framework for effective and clear management of such difficult circumstances.

Bryn Auger is a 2nd six civil pupil at Hundred Court Chambers. During his 1st six, he shadowed several experienced members of chambers in inquest matters. He accepts instructions across Chambers’ core practice areas of civil litigation and has a particular interest in developing his inquest practice.

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