I would like to request a copy of the recent review ... · The Lotus Notes database used to...

I would like to request a copy of the recent review carried out by West Yorkshire Police into the coroner's officer’s functions in West Yorkshire, which I understand was completed recently. Please see the attached document. Please see the link below for information relating to your request. https://www.gov.uk/government/collections/coroners-and-burials-statistics. Sickness in the Eastern Area Coroners team was high prior to, and at the point the review was being conducted. This was, in part due to the pressure of increasing volumes of work with staff feeling unable to cope. Due to the additional support and review of inefficient practices the affected staff have all now felt able to return to work. During the review the future position of Dewsbury District Hospital A&E Dept was unclear, however in January 2017 it was confirmed that the Hospital will be remaining open. https://www.midyorks.nhs.uk/justthefacts Unfortunately West Yorkshire Police is unable to provide you with full summary details therefore redactions have been applied by virtue of Section 31(1) – Law Enforcement and Section 40(2) - Personal information. Please see Appendix A for the full legislative explanation.

https://www.gov.uk/government/collections/coroners-and-burials-statistics

https://www.midyorks.nhs.uk/justthefacts

PROTECTIVE MARKED: CONFIDENTIAL

Protective Services (Crime)

Review of the Coroner’s Office Function

INTERIM REPORT

December 2016 PS Crime Business Change Review Team


REVIEW OF CORONERS’ OFFICERS

Executive Summary

A review of the Coroners’ Officers has been commissioned by the Head of Protective Services (Crime) to define the improvements required to ensure the service delivers the optimum quality of service to internal and external stakeholders including bereaved families. There are two HM Coroners in West Yorkshire working from the Eastern Office (Wakefield) and Western Office (Bradford). Senior Coroners’ Officer and Coroners’ Officers are employed by West Yorkshire Police, along with the Court Ushers in the Eastern Area (Wakefield). The Local Authorities of Wakefield and Bradford also provide resources to support the delivery of this function. The function currently sits within the Protective Services (Crime) portfolio. The approach to this Review has focussed on extensive consultation and engagement with staff working within this function, including those employed by the Local Authority, alongside extensive data gathering and analysis to support the evidence based proposals outlined in this Report. The key issues identified included:-

The Lotus Notes database used to document actions in relation to deaths is outdated, unreliable and provides no management information. There is lack of corporacy within both offices as to what and how data is recorded on the system.

Working practices are outdated, predominantly paper based, with photocopying and faxing being common systems to transfer information. Statements are taken in long hand, before being typed. Little use is currently made of existing technology.

It has been identified that by removing non-value added activities through the delivery of process improvements in respect of working practices and optimised use of IT, 2.8 additional FTE capacity has been created across the two offices.

Training is sparse, the majority of which is undertaken ‘on the job’. No reference manuals or visual aids appear to exist.

Benchmarking information, in general, shows a mix of ownership by the Local Authority and Police with concerns by staff of high workloads.

The proposals outlined in this report focus on the opportunities available to improve processes, systems, working practices and the management of demand, along with a number of Target Operating Model options which clearly outline the most effective structures and resource levels to meet current and projected demands and support the delivery of these improvements. The specific recommendations are:-

1. Four new structure options with the required staffing levels and costs to deliver the coronial services in both Eastern and Western Areas.

2. The opportunity to transfer the service to the Local Authority or the CJS Portfolio with appropriate accommodation.

3. The introduction of streamlined working process and practices 4. Coroner’ Officers to use Niche and optimise the use of technology 5. The introduction of a training programme for Coroners’ Officers


CONTENT PAGE NO. 1. Context 4 2. Methodology 5 3. Current Position 6 - 15 4. Findings and Proposals for Improvement

4.1 Realignment of Structures & Resources 4.1.1 Proposal 1 - Options 1 – 4 16 - 32

4.2 Process, Systems, Working Practices, IT and Corporate Ownership

4.2.1 Proposal 2 - Corporate Ownership, Management and Accommodation 33 – 37 4.2.2 Proposal 3 - Process, Systems and Working Practices 38 – 45 4.2.3 Proposal 4 - IT Optimisation 46 – 47 4.2.4 Proposal 5 - Training 48 - 49

APPENDICES APPENDIX A Potential costings for the provision of Usher Services

APPENDIX B Overview of Coronial Duties Undertaken by West Yorkshire Police APPENDIX C University Vocational Certificate in Coroners Law and Admin


FINAL REPORT – REVIEW OF CORONERS’ OFFICERS

1. CONTEXT

West Yorkshire is served by two HM Coroners, Mr Fleming (Western) who is located within the Court Building at Bradford and Mr Hinchliff (Eastern) who is based within a Local Authority Building at Northgate, Wakefield. HM Coroners are independent Judicial Officers who hold Office under the Crown but are appointed and paid for by the Local Authority. Both HM Coroners are supported by staff from the Local Authority who are co-located with them. In the Eastern Area, the HM Coroner has a number of staff providing administration and case management support. Whilst in the Western Area the HM Coroner only has administration support. West Yorkshire Police support the HM Coroners by providing Senior Coroners’ Officers and Coroners’ Officers and, in the Eastern area, WYP also provides funding for Court Ushers. Appendix ‘B’ provides a breakdown of Coronial duties undertaken by West Yorkshire Police. Senior Coroners’ Officer and Coroners’ Officers Western area are located within the Trafalgar House Police Station at Bradford with the Eastern area staff currently housed in No 18-22 Laburnum Road, Wakefield. There are around 500,000 deaths registered in England and Wales every year with 45% of these deaths reported to HM Coroners. In 2015, the Western Area dealt with 3,114 and the Eastern Area 3,813. (Source: Coroners Statistics, Ministry of Justice). The Department has been subject to a number of reviews in previous years and identified areas for improvement have included improvements to training, the quality of inputs, IT optimisation, workload management and the streamlining of administration functions. However, many of these improvements have not been implemented and a significant amount of the original issues identified still remain. In addition, there has been little in the way of the development and introduction of improved technology (including Mobile data and software applications) to enhance the effectiveness and efficiency of working practices. As a result, in June 2016, the Director of Protective Services (Crime) commissioned a thorough Review of the Coroners’ Officers function. The Review Team would wish to place on record the positive contribution made by all staff involved in or affected by the Review as they have greatly assisted in the identification of the opportunities for improvement which are outlined in this report. To enable any agreed proposals to be successfully implemented, embedded and sustained, it is proposed that consideration be given to the appointment of a dedicated Implementation Manager to drive the improvements required.


2. METHODOLOGY The Review has taken a ‘bottom up’ approach focussed on extensive engagement and consultation with staff at all levels including workshops, one-to-ones, Process Mapping, etc. Significant data gathering exercises have also taken place to ensure a robust evidence base for the proposed improvements. By way of example, an outline of key activities undertaken by the Review Team are listed below. Stakeholder Engagement and Consultation

Interviews with HM Coroners Mr Fleming and Mr Hinchliff.

Consultation meetings with staff at Bradford and Wakefield Council.

Consultation meetings with the Niche Team, Administration Officer Logistics, Superintendent Wallen and DCI Bryar.

Meetings with staff within both Coroners Offices, including Senior Coroners’ Officer, Coroners’ Officers and Ushers

IS and SHOULD Value Stream Mapping workshops, of the current/proposed processes currently employed by Coroners’ Officers with staff from the Eastern and Western offices.

IS Process Mapping of Administration and Case Preparation systems at Wakefield and Bradford Council

Regular update meetings with DI Welbourn – Temporary Manager for Western and Eastern Area.

Data Gathering and Analysis

Staffing levels, financial data, volumes and demands including ‘blood runs’, deaths reported, incoming call data, etc.

Assessment of tasks against required roles and responsibilities.

Process Activity Times in the Eastern and Western Area.

Process Activity Times Wakefield and Bradford Council

Ad Hoc dip sampling of Part B’s recorded on Lotus Notes database. General Research and Analysis

Existing / Proposed legislation.

Ministry of Justice, Coroners Statistics.

Observational research of activities undertaken and process times gathered.

Administration tasks including frequency and timings.

Benchmarking including visits to Greater Manchester, Nottinghamshire & North Yorkshire

An Equality and Human Rights Assessment (EHRA) has also been developed in liaison with HR Professionals. Benchmarking A benchmarking exercise has been undertaken with a questionnaire forwarded to 22 Forces / Local Authorities with seventeen responses. Data provided is contained within each relevant proposal. Visits have also been made to Nottinghamshire, Greater Manchester and North Yorkshire.


3.2 Key Roles and Responsibilities The Senior Coroners’ Officer is responsible for the day to day management of the Coroners’ Office whilst providing the ‘interface’ between the Coroners’ Officers and the HM Coroner. The role has responsibility for developing working practices and procedures. This role does not usually carry a workload in relation to deaths reported. Coroners’ Officers receive deaths reports and undertake the required activities necessary to investigate the death and advise the HM Coroner accordingly. This can include liaison with GPs, hospitals, relatives and obtaining statements. Ushers Only the Eastern Area currently employed staff in the roles of Ushers. During Court, their duties include:

Meeting and greeting family

Check their preferred method to give evidence under e.g. bible, Koran

Managing tape recordings during an inquest,

Sorting out stationery for use by Jurors

Swear the jury in

Care for the jury members including refreshments, ensuring expenses claims are complete for Local Authority administration to process

Reading out the opening and closing proclamations.

Deal with requests from HM Coroner e.g. photocopying, further documentation

Explain the process of obtaining death certificate at the end of court. Other duties include:

Carry out PNC checks for jury staff

Check witness/family/availability and submit calendar to Court Manager (Local Authority)

Prepare and send out summonses to witnesses

Chase up witnesses who have failed to acknowledge they are attending.

They also undertake tasks associated with warning witness including PNC checks for potential jurors. The PNC checks are undertaken on behalf of the Court Manager (Local Authority) to enable him to decide if they are suitable as jury members. If this task was retained, the PNC Bureau should be approached to undertake these checks. Interestingly, no PNC checks are undertaken in the Western Area by neither the Coroners’ Officers (who undertake the Usher role in the Western Area) nor the Local Authority. The duties that Ushers undertake are solely to support the HM Coroner in his role regarding Inquest Courts. The Ushers work from the two Coroners’ Courts, (with the Court Manager) based within the Local Authority building at Northgate, where the HM Coroner and his staff are also located. The Review Team felt that, as the work of Ushers is to support the HM Coroners Court process, these posts would be more suitable under the control and budgetary responsibility of the Local Authority. Ushers had previously assisted in the Coroners’ Office at Laburnum Road by answering telephone calls and collecting and distributing mail. These tasks have been included in the role of Clerical Officer and would no longer be undertaken by Ushers. Death Reports Reports of death are received into the office from Hospitals, Hospices, GP’s and Police, via phone, email or Niche. These will then be processed and fall into the following categories:-


The Force average sickness level for 2015/16 is 3.21% of available hours. The abstraction rate for annual leave is currently three Coroners’ Officers at any one time (adhered to in both Offices) however, should staffing levels drop through sickness, this figure would be reviewed and leave granted on an individual basis. Eastern Area Office – Initial mitigating actions to address staffing Issues In respect of the high sickness levels being experienced in the Eastern Office prior to and during the completion of this Review and the impact on workloads and levels of service, mitigating action was taken by Detective Chief Supt Rowley as Head of Protective Services (Crime) to address this issue by providing additional staff to support the Eastern Office to deal with levels of demand. This included the temporary secondment of PSC Police Staff (Investigation Officers from HMET) to assist Coroners’ Officers along with the provision of additional administrative support (Agency Staff) thereby ensuring continuity of service provision to both the HM Coroner and members of the public. In addition, to provide additional supervisory support and guidance, Detective Inspector Andy Welbourn has been temporarily seconded as Manager for both Eastern and Western Offices. He has also taken the responsibility as first line Manager for the Senior Coroners’ Officer, temporarily removing this role from DCI Bryar. To provide further support to staff in the Eastern Office and alleviate the pressure being placed on them, the Review Team immediately ensured that they worked with these staff to identify a number of interim process improvements that would provide some initial enhancements to the efficiency and effectiveness of their local working practices and provide them with additional capacity to concentrate on core responsibilities pending the outcomes of this detailed Review. A number of reviews of the Coroners’ Office have taken place over the last several years, with no real evidence of any significant improvements actually being delivered. This has been reported as a contributory factor to a reduction in staff morale and current levels of sickness, particularly in respect of the Eastern Office. Volumes and Demands Number of telephone calls & deaths recorded per month The Review Team sought to analyse the volume of phone calls and death notifications coming into each area on a monthly basis. The chart below shows the number of deaths recorded per month. It is important to note that on occasions, due to abstractions, there have been delays in updating the Lotus Notes database.


The Senior Coroners’ Officer (Cate Booth) sits on the Home Office Working Party on behalf of West Yorkshire Police. She reports that the direction of travel around MEs is still in its infancy and at the moment this piece of work is not a priority for the Government. DOLS – Deprivation of Liberty Safeguards This piece of legislation was introduced in 2015. The predicted trend is that these will increase and are time consuming to complete. The whole process around DOLS is currently subject of discussions between the Deputy Chief Constable of West Mercia and the Government as to whether they add any value. Local Authorities are involved in approving DOLS and it has recently come to light that the DOLS office in Bradford Council has not been resourced sufficiently and therefore not feeding these through to the Western area office in a timely manner. Whilst this issue has now been resolved, the Western Area office experienced high workload dealing with the backlogs. Data for the upward trends have been included in the data analysis to inform the Resource Models for the four structural options outlined in this Report. Benchmarking A benchmarking exercise was undertaken which focussed on structures, staffing levels and working practices. Out of the 17 Area benchmarking requests circulated, only eight areas responded, which are detailed below: Gloucestershire Local Authority employ 5.05 FTE Coroners’ Officers and dealt with 2,160 deaths in 2015. (MOJ figures). Kent Local Authority are split into 4 areas. Altogether they employ 17 Coroners’ Investigation Officers, 1 Coroners’ Inquest Officer, 6 Coroners’ Court Officers, 7 casual Coroners’ Court Officers and 2 additional agency staff working full time to deal with the backlog of archiving and 1 agency staff who manages inquest files of staff that have left so not to burden the new recruits. They also have the use of Coroners’ Court support service in all 4 Coronial areas. This is a registered charity who provide volunteers to attend HM Coroner Courts to support witnesses. They have a management team of 2 Coroners’ Office Managers, 1 Contracts & Project Officer.

Central and South East Kent dealt with 1,559 deaths in 2015.

Mid Kent and Medway dealt with 2,233 deaths in 2015.

North East Kent area dealt with 1,974 deaths in 2015.

North West Kent dealt with 1,668 deaths in 2015.

Total deaths for Kent was 7,434.

Blackburn Police employ 3 FTE Coroners’ Officers and 1 FTE and 1 PT Coroners Staff (LA). They dealt with 2,162 deaths in 2015. Hants Local Authority are split into 3 areas. Altogether they employ 1 FTE Office Manager, 3 FTE Coroners’ Officers, 1 PT Coroners’ Court Officer (4 days per wk.) and 3 FTE for a Death Report team (admin support).

Central Blackburn dealt with 1,438 deaths in 2015.

South East dealt with 3,215 deaths in 2015.

North East dealt with 1,429 deaths in 2015.

Total deaths for Blackburn was 6,082


Greater Manchester Police employ 4 FTE Senior Coroners’ Officers, 24 FTE Police Coroners’ Officers. These are split between 4 area Hubs each covering 3 divisions. The Local Authority employ its own Coronial staff to deal with administration, court duties and some death reports (Part A, Part B, Out/Into England)

Manchester City dealt with 3,195 deaths in 2015.

County of Greater Manchester dealt with 3,087 deaths in 2015.

Greater Manchester South dealt with 3,102 deaths in 2015.

Greater Manchester West dealt with 4,263 deaths in 2015.

The total deaths for Greater Manchester was 13,647. Lincolnshire Police employ 6 FTE Coroners’ Officers.

Central Lincolnshire dealt with 2389 deaths in 2015.

South Lincolnshire dealt with 1,308 deaths in 2015.

The total deaths for Lincolnshire was 3,697. Bournemouth/Dorset Local Authority employ 1 FTE Senior Coroners’ Officer, 6 FTE Coroners’ Officers and 2 Secretaries for the HM Coroner. They dealt with 4,195 deaths in 2015. Hertfordshire Local Authority employ 1 FTE head of services, 1 FTE Senior Coroners’ Officer, 4.6 FTE Coroners’ Officers, 2 FTE Senior Support Officers and 1 FTE Support Officer. They dealt with 3,050 deaths in 2015. As can be seen from the above information, there are different approaches to staffing levels across the different HM Coroner Areas. Some of which are Local Authority only e.g. Kent and Hertfordshire and other (Lincoln, Greater Manchester) are both Local Authority and Police. Whilst Kent appear to be highly resourced they do cover a large geographical area. Greater Manchester Police Coroners’ Officers only dealt with Investigations and Inquests as the Local Authority administer all Part A, Part B, Out and Into England deaths.


4. FINDINGS AND PROPOSALS FOR IMPROVEMENT 4.1 REALIGNMENT OF STRUCTURES AND RESOURCES

The four options detailed below provide a range of structures to deliver the services required, together with the staffing levels which meet current and projected demands with an outline of any projected costs / savings.

4.1.1 PROPOSAL ONE:

To implement a new structure to deliver the Coronial duties with the appropriate staffing levels and role profiles.

In line with the significant opportunities to improve the efficiency and effectiveness of current processes, systems and working practices, 4 Structural Options have been developed which have the capacity and capability to deliver these changes. These options also ensure resources are in place to meet current and projected demands and that roles and responsibilities are carried out at the most appropriate level. For example, each option outlined introduces a dedicated Scale 3 post to provide clerical support to each Area Team thereby removing this burden from Coroners’ Office Staff. The staffing levels in each Option have been determined through a detailed and thorough analysis of volumes and demands, projected to 2017 which has included frequencies of ‘death types’ from various sources including the Ministry of Justice Coroners Statistics, Wakefield and Bradford Local Authorities, Lotus Notes and Niche databases and the IT Department. It has also included key demands such as phone calls and the number of deaths received via Niche and electronic transfer. Alongside this, the projected staffing levels have also been informed by a significant activity analysis exercise undertaken with Eastern and Western Area staff in respect of timings for both the current ‘IS’ and proposed ‘SHOULD’ Process. The projected staffing levels for the SHOULD Process also reflects the additional capacity created through the implementation of improved working practices, optimisation of digitisation opportunities (IT) and the removal of non-value added activities which has resulted in 2.8 FTE equivalent Coroners’ Officers capacity being identified within the Eastern and Western Area Office (0.9 Eastern and 1.9 Western). In addition, Option 1, 2 and 4 includes the introduction of Coroner’s Support Officer Posts. This being a dedicated support function whose role would be to obtain statements by either telephone, email, 3rd party (20%) Station Appointments (20%) and Home visits (60%) and scan documentation and update Niche. Again, this would provide dedicated support to the Coroner’s and Senior Coroner’s Officers. It is considered that both the Western and Eastern Offices would be required to adopt the same structural Option – only the staffing levels would differ reflecting the differences in demand. Several meetings have taken place with Temporary ACC Rowley as well as meetings with T/ Detective Chief Superintendent Ridley to discuss the findings of this Review and the Resource Allocation Model Options, each developed as a result of extensive modelling work and the reengineering of working practices within the Units. Option One has been identified as the Preferred Option. Specifically In respect of Preferred Option One, T/ACC Rowley has asked that the Wakefield (Eastern) Office be allocated additional staff as he feels that there is significantly more work to be undertaken to change current working practices and improve the culture, welfare and morale within this Unit. Sickness levels are still high in this office and work is ongoing to support individuals in coming back to work. He feels the additional staff will assist in easing the transition to the New Operating Model and takes the view, that once the new working practices are embedded, a reduction in the staffing profile based on natural wastage will be achievable.


The following provides a high level summary of the 4 Structural Options that have been developed to ensure staffing meets demands and Operating Models are in place which support the delivery of identified process improvements. Option 1 – This is the preferred Option where the Coroners’ Office will be ‘split’ into two section – front and back office. The front office would have responsibility for processing deaths in relation to Part A, Part B, Out and Into England and Transfers. Investigations/Inquests would be the responsibility of the back office. The roles include Senior Coroners’ Officer, Coroners’ Officer, Coroners’ Support Office and Clerical Officer. Option 2 – As Option 1, the Coroners’ Office will be ‘split’ into two section – front and back office. The front office would have responsibility for processing deaths in relation to Part A, Part B, Out and Into England and Transfers. Investigations / Inquests would be the responsibility of the back office. Roles would include Senior Coroners’ Officer, Coroners’ Officers and Coroners’ Support Officer. As there is no Clerical Officer in this option, this work will be undertaken by the Coroners’ Support Officer. Option 3 - Is based on the current structure of Senior Coroners’ Office and Coroners’ Officers undertaking the investigation of deaths including obtaining all statements. However, the introduction of a Clerical Officer post has been introduced to undertake administration duties. Option 4 – Includes the roles of Senior Coroners’ Officer and Coroners’ Officer. The role of Coroners’ Support Officer is introduced who will have the responsibility of obtaining all statements. A Clerical Officer post has been introduced to undertake administration duties.


Projected Benefits:

By dividing the work between the front and back office, the Coroners’ Officers will know what type of death they will be dealing with from the outset and be able to move quickly through their workloads knowing what is required. It will also allow Officers to concentrate their efforts in one area resulting in a more effective service to the public and HM Coroner.

The role of Scale 4 Coroners’ Support Officer provides a ‘pathway’ to the progression of the Coroners’ Officer role.

The role of Clerical Officer will be introduced to undertake general administration duties including answering incoming telephone calls, updating systems, dealing with Undertakers etc. This will free up 0.83 FTE equivalent Coroners’ Officers capacity across both offices, to focus on their core role.

The Senior Coroners’ Officer will continue to undertake supervisory function for staff, including training, allocation of workloads and finalisation, liaison with Local Authority and staff development and guidance

The tasks associated with providing Ushers duties at Bradford Court are removed from Coroners’ Officers in the Western Area. The Local Authority would be responsible for providing resources to undertake these tasks.

Removing the Usher function from the Coroner’s Officers in the Western Office increases their capacity for them to deliver their core role and perform duties at a level commensurate with their grade – Coroner’s Officers being Scale 6 and Ushers being Scale 3.

The role of Ushers, currently in place in the Eastern Office should become the budgetary responsibility of the Local Authority as this would remove unnecessary tasks that have no benefit to WYP.

Projected Risks:

Potential additional costs of £36,888. (However, as noted, once improvements have been delivered in the Eastern Office, potential to realign staffing levels in line with demand.)

Wakefield Local Authority may not be willing to take on the budgetary responsibility for an additional 2.5 Usher Posts and Bradford Local Authority may be unwilling to accept the budgetary responsibility for providing 1 x Usher to remove the current process of a Coroners’ Officer undertaking the function. However, in mitigation, CCSS) informed the Review Team that if Coroners and Local Authority wanted them to carry out the Usher Role, they were capable of doing so and would be open to discussing this possibility.

The only task undertaken by Ushers (Eastern) which would need to remain within West Yorkshire Police would be undertaking PNC checks of potential Jurors.

Effective supervision needs to be in place to manage workloads / annual / flexi leave to ensure optimise the use of resources in line with levels of responsibility.

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Removing the Usher function from the Coroner’s Officers in the Western Office increases their capacity for them to deliver their core role and perform duties at a level commensurate with their grade – Coroners’ Officers being Scale 6 and Ushers being Scale 3.

The role of Ushers, currently in place in the Eastern Office should become the budgetary responsibility of the Local Authority as this would remove unnecessary tasks that have no benefit to WYP.

The tasks associated with providing Ushers duties at Bradford Court are removed from Coroners’ Officers in the Western Area. The Local Authority would be responsible for providing resources to undertake these tasks.

The role of Scale 4 Coroners’ Support Officer provides a ‘pathway’ to the progression of the role of Coroners’ Officer role.

The Senior Coroners’ Officer will continue to undertake supervisory function for staff, including training, allocation of workloads and finalisation, liaison with Local Authority and staff development and guidance

Projected Risks:-




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The Senior Coroners’ Officer will continue to undertake the supervisory function for staff, including training, allocation of workloads, liaison with Local Authority and staff development and guidance

There are currently 2.5 FTE Ushers employed within the Eastern Area. These posts should become the budgetary responsibility of the Local Authority. In the Western Area there are no staff currently employed as Ushers therefore, Coroners Officers undertake Usher duties at Bradford Coroners Court. These duties should also become the budgetary responsibility of the Local Authority. It should be noted the timings of Ushers duties undertaken by Coroners’ Officers have not been included in the proposed staffing levels.

Projected Risks:-




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from Coroners’ Officers. This will free up 0.83 FTE equivalent Coroners’ Officers capacity across both offices, to focus on their core role

Statement taking will be undertaken by Coroners’ Support Officer thereby providing a timely service to families and the HM Coroner.

The introduction of the Coroners’ Support Officer could be seen as a career path within the Coronial function

There are currently 2.5 FTE Ushers employed within the Eastern Area. These posts should become the budgetary responsibility of the Local Authority. In the Western Area there are no staff currently employed as Ushers therefore, Coroner’s Officers undertake Usher duties at Bradford Coroners Court. These duties should also become the budgetary responsibility of the Local Authority. It should be noted the timings of Ushers duties undertaken by Coroners’ Officers have not been included in the proposed staffing levels

Projected Risks:-




4.1.2 Structural Options – Impact on Role Profiles Staff informed the Review Team during consultation that they did not feel their current role profiles reflected the tasks they were undertaking. They feel they are not investigating deaths, just collecting information. In line with the improvements identified to current working practices, processes and systems and the structural options proposed, analysis has been undertaken of the current Role Profiles to identify the impact on the proposed changes and ensure the high level key outputs adequately reflect the requirements of the roles. It has been established that the Coroners’ Officer Role profile needs to be rewritten as it included a number of tasks they no longer undertook prior to the commencement of this Review or the changes required as a result of this Review i.e. attending the scene of deaths and post mortems. In the Eastern area, Coroners’ Officers are no longer responsible for the dealing with jurors / relatives at Court as this task is undertaken by Ushers. In the Western Area, the Local Authority do not employ Ushers and the Coroners’ Officers undertake these tasks. This removes them for undertaking their core role and perform duties at a level commensurate with their grade. Coroners’ Officers are Scale 6 (£31,140) and Ushers are Scale 3 (£22,284). Analysis of the tasks undertaken by Ushers has been carried out in order to identify which activities are solely undertaken for the Local Authority Coronial Service and which are for the Police. It is felt that the majority of the tasks undertaken by the Ushers would be better aligned to staff employed within each Local Authority. In the Western Area, a Coroners’ Officer is abstracted each day to undertake this role. Typical tasks carried out by the Ushers include meeting and greeting family, sorting out stationery for use by the jurors, ensuring that any claims forms are submitted, any photocopying required by the HM Coroner etc. The only task that would need to be retained within the Police Service relates to PNC checks for Jurors on

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behalf of the Court Manager (Local Authority) to enable him to decide if they are suitable as jury members. If this task was retained, the PNC Bureau should be approached to undertake this task. Interestingly, no PNC checks are undertaken in the Western Area by either the Coroners’ Officers (who undertaken the Usher role in the Western Area) nor the Local Authority so it could be questioned as to why one Coroner requires this information and the other does not. Coroner’s Office Roles - Key Outputs It has been recognised within this Review that the improvements identified and structural Options developed will have an impact on current Role Profiles and that, dependent on the structural options chosen, they will require amendment to a greater or lesser degree to reflect the work the postholder will undertake and the levels of responsibility. The only post that will fall into this category is the Coroners’ Support Officer Role. In Option 2 there is no Clerical Officer post and the Coroners’ Support Officer would be responsible for these tasks. This has been built in to the Resource Model for this Option. However, levels of responsibility for each role remain broadly the same. The following initial high level key outputs have been identified for each role within the Options outlined. Further work will be required with HR to develop into detailed Role Profiles. Senior Coroners Officer

To manage the day to day work of the staff within the Unit.

To manage the performance and welfare of staff within the Unit.

To review, assess and allocate deaths and ancillary tasks in order that the necessary documentation and enquiries can be made to facilitate the HM Coroner in providing a cause of death.

To ensure that staff undertake investigations in line with the HM Coroners instructions which will enable the HM Coroner to discharge their duties effectively.

To finalise and review all deaths that are dealt with by their staff.

Ensure that the training needs of internal and external customers are assessed in relation to Coronial issues. Where necessary, plan, prepare and deliver bespoke training packages.

Coroners’ Officer

Receive and process death notifications ensuring that the necessary paperwork is completed to support the role of HM Coroner.

Liaison with bereaved members of the public, health officials, hospitals, care homes etc. in order to gather and validate information on the deceased person to aid and support any decision making by the HM Coroner.

As directed by the HM Coroner arrange for Post Mortems to be undertaken and liaise with the next of kin regarding the Post Mortem and the results of the same.

Review the contents of any reports in order to ensure that they fully answer any queries raised by the HM Coroner. In addition, identify any discrepancies or areas of investigation that need exploring in order to provide a full and comprehensive service in support of the HM Coroner.

Ensure that all deaths are recorded and managed in a timely manner in accordance with Force guidance.

Obtain statements from next of kin, members of the public, other agencies and organisations as directed by the HM Coroner.

Coroners’ Support Officer

Obtain statements from next of kin, members of the public, other agencies and organisations as directed by the HM Coroner using the appropriate technology available.

To scan documentation and update NICHE.

To deal with general clerical duties including incoming telephone calls, providing advice on the work of the department where appropriate, or redirecting to the right person.


Key: = yes = no S = sometimes F = Forensics PMs

The benchmarking analysis clearly shows that Coroners Offices across a variety of Forces have similar systems and structures in place and reflect those within West Yorkshire. However, one Police area that stood out as being very different was Greater Manchester Police who have had a complete overall of their Coroners’ Office function. In 2012 as a result of the Shipman Enquiry and subsequent Report, carried out their own comprehensive 12 month review. As a result, GMP Coroners’ Officers (Police Support Staff) respond to deaths and investigate at the scene by monitoring open incident logs. On arrival, they will release the Officer in attendance to return to their duties and obtain family statements, ID statements and obtain and seize any evidence required. They are equipped with cameras, radios, vehicles, laptops and some uniform. When they leave the scene, they have everything they need and to put a file together for the HM Coroner. They do not progress Part A’s, Part B’s, Out of England, Into England and Transfers. This is carried out by the Local Authority Coroners’ Officer and Administration Function. When a sudden death is received (via a police report) the Police Coroners’ Officers research police systems to expand the report if necessary for any information held on the deceased and forward this to the Local Authority Coroners’ Officer and Admin staff to progress by contacting Drs / Hospital etc. in relation to presenting the death to the HM Coroner for their decision on an A or B pass.

4.2 PROPOSED IMPROVEMENTS TO PROCESSES, SYSTEMS, WORKING PRACTICES, IT OPTIMISATION AND CORPORATE OWNERSHIP

The following proposals apply to each of the structural options outlined above in that they detail the improvements to processes, systems, working practices, the optimisation of IT opportunities, streamlining and the better management of demand to remove non-value added activities, contributing directly to improving the effectiveness, efficiency and quality of service provided and creating significant increased capacity within the Coroners’ Officer function

The staffing levels above have been predicated on the below improvements being implemented as they provide a significant contribution to the increased capacity created through removal of administration activities from Coroners’ Officers (introduction of administrative support), removal of non-value added activities e.g. investigation work prior to results of Post Mortems, no standardisation of process, optimisation of IT to remove duplication of effort and streamlining of working practices

CORPORATE OWNERSHIP, MANAGEMENT, AND ACCOMMODATION

4.2.1 PROPOSAL TWO: Option One – Corporate Ownership

The Force should seek to progress the TUPE of Coroner’s Office staff to their respective Local Authorities.

Option Two – WYP Portfolio Ownership

Alternatively, should the wish be for staff within either Office to remain under the management and control of West Yorkshire Police, it is considered that they be transferred from the Protective Services (Crime) Portfolio to the CJS Function.


Accommodation

That appropriate accommodation including storage space (dependant the above Options) should be identified for each office

4.2.1.1 Current Position All Senior Coroners’ Officers and Coroners’ Officers and Ushers (Eastern only) are currently employed by West Yorkshire Police and report to their respective HM Coroner. The HM Coroner is also supported by staff employed by the Local Authority. In the Eastern area, administration staff receive forms (email) from Coroners’ Officers, print off and forward to HM Coroner for decisions, update computer systems, receive forms from Mortuary re short cause of death, generate fee sheets for Pathologist, movement of bodies etc., type letters to family and tape recordings from Court and filing. In the Western Area, administration staff sort and distribute post, monitor and print off emails for HM Coroner, filing, update files when originals are received and typing. The Eastern Area also have staff employed to undertake Case Management tasks. These include reviewing HM Coroner requests for information required, ‘chasing up’ documentation from Hospitals and Coroners’ Officers, if no response to chasers forward to Performance/Court Manager to deal with, receive post mortems results and carry out disclosure as appropriate, set review dates and file, type witness lists and forward to Ushers to undertake witness warnings, prepare file ensuring all statements are in order, update tracker computer system. Responsibility for the staff employed by West Yorkshire Police currently sits within the portfolio of Protective Services (Crime). The Coroners’ Officers were previously located in various satellite offices across their District. The Western area had offices in Bradford, Halifax, Huddersfield, Dewsbury and Keighley. Whilst in the Eastern Area, staff were located in Leeds, Wakefield and Pontefract. In November 2015, all Eastern area staff were relocated in Wakefield and in December 2015 all Western area staff were relocated to Bradford. The Western Office is currently located within the Trafalgar House Police Station whilst in the Eastern Area, Coroners’ Officers are based on the top floor of 18-22 Laburnum Road. Both offices do not have sufficient storage space, desks are accommodated in small spaces. The Senior Coroners’ Officer at Bradford is currently using an office ‘on loan’ from the Social Club. 4.2.1.2 Supporting Evidence Corporate Ownership Further to this desire to achieve co-location of staff within the Western Area, Bradford City Council has expressed a clear desire to pursue the TUPE transfer of WYP Coroners’ Office staff to their Local Authority. The Solicitor to the Council has already had a preliminary discussion with the DCI Protective Services (Crime) currently line-managing the function about pursuing this opportunity and the Local Authority have followed this up with a letter to the Chief Constables Office which expressly outlines their interest in pursuing TUPE transfer. In the Eastern Area, Wakefield City Council have taken the completely opposite stance with their Local Authority Solicitor indicating that they have no desire to pursue a TUPE Transfer. However, although the Eastern area HM Coroner Mr Hinchliff, has stated that it would not be his wish to TUPE WYP staff to the Local Authority, he would not rule it out as an option.


Due to the confidential nature and potential impact of this opportunity, staff have not been consulted on or informed of any potential for TUPE Transfer. Until 2008, the Coroners’ Office Function was a Unit within the Criminal Justice Department of West Yorkshire Police. The Review Team could find no evidence as to why the Coroners’ Office (Eastern and Western) were transferred from this Department to Protective Services (Crime). Anecdotal evidence suggests that this was as a result of personality clashes between the HM Coroner and the then Head of CJS. In the 2009 Review of Coroners’ Officers undertaken by DCI Long, he reported that ‘there appears to be no overwhelming reason to transfer the management structure of the Coroners’ Officer Function from CJS’. It is considered that this function sits better within CJS than Protective Services Crime due to its direct links with Case Building, HMCS, and Ministry of Justice etc. and there is also the professional knowledge and expertise within this function to provide better informed line management of staff. Whilst ever the Coroners’ Officers sit under the Protective Services (Crime) portfolio, there is a general conflict of interest. 4.2.1.3 First / Second Line Management The DCI within Protective Services Crime is first / second Line Manager for the Senior Coroners’ Officer / Coroners’ Officers, and as such, required to deal with personal and performance issues and complete their PDR’s. This may involve dealing formally or informally with the poor performance by staff and the next day, in their DCI / SIO role, having to deal with the same members of staff who are dealing with their case. Due to the issues being experienced in the Coroners’ Office Function and escalating workloads within PSC, from July 2016, temporary arrangements were put in place for DI Welbourn (Protective Services Crime) to be seconded to the Unit to act as direct Line Manager for the Senior Coroner’s Officers, thereby allowing the DCI to focus on the duties of a Senior Investigating Officer. Should the function remain within West Yorkshire Police, in order for the most appropriate level of support to be provided to HM Coroners and WYP employed staff, it is essential that the role of first / second line manager has sufficient time within their portfolio to manage the coronial functions across the Force. With the introduction of NICHE, the Senior Coroners’ Officers will be more accountable in managing the workloads of the HM Coroners on a day to day basis and managing the teams to ensure an efficient service is provided. It may be appropriate to consider a postholder, who could work with both HM Coroners, ensuring consistency of approach and agree deliverables for West Yorkshire Police, whilst providing the Senior Coroners’ Officers with some level of consistency from a management perspective and assist in building and maintaining corporate memory around coronial issues. These general supervisory duties could include:-

To act as the SPOC between WYP and the HM Coroners within the West Yorkshire Police area ensuring that service delivery is not only maintained but is efficient and effective

To progress and deal with any areas of concern raised by either WYP or the HM Coroner in relation to Coronial duties

To ensure that corporate methods and standards are used for the recording of deaths within West Yorkshire and that IT solutions utilised are fit for purpose

To manage the Senior Coroners Officers

Liaison with SIOs where there are delays in file submissions

Ensure that management data is available that meets the needs of the organisation


Should the function be transferred back to its original portfolio of CJS, it is suggested that a current member of the CJS SLT should undertake the role of first / second line Manager providing additional support in respect of the knowledge and expertise in file preparation. The advantage of this would be overall management with direction and control whilst providing management resilience and corporate memory. It would also reflect the corporate management structure in place before the transfer to PS Crime, which as has been indicated, had no clear rationale to support the transfer. If the Coroners’ Officers remain under the jurisdiction of Protective Services (Crime), a decision will be required regarding which function they should reside under and who will be first / second line Manager with sufficient time and professional knowledge to undertake the role. Should the Local Authority agree to TUPE staff, it will be within the remit of the relevant Local Authority to determine effective and appropriate line management arrangements. 4.2.1.4 Benchmarking Of the seventeen Forces who responded to our requests for information, eight (47%) said the Local Authority now had responsibility for the function of Coroners’ Officers. At the Coroners Conference, held in Milton Keynes, attended by members of the Review Team, some delegates who had already transferred to the Local Authority said they were initially apprehensive regarding the move but stated it had been for the better and much improved the overall service provided engendering joint working. Of those respondents whose function remained within the Police Service, there was a general mix of corporate ownership including Crime, CJS and LPT. However, some of their Crime Portfolios contained a wider mix of functions than those within West Yorkshire Police for example, their Criminal Justice Support functions were located within these Departments. 4.2.1.5 Accommodation Eastern Area Should the function remain within WYP, enquiries have been with HQ Estates about the use of additional ground floor accommodation in 18-22 Laburnum Road. HQ Estates have stated that the present occupants will be moving out and the accommodation will be available from December 2016 and could be utilised by WYP Eastern Areas Coroners’ Office. However, recently Wakefield District Council have offered accommodation at Northgate, Wakefield which also houses the HM Coroner, Assistant Coroner and the Local Authority - H M Coroner’s Service. This would provide co-location required by the Coroner irrespective of the decision regarding TUPE Transfer. Western Area The Western Area Office is currently located at Trafalgar House Police Station. HM Coroner Mr Fleming has indicated that he would like the Coroner’s Staff to be co-located to enable joint working. Their current accommodation is Ministry of Justice owned and inappropriate for visitors to enter through a Criminal Court building to get to the Coroner’s Court. Halifax Magistrates Court has recently closed and although no firm offers have been made, it was seen as a location with significant potential to provide the accommodation required in terms of capacity and geographic location, being equidistant across the area covered. However, it has been indicated that Bradford City Council would prefer the function to remain within Bradford. Again, should TUPE Transfer be progressed, this is something to be decided by the Local Authority.


4.2.1.6 Projected Benefits and Risks Projected Benefits:- Transferred Ownership

Responsibility transferred from the Police to the Local Authority which reflects the fact it is predominantly a Local Authority function.

Will ensure co-location of all staff involved in supporting both HM Coroners.

Will address the request to the Chief Constable by Bradford City Council for transfer to be progressed within the Western Area.

Improved and better aligned working practices by being one Team, thereby eliminating any further potential for duplication of effort, etc.

Optimisation of resource usage by pooling LA and WYP Staff. Portfolio Transfer to CJS

Provides a firewall in place to remove conflict of interest.

File preparation is a core function of Criminal Justice Unit and also the Coroner’s Function therefore would encourage the sharing of expertise and knowledge and provide effective, knowledgeable and professional CJS expertise at a supervisory and senior management level.

Opportunity for appropriate first / second line management to be in place for Senior Coroners’ Officer/Coroners’ Officers to ensure the appropriate management, guidance and direction of staff.

The Criminal Justice Department has strong links to the Ministry of Justice and oversees the implementation of any changes that affect the Police via MofJ, HMCS etc. which will impact directly on the Coroner’s function.

Will address the issue of conflict of interests in respect of Protective Services Crime – Line Management V Case Management issues.

Accommodation – Co-location

Improved working space for fully co-located staff together with appropriate storage space by co-locating within Northgate (Eastern Area Office) and Calderdale Court (Western Office)

Meets Health and Safety requirements.

Projected Risks:-

Transferred Ownership

If both Units are not the subject of TUPE could have a two tier system in place e.g. one within WYP and one with the LA which could impact on the advocated corporacy of approach.

No initial indication from Wakefield District Council that they would support a TUPE Transfer at this time.

HM Mr Hinchliff (Eastern Area) prefers the current Model of ownership but would consider any future options.

Portfolio Transfer to CJS

Although no formal discussions have taken place with CJS regarding this Proposal, they may not wish to take back the supervision of the Coroners Function. However, this proposal is subject to a decision regarding TUPE.

Accommodation

Alternative accommodation proposals outlined above, dependent on agreement between the Local Authorities and the Coroners as to which is the most appropriate and any decision on TUPE.


PROCESSES, SYSTEM AND WORKING PRACTICES 4.2.2 PROPOSAL THREE:

To establish improved and streamlined processes, systems and working practices within the Coroners’ Offices. Specifically the improved process will:-

Introduce a corporate, efficient and standardised approach to supporting the work of the Coroners.

Maximise the use of Niche – will be used for allocation, tasking, file building, finalisation and management information.

Introduce Statement taking undertaken either by: o Telephone / email / 3rd person o Station appointments o Home appointments

Make effective use of technology including agile laptops to record information whilst obtaining statements at home and at station appointments.

4.2.2.1 Current Position This proposals also links with 4.2.3 below regarding IT Optimisation. The current working practices are outdated, labour intensive and lack corporacy. They also make ineffective and inefficient use of resources. To understand the working practices currently undertaken in each area, the Review Team held ‘IS’ process mapping sessions with staff. This highlighted a number of inefficient and time consuming activities with little or no standardisation of working practices (within or across the Units) with everyone working differently and very little use of technology. At the invitation of Wakefield Council (Coroners Services) the Review Team were asked to process map their Case Management and Administration processes. This work was also replicated with HM Coroners Administration service at Bradford Council. Due to the high number of abstractions being experienced in the Eastern Area office, the Head of Protective Services (Crime) seconded Detective Inspector Andy Welbourn to assist in the management and overview of both the offices. He has also taken second line management responsibility for Coroners’ Officers and first line for Senior Coroners’ Officers. Under his guidance and liaison with the Review Team, a number of ‘quick wins’ have already been introduced to improve the efficiency of the office and the quality of services provided to families. ‘Should’ mapping sessions were held in both Districts to identify a corporate process which designed out the inefficiencies and incorporated the optimum use of technology. This also included the identification of any tasks which were being undertaken by the Coroners’ Officers and could be carried out by another role e.g. Clerical Officer. During these mapping sessions, staff were asked, using their professional judgement, to identify the minimum and maximum times each activity would take. These times have been used as part of resource modelling activities that informed the development of the Resource Model Options presented earlier in this document. Coroners’ Officers currently use Lotus Notes to document the recording and investigation of deaths that have been reported to the HM Coroner. This is an outdated system which is no longer fit for purpose. The system provides no management information.


Bereaved families receive a short guide regarding the service when they first contact the office. Relatives frequently contact Coroners’ Officers for updates and requests for further information. This short guide, perhaps because of the bereaved family’s feelings, has never been reviewed regarding its value. Whilst considering the feelings of recently bereaved families, Coroners’ Officers, on their final contact with them, could ask if the guide had been of value. Depending on the results, appropriate changes / updates could be made. This may assist in reducing the number of general telephone enquiries from bereaved families. To deal with the telephone demands in the Eastern Area, a temporary agency clerical staff member has been employed to allow both the Senior Coroners’ Officer and Coroners’ Officer to concentrate on their core duties. The appointment of a Clerical Officer (Proposal 4.1) will undertake this task on a permanent basis. Data for reporting deaths via phone has been feed into the Resource Models. Allocation of Resources Originally, an A4 book was used to record deaths received (either by phone or F49). The deaths were allocated to Coroners’ Officer on a rota basis irrespective of the death type and the complexity of the death and how long it takes to complete. This meant there was no fair allocation of workloads to Officers. This process has now been removed and as a temporary measure an excel database has been designed for use by the Senior Coroners’ Officer, who records details of deaths and type allocated to each Coroners’ Officer in a fair and equitable manner. This system will be replaced when Niche is introduced. Request for decisions from HM Coroner

During the IS process mapping workshops, staff discussed the process that was in place to acquire HM Coroners’ decisions. The Coroners’ Officer would type on paper, what information they required and placed this in a folder. At 9am /12 noon/3pm the Senior Coroners’ Officer would scan the papers from the folder to her own email then email all the papers to Northgate. She would then shred the hardcopies. Northgate would print these off, place a decision sheet on for HM Coroner to write and sign with his decisions. Northgate would scan the papers back to CO Mailbox where they were printed off and given to relevant Coroners’ Officer. This process was very time consuming and a waste of resources. Again, as a temporary measure, the system has now been replaced by using the facility scanning to email. Each ‘scan’ can be opened and sent to the relevant Coroners’ Officer by dropping it into their folder on Outlook. Again, this system will be replaced by the introduction of Niche Requests to and from Northgate to Coroners’ Officer Again, during IS Mapping workshops, staff stated they received details from the HM Coroner regarding his requirements and decisions but found it difficult to read his handwriting which resulted in mistakes. Through consultation with Northgate, they have agreed that they will provide a typed version. Dates for Investigations / Inquests Coroners’ Officers said they were not always aware of forthcoming dates for the above and the planning this can involve. Through liaison with the Local Authority, they have agreed to create a diary entry which places a notification of the review date in the Coroners’ Officers diary. 4.2.2.3 Proposed New working practices Tasks undertaken whilst waiting results of Post Mortem


Some Coroners’ Officers informed the Review Team that they felt time was being wasted by undertaking unnecessary tasks on behalf of the HM Coroner when an investigation had been opened but before the results of the Post Mortem were known. When the results were received that identified a natural death, the investigation would be discontinued and the paperwork filed. A dip sample was undertaken using the Coroners’ Officers Lotus Notes database to examine all Part B’s recorded for both Eastern and Western Area in 2015. The recorded deaths that had taken longer than fourteen days have been examined and checked for any further investigations carried out (other than family statements). The results displayed: Eastern Area had a total of 828 deaths recorded that required at Post Mortem. Of these, 98 (12%) deaths showed more tasks had been undertaken over and above the family statements. This is an average of 3.5 tasks per death. The majority of these were requests for GP/Drs reports, toxicology, Police Reports or Statements, CSI photographs and Identification. These requests had been made either by phone or email by the Coroners’ Officer. In the Western Area, 955 deaths were recorded as requiring a Post Mortem. Out of these 44 (4.6% showed more tasks had been undertaken. This is an average of 1.6 per death. This low figures can been attributed to the HM Coroner who allows his Coroners’ Officers to decide which, if any, further investigations are required but only undertaken when the results of Post Mortem is known. This dip sample shows that there is little evidence to substantiate the Coroners’ Officers concerns of large amounts of work being undertaken that prove to be unnecessary. However the HM Coroner (Western) has now agreed that only a family statement should be obtained until the results of the Post Mortem are known, thereby eliminating non value added work. The Senior Coroners’ Officer should monitor this situation to ensure that only a family statement is obtained prior to the post mortem result being available. Updating Niche to record deaths Coroners’ Officers should look at Niche to identify if the deceased is on the system. If so, an email should be forwarded to the Central Resulting Unit. They will then show the Niche nominal as deceased. By identifying their death at an early stage on Niche, it will save Officer time and West Yorkshire Police reputation if Officers were aware of the death. Toxicology Tests The issue has been raised by staff, regarding the time it takes for results for toxicology tests to be return from the Laboratory and the costs incurred. The Review Team have undertaken some analysis of both the cost and time involved. The HM Coroner will decide whether there is a need for toxicology based on the circumstances of death. The two HM Coroners within West Yorkshire currently use two different Laboratories. The Western Area Coroner uses , whereas the Eastern Area Coroner uses . West Yorkshire Police have employed a part time Forensics and Logistic Courier (FLC) specifically to transfer samples for the Coroners’ Officers. Data for the period 1 June 2016 till 31 July 2016 has been analysed in order to establish current costs to West Yorkshire Police and to identify additional costs incurred by utilising as opposed to . Table 1 and 2 – Current and Predicted Costs These costs are based on the assumption that the FLC will make individual trips for each sample.

S31 & S40 S31 & S40

S31 & S40

S31 & S40


Deaths will be ‘received’ in the office by either electronic referrals (into Coroners Mailbox) or via Niche thereby allowing management of workloads

The Senior Coroners Officer will be able to allocate deaths to Coroners’ Officers based on workloads and deaths types thereby ensuring fair allocation

Remove the paper flows, either via fax, paper or scan between the Coroners Offices and the HM Coroners

Email direct from Niche

Allow Coroners’ Officers to place report of death if nominal on Niche

Removal of Lotus Notes database

Files will be built on Niche and forward to LA Admin for the attention of HM Coroner via email

Any work outstanding due to abstractions, will be visible to the Senior Coroners’ Officer who can reallocate the work

Allows the Senior Coroners’ Officer to ensure that all tasks have been undertaken prior to finalisation, thereby providing and efficient service to HM Coroner and bereaved families.

Clerical Officer to undertake administration tasks, updating Niche, answering telephones, liaison with Funeral Directors

Quicker turnaround of toxicology results

Statements to be obtained by Coroners’ Support Officers in a timely manner

Statements typed directly onto system thereby removing ‘double handling’

Removal of different working practices – introduction of one process for all staff

Removal of tasks prior to results of Post Mortems being known

Provision of Management Information 4.2.2.4 Process Improvements - Efficiency Savings As highlighted earlier in this Report, ‘IS’ Process Maps were developed, in consultation with Eastern and Western Area staff. This allowed the Review Team to understand and determine the current working practices and the key issues. Data was then gathered from staff, using their professional judgement to ascertain the times of the activities they undertook. This data was then used to inform the development of the Resource Allocation Models to identify the efficiency savings resulting from the improvements made tin the SHOULD Process be removing non-value added activities, removing duplication of effort, optimising use of IT – Please see Section below regarding IT Improvements. As indicated earlier in the Report, it has been calculated that the equivalent of 2.8 additional FTE capacity has been identified across both offices (Eastern 0.9 FTE and Western 1.9 FTE) as a direct result of these process improvements 4.2.2.5 Projected Benefits and Risks Projected Benefits:-

Saving of 2.8 FTE equivalent Coroner’s Officers

Introduction of a standardised process and IT system for all staff to use.

Niche is a Forcewide system with the ability to allocate workloads, task, file building and provide management information and therefore will improve management information recording, management and allocation of workloads, auditing of working practices, etc.

Officers at the scene will be able to submit sudden deaths direct from the scene (F49 Mobile App).

Statement Taking options to suit the Force and bereaved families in a timely manner e.g. use of Agile Laptops.

Optimises use of available technology – more efficient and effective working practices.

Improved quality of service to bereaved families.

Coroner’s Officers able to concentrate on core role e.g. not undertaking clerical duties.

Tasks only completed when results of Post Mortems known.


Removal of inefficient paper flows between Coroners’ Offices, Local Authority staff and HM Coroner. Projected Risks:-

Adequate and appropriate training in Niche required to ensure staff can utilise the new system.

NICHE Proposal may be impacted upon if TUPE is progressed.

Supervision of statement taking options to ensure that staff are obtaining all by home or station visits.

Staff do not buy into the new process and working practices to ensure corporacy. The Senior Coroners’ Officer should monitor to ensure staff adhere to the new working practices.

Supervisors (Senior Coroners’ Officers) need to drive and manage the delivery of any approved improvements and ensure their continuous improvement. This delivery needs to be monitored to ensure improvements are delivered effectively.


IT OPTIMISATION 4.2.3 PROPOSAL FOUR

To optimise the use of technology in the Coroners’ Office with the o Introduction of Niche as a database to record and manage deaths within West Yorkshire, as

an alternative to the current Lotus Notes system. Ongoing liaison with the Niche Team to establish a full specification including an effective management information system which will meet the needs of Management and the Coroners’ Officers.

o Use of technology to obtain statements electronically, thereby, removing the need to draft statement long hand, then require them to be typed retrospectively

4.2.3.1 Current Position As identified in the previous section, the Coroners’ Officers currently record death reports on a Lotus Notes Database. This database is an antiquated system which is not fit for purpose and is due to be decommissioned. No changes or upgrades can be made to the system. It has limited searchable fields, is not auditable and can only provide very limited management information. The system cannot support any workload allocation and management or show the status of outstanding cases Also, when statements are obtained in person, they are drafted in long hand and then typed up on return to the office. This is time consuming, inefficient and does not make optimum use of the agile technology available. 4.2.3.2 Supporting Evidence Staff recognise that Lotus Notes is antiquated and to add to their frustration, keeps crashing. Although other ‘Coroners’ systems exist, such as IRIS (which is reported to be antiquated and just keeps being patched) and the new CIVICA, which looks ‘impressive but remains unproven’ for recording and dealing with sudden deaths, Niche is the current operations system used in force for activities including allocation, tasking and finalisation. The Force Digital Mobile Police Team have developed a sudden death report (F49) mobile app form on Niche. All front line Police Officers/PCSO and Investigators are provided with a Samsung Galaxy Note 2 mobile device. Through the Pronto system, interaction can be made with West Yorkshire Police Systems including Niche of which it has a full raft of interconnectivity with. The mobile app would allow Officers at the scene to complete the Sudden Death Form which would have instant transfer to the Coroners’ Officers. This would allow Coroners’ Officer to communicate with the Officer at the scene due to the ‘live time’ nature of the system. The Sudden Death form has mandatory fields which must be completed prior to transmission. PS Philip Hudson from the Force Digital Mobile Team informed the Review Team that the mobile app is due to come through in December for ‘testing’ with potential launch in January / February 2017. Once the system has been through the ‘testing’ PS Hudson would be happy to demonstrate the product. All data fields can provide information dependant on what is required and will provide Management Information. Meetings have been held with the Niche Team, where discussion have taken regarding potential changes that would be required to meet the needs of the Coroners’ Officers. The Team stated that they can build in the requirements although they would require a detailed specification. This specification should also include the type of management information which would be required.


The facility exists to have a ‘fold out’ keyboard attached to the Samsung Galaxy Note 2 device. This will enable the typing of statements directly onto the system instead of being hand written, then typed, thus removing double handling and is a more cost effective process. 4.2.3.2 Benchmarking A visit to Nottinghamshire identified them as being a Force who were about to record all their deaths on NICHE from start to finish. The aspiration for Nottinghamshire was to manage all case files on NICHE and to ultimately look at an interface from NICHE to the Local Authorities system for automatic creation of records. Nottinghamshire Police are part of the East Midlands Consortium which consists of Lincolnshire, Leicestershire, Nottinghamshire, Northamptonshire and Derbyshire. The HM Coroners for each of the Forces have agreed to the respective Forces using NICHE. 4.2.3.3 Projected Benefits and Risks Projected Benefits:-

The Niche database is currently used Force wide and is also available via a mobile database.

Training courses are provided in-house and the system is supported by IT. A request for training slots has been submitted to IT Training for dates late February – early March.

Niche has already received the approval for use in Coroners’ Offices by the East Midlands consortium.

Through the mobile app, ‘Live time’ which would allow contact with Officers at the scene therefore saving time and further questions at a later date with bereaved families.

Allocation, tasking and finalisation via Niche – Senior Coroners’ Officer can ensure all work has been undertaken prior to finalisation.

System (Sudden Death Reports) could go live early next year.

Allow Managers to manage workloads by allocating deaths. Projected Risks:-

Insufficient training provided for staff to operate the system.

New system could impact upon service delivery until the users become familiar with using Niche.

Should TUPE be progressed, NICHE may not be an option for Local Authorities as a Police Service System and therefore alternative IT opportunities may need to be sourced for both this and mobile / agile IT Solutions.


TRAINING

4.2.4 PROPOSAL FIVE To introduce a structured training programme for Coroners’ Officers that enables the effective discharge of roles and responsibilities together with corporate training / guidance given to Officers in order to raise an awareness of the role they play in relation to sudden deaths. 4.2.4.1 Current Position Coroners’ Officers currently have limited structured training. With the exception of a two day course at Daventry, all training is carried out within the Coroners’ Office, usually by the Senior Coroners’ Officer and / or colleagues. This has led to a lack of corporacy, consistency and knowledge amongst the Coroners’ Officers and contributed to the development of disparate and inefficient working practices within and across the Offices. In the Senior Coroners’ Officers Role Profile it states that they should “ensure that the training needs of internal and external customers are assessed in relation to Coronial issues. Where necessary, plan, prepare and deliver bespoke training packages”. This is currently on hold within the Eastern Area of the Force, due to long term staffing abstractions. However, the Senior Coroners’ Officer, Western Area has delivered inputs to the newly appointed Drs Intake Training which is held twice yearly (February / August) and also to Care Home Managers in relation to the reporting of DOLS. The Coroners’ Officer Role Profile also states they should ‘With Internal and external partners, deliver training and awareness in relation to the core functions of the Coroners Service’ Ideally, training inputs should be provided to the following internal and external stakeholders to ensure they have a thorough understanding of their role with the HM Coroners jurisdiction:-

Probationer Constables – The role of the HM Coroner and his officers, what to do at a sudden death, how to complete a Form 49 etc.

Junior Doctors induction – The role of the HM Coroner and his officers why, how and which deaths should be reported etc.

Police officers of all levels – Again about the HM Coroner’s role and Coroners’ Officers, along with any other area of expertise depending on the subject being discussed.

Additionally, the training needs to be supplemented with a training manual and visual aids. This should include a ‘secondment’ to the Local Authority so that the Coroners’ Officers understand their working practices and requirements 4.2.4.2 Supporting Evidence During consultation, staff raised the following issues:

Training is hands on, sat with another member of staff. No formal training. The Western area works differently to the Eastern.

New Coroners’ Officers are asking Northgate (Local Authority) for advice, they should ask their own Manager.

The HM Coroners expect their Coroners’ Officers to attend a two day training course held at Daventry. The table below shows the current position in relation to attendance on this Course by the Coroners’ Officers


North Yorkshire are currently considering sending their staff on a course being held at Leeds Beckett University ‘University Vocational Certificate in Coroners Law and Administration’ at a cost of £1,195 each (Appendix C). It is also understood that Wakefield Council are considering sending staff from Northgate on this course. 4.2.4.4 Projected Benefits and Risks Projected Benefits:-

The introduction of corporate formal training would ensure staff are knowledgeable in all aspects of reported sudden deaths to ensure the delivery of the required service.

Staff have a thorough understanding of corporate requirements / working practices.

Would encourage consistent standards of service delivery.

Training to be kept up to date with new legislation.

Would develop further understanding of their role in the delivery of HM Coroners duties.

Continual development for staff in line with PDR system

Improved service delivery to members of the public, bereaved families, external and internal stakeholders Projected Risks:-

Inadequate training could lead to poor service delivery, both internal and external.

Inadequate development of initial and refresher training would have an impact on performance, service delivery and quality outputs.


APPENDIX B Overview of tasks involved with Sudden Death Reports

Reports of deaths are received into the office from Hospitals, Hospices, GP’s and Police via phone, email or Niche. Electron referrals have recently been introduced for Hospitals, GPs, etc.

The deaths are given to Coroners’ Officers (CO) who record the details of the deceased on the Coroners’ index (Lotus Notes). Contact is made with the families/hospitals/GP’s etc. and then obtain necessary information to assess the death to see if it is suitable for a Dr to give an “offer” (cause of death). If the death is natural and the Doctor is willing to give a cause and the family are happy with the result the CO enters the details onto the Coroners index and attaches any reports (hospital electronic referrals etc.), then forwards to HM Coroner via his admin staff (Northgate) asking for him to consider a Part A. Also completes a typed F49.

If the Coroner agrees that the death is natural and expected and accepts the Drs “offer” he will ‘pass’ the Part A and sign a front sheet which is added by his Admin staff. The paperwork is returned to the CO and they can inform the family and organise the return of the body (possibly via the undertaker) and inform them how to collect the death certificate and register the death and notify Hospitals and Doctors of the result.

The Part B comes along when there is no “offer” from the Dr, or the Family have concerns about the death. So the circumstances change at the point of papers to the HM Coroner as the report will ask for him to consider a Part B which means no cause of death has been given and therefore a Post Mortem is requested. Once back from the HM Coroner saying he agrees with a Post Mortem the CO then has to arranged the Post Mortem and inform the family. The HM Coroner at this stage opens an investigation and may instruct the Coroners’ Officer as to what he requires to be obtained i.e. send bloods for toxicology, family statement etc.

If the results of the PM are death by natural causes, the Pathologist will write a “Short cause report” with the cause of death and all paperwork will then be forwarded again to HM Coroner requesting a B Pass. If agreed it is filed at this stage

If the Results of the PM are not clear, Toxicology (blood) and Histology samples will usually have to be obtained and will be sent off for analysis.

The CO will update the family as to the probable delay in finding the cause of death and the next steps for them.

The HM Coroner give his permission for the deceased to be released back to the family. He will deal with a cremation order, if required and a temporary fact of death certificate is issued so that the family can go ahead with a funeral and deal with banks etc. The CO will update the family and undertakers.

If this progresses to an Inquest (more typically so if the death was in a hospital/care home etc.) and the family have shown concern about treatment of the deceased. The HM Coroner will instruct his requirements and the CO may be asked to obtain GP notes, Care Home notes, further statements etc.

At some point the information/statements/notes are given to the Case Progression staff, Northgate who collate all the documentation and prepare the file to be presented to the HM Coroner who


decides upon the next course of action depending on his findings. Western area Coroners’ Officers currently prepare the file themselves then forward to HM Coroners Admin.

Some deaths received are automatically taken through to Inquest, such as suicide, road traffic deaths, deaths in custody and drugs deaths etc. Basically, deaths that are deemed un-natural but not suspicious. They enter the Coroner’s Office in the same manner and are progressed initially the same to the HM Coroner who will consider at Post Mortem then open an inquest and direct the Coroners’ Officer with what reports and statements that he requires. The Coroners’ Officer then requests there and on receipt, forward for the file to be built.

Out of England - This is a request made by the Family/Funeral Director to the HM Coroner via the CO to take the Deceased out of England to bury/cremate elsewhere. A wet signature is required from the HM Coroner and the CO asks the Referee to send paperwork to Northgate.

Into England - The CO is notified by the Funeral Director when a body has been returned to England, papers are received with the body, which are faxed to the CO. If there is no cause of death a PM is required. The CO will prepare the paperwork and submit to the HM Coroner. If there is a cause of death the HM Coroner will issue a cremation order and death abroad schedule where appropriate. ID will need to be confirmed.

Organ donation - Contact is made from either Hospital or Hospice. The CO establishes what is to be harvested, establish family fully understands, speak with the HM Coroner and speak with transplant team.

DOLS - The CO is contacted by the Care Home, GP, Hospitals registrars and Adult Safeguarding (Local Authority). The CO ensures that the DOLS is “live” (in place) by contacting Adult Safeguarding. If not live, it returns to standard process if a natural cause of death is found.

IF live, the CO will contact the GP to obtain cause of death (in a report) in lieu of PM, obtain report from care home manager and obtain family historic background. Then return to standard process (inquest route).

Advice Only – calls are received into the office from Drs requiring advice only which is dealt with by CO

APPENDIX C


Coroners Service

University Vocational Certificate in Coroners Law and Administration


Leeds Law School at Leeds Beckett University is working with the Coroners Service to provide qualifications for all staff. We are providing a general qualification which will be able to be provided anywhere in the country. Background After initial discussions with the service we identified a desire to provide a programme that fulfilled two elements; a practical applied programme that would enhance peoples’ skills and a qualification. Within the Business School at the University we have our Leadership Centre which is one of the country’s largest Institute of Leadership and Management (ILM) Centres. Given the popularity of their qualifications with organisations, as they give practical applied knowledge and skills, it seemed wise to have this as part of the programme. To further enhance the programme and to provide clearer progression routes for everyone we also felt it was important to also add a University qualification. Programme The programme that has been developed starts with an ILM Level 3 Award in Leadership and Management that will ease people into the programme and provide them with learning, but will also ensure they apply what they learn back into the workplace. After completing the ILM programme the delegates will then go onto the University programme which is a Level 4 programme (this is the same level as a first year undergraduate programme). For this we have created a University Vocational Certificate for the service that consists of two modules; the first is a taught module covering areas around Coroners Law and Administration. The second module is a work based learning module. These two modules will overlap somewhat as we will expect the delegates to put into practice what they have learnt and this will be achieved via a ‘learning contract’ which basically means we will discuss with each person a possible work based project which they can use to incorporate and reflect on their learning. By undertaking a work based learning module it reduces the amount of time you would be away from work but you are still given considerable support to help you complete it. The projects can also be used (if desired) to look into issues within the organisation or can be used to investigate new ideas etc. The Learning outcomes for the programme are as follows:

To demonstrate knowledge of the underlying concepts and principles associated with the work of the coroners service

To identify and describe the sources of coroners law and practice

To understand and adhere to the appropriate standards of professionalism required of staff in a coroner’s office

To explore and evaluate the contribution administration makes to the work of the coroners courts. As mentioned the first part of the programme is an: ILM Level 3 award in Leadership and Management. This programme consists of the following modules: Understanding Self Solving Problems and Making Decisions Learning Outcomes:

• Know how to describe a problem, its nature, scope and impact


• Know how to gather and interpret information to solve a problem • Know how to evaluate options to make a decision • Know how to plan, monitor and review the implementation and communication of decisions

Understanding and Developing Relationships in the Workplace Learning Outcomes:

• Understand the needs and/or expectations of others • Know how to meet the needs and/or expectations of others • Know how to manage relationships where it is not possible to meet the needs and/or expectations of

others The Vocational Certificate in Coroners Law and Administration then follows and this is made up of two modules: Module 1 – Coroners Law and Practice The module will examine the general principles of criminal law which govern the question of criminal responsibility, together with selected, specific, offences. Upon successful completion of this module students should be able to:

Demonstrate knowledge of the underlying concepts and principles associated with the work of the coroners service

Describe and identify the sources of coroners law and practice

Understand and adhere to the appropriate standards of professionalism required of staff in a coroner’s office

Evaluate and explore the contribution administration makes to the work of the coroners courts The module will cover the following areas:

Primary and Secondary Legislation in the Coroners and Justice Act 2009, the Coroners (Investigations) Regulations 2009 and the Coroners (Inquests) Rules 2013 and associated case law and precedent

Advice and guidance from the Chief Coroner

The powers of a coroner

Inquest verdicts and ramifications of the verdicts

Data Protection and confidentiality and freedom of information

Knowledge and structures of the legal system, PACE , the police, and of police investigations

Medical terminology including causes of death, and the death process Module 2 - Work Based Learning This module is designed to enhance the learner’s workplace practice and provides a framework for the negotiation of the workplace activities, enhancement project and the learning and skills development. The learner will negotiate their workplace study with their line manager and Work Based Learning tutor. They will be required to draw on learning from other modules and elsewhere and incorporate these into their study. Upon successful completion of this module students should be able to:

Identify and apply key concepts and theories required for experiential learning and for the execution of their enhancement project as negotiated within the Learning Agreement.


Demonstrate an understanding of their workplace context and their role within it through their practice based activities, team working, problem solving and task completion.

Describe the processes undertaken and reflect on practice in order to identify key learning achievements, personal development, future plans and learning needs.

The aim of the modules is to enable students to:

• Undertake negotiated Work-based Learning activities that can be measured against objectives. • Gain a deeper understanding of the environment in which they work. • Understand the nature, structure, culture and values of their organisation. • Recognise the procedures and systems of their working environment and their role within this • Develop learners workplace capability through application and reflection on practice, subject matter

and broader professional skills The purpose of this module is to provide learners with an integrated approach to study: learners combine both academic and professional learning with reflective practical application in the workplace and at the same time align their learning with their personal development needs. The emphasis of this work based activity is about the learning that arises from the process rather than the solution to the problem. The content including the specific subject area, the rationale and specific aims of the enhancement project will reflect this, and will therefore be individually negotiated, determined and agreed in discussion between the learner and the Work Based Learning tutor in consultation with the learner’s line manager. Specifically it offers opportunities for:

• learners to develop personal confidence through a practice based appreciation of the bigger picture, their organisations values and their role within it

• learners to gain experience of, and demonstrate, the application of technical and work-specific knowledge and skills relevant to individual and organisational needs

• learners to reflect upon and integrate learning with personal development plans, performance reviews and development activities

• assisting learners’ career progression through the development of a broad set of intellectual, practical and transferable skills

• Adding value to employer organisations through improved awareness, performance and progression by individual learners.

Learning for the programme is centred on the working environment and will focus on work-place problems and issues that start with a problem, can be explored from different perspectives. Costs The cost of this programme is £1,195 per person. This is the total cost as the University does not charge VAT.

Appendix A The Freedom of Information Act 2000 creates a statutory right of access to information held by public authorities. A public authority in receipt of a request must, if permitted, state under Section 1(a) of the Act, whether it holds the requested information and, if held, then communicate that information to the applicant under Section 1(b) of the Act. The right of access to information is not without exception and is subject to a number of exemptions which are designed to enable public authorities, to withhold information that is unsuitable for release. Importantly the Act is designed to place information into the public domain. Information is granted to one person under the Act, it is then considered public information and must be communicated to any individual, should a request be received. DECISION Your request for information has been considered and I regret to inform you that West Yorkshire Police cannot comply. This letter serves as a Refusal Notice under Section 17 of the Freedom of Information Act 2000. Section 17 of the Act provides: (1) A public authority which, in relation to any request for information, is to any extent relying on a claim that information is exempt information must, within the time for complying with Section 1(1), give the applicant a notice which:- (a) States the fact, (b) Specifies the exemption in question, and (c) States (if that would not otherwise be apparent) why the exemption applies. REASONS FOR DECISION The reason that we are unable to provide you with this information is covered by the following exemptions: Section 31(1) – Law Enforcement Section 40(2) - Personal information Section 31(1) – Law Enforcement. In relation to the above qualified exemption I am obliged to conduct a public interest test on the information held and here are my considerations: Factors favouring disclosure Disclosure would adhere to the basic principle of being open and transparent and would allow for a more accurate public debate. Factors favouring non-disclosure Disclosure would undermine public trust, law enforcement partnerships would be compromised which would hinder the prevention and detection of crime. More crime would be committed and individuals would be placed at risk, which would impact on police resources. Balancing Test: The Police Service is tasked with enforcing the law and protecting the community we serve and there is a public interest argument in ensuring we are open and transparent with regard to policing. The ability of West Yorkshire Police to conduct such enquiries is crucial to the

principles of prevention and detection of crime. As much as there is public interest in knowing that policing activity is appropriate and balanced, this will only be overridden in exceptional circumstances. It is therefore our opinion that the balance lies in favour of non-disclosure of the information at this time. Section 40(2) – Personal Information This is an absolute and class based exemption and so requires no harm or public interest test to be undertaken. To disclose the redacted information would breach principle 1 (fairly and lawfully processed) of the Data Protection Act 1998. Please note that police forces do not use generic systems or identical procedures for capturing the data. For these reasons this response to your questions, should not be used for comparison purposes with responses you may have received from other police forces.

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