A senior coroner is formally warned after failing to hold an inquest for over four years, sparking outrage
A senior coroner has been sanctioned for misconduct after failing to hold an inquest for more than four years—a delay investigators found unjustifiable, despite a series of excuses ranging from staffing shortages to COVID disruptions.
The inquest, originally referred to senior coroner Caroline Sumeray over four years ago, was the subject of a formal complaint by a bereaved family member. Although Sumeray claimed the investigation and inquest had now been completed, she denied that the delay was unjustified.
However, a detailed inquiry by the Judicial Conduct Investigations Office (JCIO) reached a different conclusion. The JCIO found “no reasonable explanation” for the inquest’s extreme delay, noting that under the Coroners (Inquests) Rules 2013, the hearing should have taken place by the end of 2022—almost two years before it was eventually concluded.
Embed from Getty ImagesSumeray blamed a cocktail of problems: severe long-term staffing issues, difficulties getting responses from third parties, a lack of suitable court premises, and the knock-on effects of the COVID-19 pandemic. She also cited personal circumstances. But investigators said those factors, though significant, did not excuse a delay of this magnitude.
The JCIO concluded that the prolonged delay “amounted to misconduct” and formally sanctioned Sumeray. The misconduct finding carries serious implications. Judicial office holders are expected to demonstrate diligence and care, and the rules clearly state that an inquest must be completed within six months of a coroner being made aware of the death, or as soon as reasonably practicable.
The punishment—a formal warning—is a mid-level sanction, more severe than advice but falling short of a reprimand or removal from office. In deciding on this level of sanction, the lady chief justice and the lord chancellor acknowledged Sumeray’s previously clean record and the extraordinary pressures the coronial system has faced post-pandemic.
In the aftermath of the decision, the Isle of Wight Council, which oversees the functioning of the local coroner’s service, admitted it bore part of the blame. A council spokesperson said both the council and Sumeray “regret the distress caused” by the prolonged delay and admitted the service had been hampered by infrastructure problems and staff shortages.
Since the pandemic, the council stated, it had struggled to maintain a consistent standard of service, contributing to the backlog. Officials said they are now working in tandem with Sumeray to implement a full recovery plan, which includes a strategy to clear case backlogs and address long-term staffing gaps.
The case has reignited concerns about systemic delays in coroners’ courts across England and Wales. Some legal commentators suggest this could be the tip of the iceberg, as years of under-resourcing and pandemic backlogs collide with growing public demand for timely inquests and accountability.
As scrutiny of coronial efficiency intensifies, this case serves as a stark reminder that delays in death investigations don’t just burden court calendars—they leave families trapped in limbo, waiting years for closure.
