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The Guardian began an article on the third report of the Shipman inquiry thus:
"All deaths, including those that do not appear suspicious, must be investigated to ensure that murders such as those committed by Britain's worst serial killer, Harold Shipman, do not go undetected".
Dame Janet Smith, who presided over the inquiry, identified an urgent need for a more focused, professional and consistent approach to coroners' investigations. She said:
"There must be radical reform and a complete break from the past, as to organisation, philosophy, sense of purpose and mode of operation".
In a joint statement, the Home Secretary and the Secretary of State for Health said that work was already under way to identify how best to reform the coroner system.
Eventually, in March this year the Home Office produced a position paper proposing a coherent system based on full-time coroners with legal qualifications, closely supported by appropriate medical expertise, together with tighter rules for death certification, notification of all deaths to coroners and stronger support for scrutinising cases and investigation where necessary. A coroner and burial team was set up. In a news release, the Minister said:
"The proposals outlined today will introduce a new system that will combine an independent check on all deaths and a professional oversight of death patterns with, for the majority of cases, the minimum of bureaucracy".
A BBC news report on the Home Office plans suggested that those changes had taken place. It said that all deaths would be referred to an independent medical examiner and that a wide-ranging review would result in the numbers falling from 127 part-time coroners to a total of 40 to 60 full-time coroners. Coroners have been handed new powers to seize documents, and the reforms will change the way in which verdicts are recorded, doing away with terms such as "suicide" and "misadventure" and replacing them with a short narrative account of the facts of the death.
The Minister was reported as saying that the proposals would prevent an individual doctor from being able to ensure that someone was buried without any further scrutiny within the system. He said that that was "a huge step forward". What has happened since March 2004, and what urgency has been ascribed to this policy area by the Home Office? In September the independent support group INQUEST described the position paper as "aspirational" and drew attention to the lack of clearly stated commitments. It expressed concern because any changes were expected to take place within existing budgets and without any new money. The Luce report, however, recommended a
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series of reforms which, it estimated, would cost an additional 10 per cent. over and above the current £70 million budget for coroners' courts.
Will the Minister explain what has been done since March 2004? Which of the proposals in the position paper have been put into practice? What is still to be done before new legislation is introduced? The Luce report helpfully includes a section on what can be done without waiting for a new Act of Parliament. NHS doctors could be allocated to work in an advisory capacity with the registration service and local coroners. The existing coroners' rules could be changed to reflect the recommendations on the outcome, conduct and scope of inquests. The registration service, the Home Office and the chief medical officers could give guidance on the use of autopsies. Here I interpose that in the third report of the Shipman inquiry, it is said that the immediate resort to autopsies by coroners is undesirable, and some coroners' autopsies are "seriously deficient".
As further examples of what can be done now, a new charter of standards of service to families could be produced. Training programmes for coroners' officers should be introduced with some support from central funds, and the development of new training arrangements for coroners themselves could be started. Informal piloting of death certification changes could be started. A new coronial council could be appointed on an informal basis and asked to oversee progress with the reforms. That is an excellent idea. The report states on page 219:
I am asking for reassurance. Will my hon. Friend the Minister reassure me and the public at large? I am talking about the relatives of those who die tragically in suspicious circumstances, in the custody of the state or in a terrible disaster; the technical and expert groups such as the Office for National Statistics, which collects and publishes the data on deaths, and the Health and Safety Executive, which has responsibility for preventing avoidable deaths at work; the organisations that work professionally with the coroners, such as doctors, police and prosecutors; and the media and all those who have a legitimate interest in the process and outcome of coroners' investigations?
When will we have a modern coronial jurisdiction with national coherence? Will we have a standing rules committee, a coronial council and an inspectorate? Will we have a nationally consistent complaints procedure, an appeals process and compulsory training? Can my hon. Friend tell me that defects in coroners' powers as identified in the reports that have been published will be remedied, and that in future coroners will not solely be reactive, but will be able to investigate any death or group of deaths on their own initiative, making recommendations that may avert further deaths from similar causes in future?
Can my hon. Friend tell me that in future, coroners will have the back-up that they need for expert medical input and effective investigations, and that families will by right have access to reports and to investigators, and that they will be accorded the assistance and the respect to which they are entitled throughout the investigative process, including at an inquest, if one is held? Will he
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tell me when all this will happen? Can he tell me that that will be soon? It is urgent. Can he tell me that the media will be able to report those actions as fact, because they will be fact?
When my hon. Friend says that he remains committed to taking urgent action, when he reassures all those with an interest in the coroners' court system, especially the families of the deceased, the coroners and their staff, that he is constantly on their case, and when he says that he is determined to see through radical reform in a timely and cost-effective way, I will be satisfied that this debate is worth while, and that some good will come of it.
7.58 pm
Ross Cranston (Dudley, North) (Lab): I congratulate my hon. Friend the Member for Stafford (Mr. Kidney) on securing the debate and putting the case for reform of the coronial system in a thorough and persuasive way. There is one aspect that I shall mention briefly—the Luce recommendation about bringing the coronial courts into line with the ordinary courts system, where there is a structured system of appeal.
The issue was brought home to me about a year ago, when one of my constituents, a Methodist minister, was criticised by a coroner after a death outside his church. It is neither appropriate nor possible for me to go into the details, but when my constituent sought my advice, all I could say was that he could challenge the finding by judicial review, or possibly by getting the Attorney-General to support a High Court application. Neither course of action was practical, given the cost involved. Ultimately, the coroner was prepared to enter into correspondence with me, and at the end of the day my constituent and I felt that justice had been done. I urge my hon. Friend the Minister to recognise that this is an important issue, on which the agenda must move forward quickly.
7.59 pm
The Parliamentary Under-Secretary of State for the Home Department (Paul Goggins): I congratulate my hon. Friend the Member for Stafford (Mr. Kidney) on obtaining this debate and giving us the opportunity to discuss the important issue of the reform of the coroner service. He is clearly knowledgeable about the issue and, as my hon. and learned Friend the Member for Dudley, North (Ross Cranston) pointed out, he spoke eloquently and persuasively. I also welcome my hon. and learned Friend's contribution to the debate.
I have been a Minister long enough now to have my earlier remarks quoted back at me. I have also been a Minister for long enough to know that it is a long way from a position paper to a fully reformed system. However, I agree that the issue is important. I reiterate the need diligently to follow through on it and again place on record my determination to do so.
The coroner's office and death certification are, thankfully, places and systems to which we do not often have to go. When we use them, we may be upset and distressed, which is all the more reason why the Government need to ensure that the systems are reliable and effective. As my hon. Friend the Member for
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Stafford said, the system goes back many hundreds of years. It functions as well as it does largely because of the dedication and professionalism of the staff involved. I assert that we owe it to them and the wider public to modernise the system so that it is fit for purpose and fully effective.
The Government set out our proposals for reform in the position paper that we issued in March this year. As we said then, our intention is to issue a White Paper early next year. The work undertaken by Dame Janet Smith, which is contained in her third report from the Shipman inquiry, and by Tom Luce, in the fundamental review he carried out on behalf of the Home Office, has been crucial in helping to inform and work out our proposals for the way forward. We need a system that is simple to understand and easy to run. We need to close any gaps that could be exploited by those who have criminal intent or who fail to provide proper care. In particular, we must do all we can to ensure that horrific crimes such as those carried out by Harold Shipman can never happen again.
To do that, we must connect a number of different but associated systems, such as the registration service and arrangements for forensic pathology. In addition, we will also need strong links between coroners and health services. It is essential that we learn from deaths of all kinds and use that knowledge to prevent avoidable and unnecessary deaths. We must also make sure that the public have a better understanding of how the system operates.
We plan to reform not only the coroner system, but the arrangements for death certification. New procedures to verify the fact of death will be introduced, and the system will be the same for all deaths, whether there is to be a cremation or a burial. We will also ensure much stronger medical oversight. The new system will mean that in future all deaths, whether or not they need to be reported to the coroner, will be reviewed by medically trained professionals based within the coroner's office.
Those trained doctors—in the position paper, we call them medical examiners—will review the medical certificates of the cause of death in all cases. They will have new powers to call for supporting documentation and make any inquiries that they see fit in order to satisfy themselves that each death is properly certified and that there is no reason for a coroner's investigation. They will also need to be able to review cases as quickly as possible, so that our new procedures do not lead to delay and additional distress for the bereaved.
Each medical examiner will be properly trained in death certification and will work full-time in fulfilling their duties. The checks that they make will be much more effective, and the availability of that additional medical expertise will assist lawyer coroners to interpret and understand the medical information about a death and the details of any medical treatment and procedures that the deceased may have been receiving prior to the death. All that will help coroners to decide what action they may need to take in each case. In turn, we expect that better medical information, and the greater competence and confidence it brings, to lead to a reduction in the number of post-mortem examinations.
Families will have a crucial role in this reformed process. I know, not least from the consultations we have carried out, just how important it is for families to
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have an opportunity to provide information, to raise questions and to express their own views. Under our proposals, families will have new rights to receive information about a death and to challenge anything that seems to them to be wrong. Their views will also be taken into account when key decisions are taken about the investigation of a death. There will be new and more accessible opportunities to appeal such decisions. Although I cannot at this stage go into the details of that, I hope that my hon. and learned Friend the Member for Dudley, North will appreciate that we are committed to ensuring that families have more opportunities for redress.
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