Examination of Witness (Quesitons 35-39)
RT HON
DAME JANET
SMITH DBE
7 FEBRUARY 2006
Q35 Chairman: Good afternoon, Dame Janet,
and welcome. We are very glad to have your help in this matter.
You presided over and did an enormous amount of work on a very
major inquiry into a quite horrific series of deaths which I suppose
you could say tested the system to destruction and demonstrated
its most serious weakness although one hopes in a very untypical
set of circumstances. Having heard the exchanges that we have
just had, perhaps you would like to start us off by saying what
functions you think the death investigation and certification
system needs to perform.
Dame Janet Smith: Historically,
of course, it has always been there to detect wrongdoing and that
is still a very important function. In wrongdoing I would include
not just deliberate wrongdoing such as Shipman but wrongdoing
by neglect, wrongdoing by error because it is important that those
things should be discovered as well. In modern society there are
other important functions that are served by a system of death
certification. For example, much medical research and epidemiology
is based upon cause of death and if we do not have cause of death
established accurately then that research and epidemiology is
inaccurate. That research and epidemiology serves and informs
to a great extent the disposal of resources, particularly in the
Health Service and they are enormous as you will know. If that
research and epidemiology is at fault then the ways in which those
functions are carried out also fail. There are important and direct
functions and purposes behind death certification but there are
also broader ones which in my view are no less important.
Q36 Chairman: Do we need coroners
as a key element, having got the certification system right?
Dame Janet Smith: I recommended
that we should keep the coroner system although I wanted to see
it radically reformed. The inquiry looked at a number of foreign
systems, some of which depended wholly on the medical examiner
making decisions about the cause of death and also in some jurisdictions
the medical examiner gives an opinion as to the circumstances
to some extent, but essentially it is a medical process in those
jurisdictions. It seemed to me that one needs somebody who can
make decisions about circumstances and, in particular, where the
circumstances are disputed, as they sometimes are. The best person
to do that is a coroner who should be a judicial figure as opposed
to a medical figure. I see an important role for both doctors
and lawyers as judicial coroners in the system. I am a great believer
in professional horses for courses. I would like to see the medical
tasks being performed by doctors and the judicial tasks being
performed by legally qualified coroners.
Q37 Dr Whitehead: In your third report
on the Shipman Inquiry you effectively stated that the whole coronial
system had failed as far as Harold Shipman was concerned and as
a result you called for the whole-scale reform of the entire system.
Do you think that the failure in one case, admittedly a very significant
case, really justifies the whole-scale reform of the system which
over and above that considered over 226,000 deaths in 2004?
Dame Janet Smith: I have been
listening to Michael Burgess and it does not appear to me that,
quite apart from Shipman, there is a great deal to be proud of
in many aspects of the coronial system. I was very careful during
the inquiry when, of course, I had to focus on the Shipman events,
but I was determined that the recommendations that I had made
would be of general application and general usefulness. It is
true that I pointed to the ways in which the system had failed
to detect or deter Shipman. I do want to impress upon this committee
that the announcements that were made yesterday in the House would
go no way at all towards remedying the defects that failed to
catch or deter Shipman. If these reforms go through—and
they are good in themselves and I have no criticism of them in
themselves—there could still be a Shipman out there still
killing patients, still certifying their deaths, handing the MCCDs
to the member of the family who takes it to the Registrar's Office
to register the death. Nothing will have changed and I think that
is a cause for significant concern. I hope this committee will
agree with that. I am not suggesting we have a new system just
because one wants to make sure that one would catch another Shipman,
but if you have a new system and it cannot catch a Shipman it
seems to me that something is wrong.
Q38 Chairman: Was it the individual
nature of the registrar system as much as the individual nature
of the coroner system which is the key gap here? What is the key
change it does not address?
Dame Janet Smith: I think the
key difficulty and problem is that too much is left to the individual
doctor. The individual doctor's decision warrants two things.
He is saying I warrant that I know the cause of death and I warrant
that the circumstances of the death do not require referral to
the coroner. It was Shipman's ability to certify false causes
of death and avoid the coroner system completely that is the point
because not one single death of Shipman's victims was reported
to the coroner. Occasionally he would have a quick telephone call
with somebody in the coroner's office saying that he proposed
to certify the death as due to such-and-such and would that be
alright and the answer he always got, and it only happened on
a few occasions, was "Yes, it's quite alright, Dr Shipman".
So there was no check. I must put in a word in defence of the
system of registration. Registrars are administrators, they are
doing an administrative job and they are not equipped to scrutinise
the medical certificate or cause of death that is issued by an
individual doctor. It is not their fault if false causes of death
go past them.
Q39 Keith Vaz: Dame Janet, you said
something quite profound just now, which is that you do not feel
the proposals as outlined yesterday would deal with the kind of
issues that were raised in your very important inquiries. This
is a very profound statement because I think ministers and Members
of Parliament believe that they would deal with those problems.
Were you consulted by the Lord Chancellor or ministers before
they published these proposals?
Dame Janet Smith: Very recently.
In fact, soon after my report was published I had a series of
meetings with the then Home Secretary Mr Blunkett and a Minister
of State in the Home Office called Mr Goggins and I was quite
extensively consulted at the time of the Position Paper which
was produced by the Home Office in March 2004, it was about nine
months after I had produced my report, and the Luce Report came
out at more or less the same time and Tom Luce was certainly consulted
at that time as well.
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