Examination of Witnesses (Questions 126-139)
CHIEF CONSTABLE
PETER FAHY,
COUNCILLOR BRYONY
RUDKIN, STEVE
CHARTERIS AND
CHRISTINE HURST
13 JUNE 2006
Q126 Chairman: Welcome. You have obviously
all listened to the proceedings before this, so you are already
reminded of some of the issues. Can I just throw at you as well
a general question. You are all familiar from various standpoints
with the coroners and inquest system. Do we really need such a
system or does it involve us in formalised procedures which in
a number of other jurisdictions—they do it in Scotland—people
do not find necessary except in a much smaller number of cases.
Does anyone have any thoughts about?
Chief Constable Fahy: If I can
start, I think that if the system is to continue as it is now,
that is a very good question to ask. I think there is an opportunity,
or there could have been an opportunity in terms of strengthening
the system, strengthening a lessons learned approach and clarifying
the processes and the roles of all the people involved in the
system for the coroners system to be of real worth and real value.
I think the consensus at the moment is that it is an opportunity
missed, and therefore I think you are right to question the continuing
ability of a system like this, unless it has access to all the
information, unless it has well trained people out there making
inquiries, so it gets the best possible picture of the issues
behind deaths, behind accidents, and lessons can be learned, good
service can be given to the families involved and hopefully we
can try and prevent those deaths that can be prevented in the
future.
Q127 Chairman: It is a bit of a steamroller
cracking a nut sometimes, in that it invokes a whole series of
procedures which may be absolutely essential in some sorts of
cases and entirely appropriate, but cumbersome and perhaps even
distressing in a lot of cases where a more limited and informal
inquiry might be sufficient.
Councillor Rudkin: A service to
the public is what local government would see as being the starting
point. If you say "Do we need this service?" well, maybe
not that service but we need a service, and you are right to say
"How does it have to feel for everybody?" Not everybody
needs the really intense end of investigation. Everybody needs
a service, and we in local government would certainly see the
customer care end of that as being one of the most important aspects
for us, to make sure that it is seen to be done properly but that
it does it in a way that people feel comfortable with.
Christine Hurst: From a coroner's
officer's point of view, we are the interface with the families,
with the bereaved, and I think the bereaved actually do get a
lot of reassurance when we are involved. We can then explain to
them what the procedures are going to be and what inquiries we
are going to make, and I think it is the appropriate questioning,
the questioning that the coroner's officer gives to the family,
and the appropriate investigation or inquiries that we make for
them that gives them the reassurance.
Q128 James Brokenshire: I would like
to come back to the issue of death certification and your thoughts
on that. I know ACPO in their written submissions to this Committee
said that no system can be perfect but given that the Government
has decided not to include death certification within the Bill
that we now see before us, do you think that it strikes a good
balance between safeguards against Shipman-type incidents on the
one hand and public safety on the other?
Chief Constable Fahy: No. You
have heard some of the concerns from Victor Round about the fact
that there is a lot of lack of clarity about the roles and responsibilities
of various people in the system, and so there is a real need,
I think, for a major piece of work to try and clarify those issues.
I know coroners' officers spend a huge amount of time answering
queries from doctors themselves as to what they should be saying,
as to whether they can issue a certificate. I do not know whether
you are aware that doctors can issue a certificate without actually
seeing the body. So there is a big problem about all sorts of
people involved in the system. The roles and responsibilities
are actually unclear. The system only really survives because
of the seriousness of it and the fact that on the whole, people
will try and do their best in the circumstances, but for instance,
the responsibility of people who attend the scene of a death,
the responsibilities of the ambulance service, the doctor, the
police officers, on the whole are fairly unclear. So in terms
of that issue about death certification, what is necessary is
a whole-system approach and as many safeguards as possible. That
comes from a good system of data capture, data analysis, and opportunities
for families and other people to raise concerns. As has been said,
the coroners' officers play a vital role. They are the foot soldiers
here. They know who are the doctors they need to be wary of, they
know the circumstances, they know the suspicions and the circumstances
in which they need to ask further questions, but it is really
about having a number of safeguards within the system, and really,
even if there were, for instance, two doctors each time for a
death certificate, yet that was still done on the basis of just
a paper exercise, clearly, that would not be much of a safeguard.
I think a lot more work needs to be done to be absolutely clear
about what are the processes and what are the situations in which
a doctor can issue a certificate or not. The system has to rely
on doctors, on trust in the medical system. At the end of the
day, you are relying on a doctor to give an opinion one way or
the other, unless you are going to do a post mortem and toxicology
in each case. So really, where we are disappointed is that there
is still a need for much more detailed piece of work to actually
clarify the roles and responsibilities. I think also, to deal
with that issue the Chairman asked about the steamroller to crack
the nut, well, actually in some cases, yes, a lot of the processes
probably could be simplified and clarified but we need to do that
piece of work because the problem is, as is outlined in the reports,
that there is a huge variation in the way that the coroners service
operates across the country.
Q129 James Brokenshire: It certainly
sounded from the evidence given by our previous witness that a
lot of the pressure falls on the coroners' officers and that that
will obviously remain post the implementation of this new structure.
I do not know, Mrs Hurst, whether you have any comments on what
you use in terms of the current practical situation and the implications
of what this might mean moving forward, given that in essence
nothing is changing here.
Christine Hurst: That is basically
it. I do not think there would be any move forward at all. The
Coroners' Officers Association believe that all deaths should
be reported to the coroners service and we agree with Dame Janet
Smith that it would go some way to remedying the defects within
the death reporting system, but that would also enable the coroner's
officer to make appropriate inquiries with the doctor, with the
bereaved and with all parties concerned, thereby giving them the
opportunity to raise any concerns that they have. We also think
that if all deaths were reported to the coroners service, that
would also eliminate any doubt that doctors have as to what cases
should be reported to the service. We also believe that if you
have a system where every death is reported to the service, it
would alleviate a lot of alarm and distress that some families
feel when they find that their loved one's case has actually been
referred to the coroners service. It can be quite alarming for
them, and we have to spend quite some time reassuring them why
we are involved. I think the reporting of all deaths would also
facilitate a programme that could be interrogated, and that then
would highlight any anomalies and detect any trends, and maybe
the likes of Shipman might be brought to the fore a lot sooner.
I know at the present time in my own area we are looking at a
number of nursing homes and there is a certain amount of deaths
that have come from one nursing home, and we are focusing on that
particular nursing home.
Q130 James Brokenshire: Obviously
you heard some of the comments that Mr Round made in his previous
session, and the points I was probing as to whether inadvertently
the lack of change and some of the tensions that exist at the
moment might exacerbate or make the problems worse in some way.
Would you share that view or would you have any other comments?
Christine Hurst: The Coroners'
Officers Association really did want some change, and we are very
disappointed in the lack of any change really with regard to coroners'
officers. We are now, I think, losing a lot of experienced officers,
and there is no formalised training for officers. The COA in partnership
with Teesside has formulated some accredited training courses
but there is no support for the officers to go on that; there
is no resilience in the service for them to be allowed to go on
that. There are a lot of problems, and we are getting experienced
officers now leaving. There are only about 450 officers in England
and Wales dealing with 232,000 deaths, so it is quite a heavy
workload that officers have. I can only see that, if we are losing
experienced officers because of the poor morale that they have
now and the lack of support by some employers for them, with resourcing
and training, then it has got to impact. We will have new people
coming in, they are not going to be trained, and that has got
to have an impact on the bereaved. So yes, I think lack of change.
Q131 James Brokenshire: I do not
know if your colleagues from the LGA have anything to add in relation
to this, whether you have any comments on what you have heard.
Steve Charteris: Peter raised
a fundamental issue that seems to be avoided in the draft Bill,
the issue of the tripartite relationship between the coroner,
the local authority and the police. The clarity in the responsibilities
is essential for the service to move forward, and this does not
seem to assist. It seems to leave everything to local agreement
where that can be achieved. We can see nationally that this has
always been the case, and some areas have managed to develop local
agreements but others have not.
Q132 James Brokenshire: I am sure
we are going to come on to probe some of the structural arrangements
in all of this. One interlinked point relates to the provisions
that are contained in the Bill which seem to give the power or
the right for a coroner to report a matter to a person who has
power to take action in relation to a particular incident, and
indeed also to report facts on to the Chief Coroner. You might
suggest that that may be a way of trying to raise alarm bells
in some way if there is some problem that has been identified.
Do you think that that type of approach—I will direct this
to you, Mr Fahy—goes far enough to meet ACPO's concerns
about the use of information generated by the coronial system
for public health and safety purposes?
Chief Constable Fahy: I am not
sure there is enough clarity behind that particular proposal to
be absolutely sure. What has happened is that really, over the
last 10 years the whole world of partnership working at local
level has developed enormously, and the point I was trying to
make on the evidence really is that the coroner is not connected
really to that at all. So at the moment he can issue recommendations
and write letters and actually nothing happens. It is a huge opportunity
missed. There are all sorts of issues which could be looked into
in terms of particularly things like deaths from domestic violence,
deaths from drug overdoses, obviously child deaths, where there
could be important lessons learned which are not being fed into
the system. So I think it needs to be a bit more structured than
the way it is termed in the Bill to make sure that there is, as
I say, a more robust process, making sure that we are learning
those lessons and that there is clarity about how the coroners
system feeds into all these different streams, local area agreements,
safer and stronger communities groups and, as I say, this huge
network of partnership working which has evolved and which at
the moment the coroner is completely outside.
Councillor Rudkin: Directors of
public health in the health system where we had health authorities
and PCTs would make annual reports that would have exactly those
sort of flavours towards them. There might be some particular
trends with child deaths that local authorities could pick up
on and could certainly do something with and could learn and could
actually spread good practice amongst themselves. There are models
already in the partnership working that has been described where
we do listen to people who would talk to local authorities and
talk to the police and say, you know, these are things we can
do collectively, but I do not see how this . . . and coroners
could be vital in that. It could be very helpful to everybody
but I do not see how that actually fits into this. For health,
for example, there is health scrutiny that exists, so local authorities
can scrutinise health bodies and learn lessons, and there does
not seem to be that kind of accountability. Steve was saying about
accountability; we do not feel that that is embedded in this in
a way that could be useful and practical to everybody.
Q133 James Brokenshire: Just to follow
that through, because in essence, the key word here is "may";
it is not "shall". Certainly, from my understanding
of the way that fatal accident inquiries operate in Scotland,
at the end of the inquiry what would happen is that the sheriff
would actually specifically report on precautions by which the
death might have been avoided and any defects in the system that
caused or contributed to the death. Would you welcome something
actually being physically codified there so that in essence coroners
are required to set their minds to that type of approach so that
it is actually on the record and therefore the information can
be used whether it is reported on or not?
Councillor Rudkin: I think, yes.
I would be guarded in so much as it goes back to the questions
you were quite rightly asking about training and wanting to make
sure that there was some kind of standardised approach so that
one did not have a maverick coroner who particularly went down
one alleyway with one issue. But if there were to be some regularisation
of training and approach, I can see that there would be value
in highlighting certain trends and actions, and again, that is
where good practice comes in, so that if you knew somewhere else
somebody had made a recommendation that was of use, you could
pass that on, and it would seem to me that that would also be
part of training, sharing good practice and improvement. I can
see the merit in it, yes.
Chief Constable Fahy: It is hard
to underestimate really the huge amount of material that coroners
actually gather. For instance, for every fatal road accident there
will be a huge file and a huge amount of evidence about that particular
accident. In a lot of cases it will not go into the criminal court
system for various reasons, and I think it is opportunities like
that that are sometimes lost because the coroner is perhaps not
tied into all the other work the various agencies are carrying
out on road safety in general. That is some of the weaknesses.
We are just too close to a judicial approach to this. It has got
to be very firmly, I think, a lessons-learned approach, where
the coroner is able to connect into the different agencies and
to try and make sure that lessons are being learned, and could
be in a powerful position to knock heads together to make sure
that is actually happening.
Q134 James Brokenshire: Obviously,
the Chief Coroner has a role in collecting information from the
regional coroners under the new system that is proposed here,
so there is quite a lot of data, as you have rightly highlighted.
How do you think that needs to be used or shared or in some way
passed on in order to have some of the wider public health and
safety issues that you have rightly alluded to in terms of things
happening on the ground?
Chief Constable Fahy: I personally
see that happening at a national level as quite difficult. I have
to express some confusion about how it links into all the other
systems collecting data in things like accident and emergency
departments, where clearly they will collect huge amounts of data
as to how accidents are caused and injuries and things like that.
I think the value of that role is more actually at a local level.
There may be some national trends to be picked up but it is probably
more about how agencies are working at a local level in terms
of perhaps picking up people that may have problems with depression
that may lead to suicide, or issues about the agencies not working
together well enough on road safety issues, whatever it might
be, to the way the agencies are working together to try and prevent
deaths in domestic abuse. That is more likely to operate at a
local level but really at a high enough local level, shall we
say, which again is tied into the partnership working. That is
difficult, because obviously everything is changing in terms of
local government and police and everything else, but certainly
at the moment, at the sort of county level, certainly in shire
areas, which at the moment is where most of the key agencies join
up.
Councillor Rudkin: We do have
models of sharing good practice. I absolutely agree about the
local. I can think of a local road safety issue in Suffolk, which
is very particular about a road where there had been a spate of
accidents, and what we do locally together, fire service and other
agencies, together, but actually, local government is getting
better about sharing good practice amongst itself. The Local Government
Association takes a lead role in that. So whilst there are some
things that are local, the local can become of national use in
terms of informing on a different area, and we are getting much,
much better about being ambassadors for ourselves and helping
each other, and I would see that kind of local knowledge being
translated into national use elsewhere as being a key to actually
getting more added value from a coroners service and collecting
all that data that you have referred to.
Q135 James Brokenshire: Obviously,
this all comes down to time and resource and also maintaining
that local link, but in essence what you are telling me is it
should be very much bottom up in terms of the use of the information
rather than top down.
Councillor Rudkin: Ultimately,
though, it could save lives and therefore it could save money
to all sorts of parts of the system. Therefore, although it has
a cost, I think we would also want to take on that challenge of
eventually turning that round, so that in fact there were fewer
deaths in some of those areas we talked about. That has got to
be a better and more efficient use, apart from also the human
cost, that has to be better for everybody.
Steve Charteris: The coroners
are nationally feeding a lot of different information into different
agencies. I know in Hertfordshire we are feeding that information
into suicide audits. There are lots of different forms of information
that we pass to other agencies. It just feels as if there is no
national approach to that. I know recently coroners expressed
concern that they were being asked to supply data to so many different
agencies and the time constraints, etc, were causing problems.
There is information being passed, but it is not nationally organised.
Q136 Dr Whitehead: The Government
in the Bill is suggesting that there will be additional costs
of the new system, particularly with the new responsibilities
for maintaining proper accommodation for coroners, for example,
and they have suggested, I think, that estimated costs will come
to start-up costs of £14.5 million and additional running
costs of £5 million per annum. How do you see that from the
LGA's point of view, particularly in terms of those costs falling
on local authorities, whether or not the Government agrees in
theory to underwrite them?
Councillor Rudkin: I think to
begin with we would question that. We can provide the detail of
this but we would say that actually only £9.4 million of
that would go to local authorities, including police authorities
if you put the two in together. So we are not convinced by what
we have been told about the money there. I think we could also
point to other examples: the new licensing system which has been
set up, which also falls into my brief at the Local Government
Act, is something where I think as the year has gone on, the new
legislation was introduced in November, and obviously time has
passed and the cost of that. We are seeing a heavy use now of
extended licences at the moment during the World Cup, and I know
there are questions about what the real cost is. I think anybody
who tries to predict in advance is doing better than predicting
football scores, frankly, because I do not think that we know
and that we can say, and we would certainly want to question that.
Of course, there are variations. The truth is that because, I
think, local authorities have felt that reform was coming for
such a long period of time, some authorities, police authorities
and local authorities together, have perhaps not invested the
money that they should have done because they have been waiting
for something else to happen. Therefore there have been deficits.
I have seen evidence of deficits in my own region. We must take
responsibility for that but it is actually a part of the system
about waiting for change really. We would certainly want to question
that. We will look in more detail at those figures, and we would
be happy to come back with what our members say, what our constituents
say.
Q137 Chairman: Are you going to do
serious cost estimates on what the Bill proposes—not your
idea of what the perfect system would be but what the Bill is
actually proposing—bearing in mind that, as I understand
it, quite a lot of the part-time coroners have an administrative
support system which is really on the cheap, because it is a part
of their practice offices, and if you were to set up an office
wholly devoted to a coroner's duties, new costs would be involved?
On the police side not all costs are charged out to coroners.
Therefore, there is quite an exercise to do, which your two organisations
are probably best placed to do.
Councillor Rudkin: Indeed, and
there is an awful lot of—the Chief Constable in Suffolk
described it to me as not so much good will but custom and practice
in terms of the money that the police in Suffolk have put into
it, and at any one time a police authority could turn round and
say, "Actually, we are not going to do that any more."
We are all under budget pressures.
Q138 Chairman: Or "You are going
to have to pay us for it."
Councillor Rudkin: Yes, quite,
and I have to say that with the amalgamation of forces and the
review that is going on, I have no doubt that in looking at the
base budgets of different constituent authorities that there will
be some questions asked if it is found that a particular authority
has a particularly generous kind of arrangement and somebody else
is giving not very much. This will be part of the discussion,
frankly.
Q139 Dr Whitehead: So bearing in
mind that there may be quite a lot of additional expenditure which
you are not too clear about the funding of, and indeed, I think
ACPO has in its evidence to this Committee suggested there ought
to be a clearer form of funding upon local authorities, your evidence
to this Committee suggests either that the coroners service should
be brought fully into the judiciary or should be integrated as
part of a local authority, I presume on the lines that accountability
should follow financial responsibility. Which of those do you
think is the preferred outcome as far as LGAs are concerned, if
you had an ideal clean sheet of paper to write a draft Bill?
Councillor Rudkin: I suppose for
the LGA we would have to say that, as we do believe in local delivery
of service and this bottom up approach that was used, I would
personally want to go for the local authority approach because
I also think that gives an accountability that people recognise
and understand and is there. But I think you have hit the nail
on the head in as much as what we want is something that is clear
and is obvious and in terms of the finance is something that we
can be accountable for and we can control. I do not mean that
in the control freak sense of the word but in so much that we
would have greater powers than we do over the moneys that are
spent. My board has not discussed this so that is just my personal
view but on the basis that I think we are into local service delivery.
Given that it is local authorities with the police with the kind
of partnership working models that we now have, which are now
complex and sophisticated but actually very good and very good
for the public, I think that is what I would welcome.
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