Examination of Witnesses (Questions 220-237)
PHILLIP NOYES,
LUCY THORPE
AND PIP
FINUCANE
27 JUNE 2006
Q220 Chairman: Mrs Finucane, did
you want to add something to that?
Mrs Finucane: Yes. We are looking
at death investigations—and you specifically asked about
child death investigations—we are very concerned, and many
organisations are expressing a concern in the standard of investigations
across the board. With the shortage of paediatric pathologists,
and the shortage of forensic pathologists in some cases, the question
of how adequate a post-mortem is is really a question that should
be raised. And looking at the situation I cannot find any suggestion
that any quality assurance with respect to post-mortems is available.
The Royal College of Pathologists set the guidelines for practice
but who actually checks that the post-mortems are done to a particular
standard?
Q221 Dr Whitehead: Perhaps if we
could remain with the question of child deaths for the moment.
Ms Thorpe, you mentioned the possible change in the new legislation
which would enable, as it were, bodies to be moved, which may
therefore make a difference in terms of the availability of paediatric
pathologists, and that presumably would need to be undertaken
under the authority of the coroner, and therefore the understanding
of the coroner that there were significant differences in what
investigations might consist of?
Ms Thorpe: Yes, I think coroners
clearly need a full understanding of the benefits.
Q222 Dr Whitehead: Is it your view
that it is a general understanding that there are very difficult
circumstances in investigations, but that paediatric pathologists
are not available; or is it the case that there is a wider view
that actually forensic pathologists are perfectly able to undertake
all the relevant areas of investigation?
Ms Thorpe: I cannot really comment
on all of the coroners and what their practice is, I am afraid,
but I do understand that there are some coroners who have maybe
greater specialisation in child deaths, responding to child deaths
than others. So, yes, we would want clearly all coroners to have
the same standard of approach and the same understanding about
these issues to ensure that there was an appropriate response
in every case.
Q223 Dr Whitehead: It has been suggested
to us that there are a number of instances therefore of registration
of inaccurate causes of death in children and infants. What do
you think might be the primary reasons for that, particularly
in the light of what you have just said?
Ms Thorpe: That could be one factor,
that the post mortems are not carried out to a proper paediatric
protocol. There are other factors in terms of ascribing cause
of child death because, for example, maltreatment may be a factor,
but without proper and full investigation you are not necessarily
going to uncover that. So it can be very difficult at the very
beginning to make that kind of judgment and it is the process
of investigation itself which will help you to arrive at that
judgment. So that needs to be as thorough as possible. I think
it is also fair to say that clearly these are very distressing
circumstances that the families face—and that professionals
face as well. There was some research done by the NSPCC that looked
at attribution of cause of death within hospitals, which highlighted
the difficulties of dealing with these circumstances: the emotions
of the professionals themselves and the emotions of the parents
and the sheer difficulties sometimes of facing these questions
and maintaining an open mind, because while obviously it is very
necessary to support parents and be very sensitive, in a tiny
minority of cases they may have contributed to the death of the
child; so there is a need to maintain that open mindedness. Hierarchies
within hospitals, different views of professionals can also contribute
to reaching different decisions on cause of death.
Q224 Dr Whitehead: Is there information
that is produced by the coronial system itself, other than that
which is collated by the Office of National Statistics, which
might be useful in terms of those considerations of the Child
Protection Agencies and particularly the work that they do? And
if that information is available how might that be collated and
used better?
Ms Thorpe: One of the things that
has happened, as my colleague Phillip has said, is that there
is now a new system being introduced—or will be from April
2008—that local Safeguarding Children Boards will be following
an agreed multi-agency protocol to investigate every unexpected
child death, and as well as that there is another layer of scrutiny,
if you like, in that there will be child death overview panels
convened by the Local Safeguarding Children Boards, who will review
all child deaths. So that is a very helpful development structurally,
and also in terms of the work of the coroner because it will no
longer only be them who will be formally having a view of these
things. So we do feel that it will be very helpful for these two
processes to be linked together and for there to be some sort
of formal relationship outlined in the Bill between those processes.
What is happening at the moment is that those new processes are
being piloted by the DfES in the next two years and we would hope
that that would therefore include looking at how the relationship
with the coroner works in those areas, and developing protocols
for sharing information.
Mr Noyes: On a very specific issue
data provided by coroners on deaths reported to them in England
and Wales are not broken down by age, and it would be very helpful
indeed if they were to be broken down by age under 1, 1 to 4,
5 to 15 and 16 and over—because that would enable a much
better understanding of the cause of death of people under 17.
Q225 Dr Whitehead: Would that in
any event not be a necessary pre-condition for the idea that the
process that you have described of the DfES and the coronial system
might better inter-relate?
Mr Noyes: Yes. We think it would
be good if the two processes came together into a common data
set that should include common language about the cause of death,
and also an analysis of whether the death could have been prevented,
in common language, and, if so, what would have prevented it.
I think that does apply in some American States. The aggregate
of that would be very powerful in describing through England and
Wales what young people die from, the extent to which coroners
thought that deaths could have been prevented, and then obviously
what steps could have been taken to prevent the deaths. This is
most obvious, I guess, in relation to bad bits of road, relating
to road traffic accidents, but actually there is a very important
learning that could be shared nationally about how we might prevent
not only accidents but also suicides and deaths from maltreatment.
So the data collection aggregatable to a national level feels
very important.
Q226 Chairman: I am sure that I misheard
you, but are you suggesting that in every case the coroner would
record if the death could have been prevented by something? You
could get into quite a difficult area of saying that the death
of an 80-year old could perhaps have been prevented if they had
not smoked in their youth, or whatever it might be.
Mr Noyes: We were reflecting on
deaths of children.
Q227 Chairman: Specifically deaths
of children.
Mr Noyes: We were reflecting on
the deaths of children and referring, I think, to clause 12 in
the Bill that talked about the preventive role of the coroner,
which we greatly welcome.
Q228 Keith Vaz: The Committee has
received evidence of both good and bad practice as far as contact
with the bereaved is concerned. What are your views on the current
quality of service for the bereaved, and do you think that the
proposals of the government will make that experience better?
Mrs Finucane: The major causes
of complaint in the nine years I have been involved has been lack
of information and lack of sustained communication during the
whole process. At the moment things are improving and did improve
tremendously in criminal cases where FLOs—police family
liaison officers—started to be appointed, and of course
since about 2000 the training of FLOs has got well underway and
now it is well-established. On the other hand I hear recently,
of course, that they are cutting back on FLO training courses.
I think the other problem is that there seems to be a gap in perception
of what the coroners are dealing with because when a murder or
road death occurs and FLO is assigned, but when a death occurs
in hospital or in the community an FLO is not assigned and these
people are left very much high and dry. Recently we have been
trying to involve people in our liaison forum meetings, which
you are aware of, by bringing in bereaved representatives, who
come from deaths in the community circumstances, like epilepsy
deaths or cardiac death in young adults—sudden death in
young adults—but also deaths in hospital where there may
be suspected clinical negligence, and who is to help these people?
In hospital you have the immediate help of the hospital staff
and the Department of Health, of course, has been pushing for
the appointment of bereavement officers in hospital, and this
is happening, and we know this because we are now getting requests
for our booklets from A&E departments, bereavement departments,
mortuary departments and recently ambulance services, which is
helping to provide immediate information, which is so urgently
needed. I think the other problem is that people do not realise
just how urgently that information is needed, and sometimes you
ask the question, "Why was information not provided to the
family?" and the answer you get is that it is left, in the
case of police, to the officer's discretion at the time. Then
you talk to the police and they say, "We have to decide when
to provide the information." We would say that there is no
question; you must provide information immediately, not only oral
information but written information as well. It is no use feeling
that the family may not take it in or the relatives may not read
it, but very urgently the information is needed—information
about post-mortems particularly because they happen very quickly
and families do not know what is happening and they are not told
necessarily that there will even be a post-mortem always. So they
are left high and dry. But the problem of communicating the information
is who is going to do it in the hospital and who should do it
in the community, outside of the criminal justice cases.
Q229 Keith Vaz: Do you think that
the experience that people have had—and this is also to
the NSPCC—varies according to location? We have had evidence
submitted to us which shows that there are inconsistencies because
of where somebody happens to have died. So do you think that these
reforms will go any way towards dealing with the issue of location
problems?
Ms Thorpe: I would like to comment
on this in the context of training, which would be across the
board for coroners' officers, and how to respond to the bereaved
is a very important element of that. Having looked at other evidence
we understand that there are questions about the amount of resources
that are going to be made available for training and whether indeed
coroners' officers and others are released to attend training
and whether there is cover for their role. I think those kinds
of issues are very important in the context of this because currently
our understanding is that training is provided in coroners' own
time and it is more ad hoc and that there is not a definite
training programme plus continuous professional development, and
we would like to see that in a range of issues, including this
but also including child protection issues as well.
Q230 Chairman: In that context what
about coroners' officers?
Ms Thorpe: Absolutely. They should
also have clear programmes of training.
Q231 Chairman: Who play an absolutely
crucial role in relation to the bereaved, and the government's
proposals so far do not appear to involve any additional resources
or indeed any change in the system from which they are employed
on an ad hoc basis by individual coroners.
Mrs Finucane: The question of
coroners' officers is one that is very important to us because
at the moment, as far as we can see, the central role of the coroner's
officer is being ignored. Apart from the training issue, which
I would like to come back to, the actual employment of coroners'
officers by the police is still a question; a large number of
coroners' officers are still employed by the police—some
are employed by local authorities. But then I notice in some of
the transcripts this question of the local agreement causes a
problem because how much time is wasted on having discussions
about who is going to agree to what. This is one of the reasons
why we feel it is so important to go to a national service, so
that coroners' officers are included in the coroners' service,
but the Bill does not mention them. But they are central to dealing
with the bereaved. Who else is going to do it? I have just given
you the example that an FLO may be appointed, but in hospitals
the coroner's officer could be a key role. One bereavement officer
I spoke to recently was quite upset because the coroner's officers
were removed from the hospital premises back to the police station.
This sort of thing is going on across the country. We cannot understand
why there is not recognition of the coroner's officer's role—it
is long overdue. They need to have a recognised status and professional
standing and be employed within a coroner service, so that the
coroners themselves have responsibility for them directly.
Q232 Chairman: I will just raise
a couple of other points with you. One is the fact that under
the Bill although inquests will generally be held in public coroners
can ban publication of information which would identify the deceased
and they can take evidence via live-link from children under 17
in a court room cleared of everyone not essential to the proceedings.
There are various ways in which open inquests could be held, for
understandable reasons. Do you see those as potentially beneficial
for the bereaved or are you worried about any dangers in those
provisions?
Mrs Finucane: I think the problem,
as I certainly understand it, and I think the people I work with
in the victims' charities and the specialist organisations dealing
with the bereaved, feel that . . . I am sorry, I have lost track
for the moment.
Q233 Chairman: About open inquests?
Mrs Finucane: Yes, I think the
problem is the media attention of course, which is something which
is very unwelcome. From the point of view of being open and in
the public interest, I do not know; I think this needs a bit more
thought, perhaps.
Q234 Chairman: Do the NSPCC have
any views from the children's standpoint on this?
Mr Noyes: We were pleased to see
the proposals to let children give evidence on video-link. It
was quite surprising that vulnerable adults were not included
in those provisions as they are in other settings. We have a view
that the process should be as public as possible. But, there are
some issues then about the transmission and receipt of information
in relation to child protection issues, for example from serious
case reviews. Our understanding is that work is needed to establish
a protocol as to how information might be given from a serious
case review to a coroner. We understand that something is happening
on that in Northern Ireland, which may be relevant to the Committee,
and we will look into that separately.
Q235 Chairman: Finally and more generally,
you have seen the comments that have been made, including by Dame
Janet Smith, that taken together these proposals would not be
enough to prevent another Shipman. Do you have any general
reflection on that?
Mrs Finucane: Clearly the public
are very concerned that there should not be another one. A lot
of comments were made again in the transcripts about the question
of death certification and inaccurate causes of death and so on.
I do think the Bill would deal with this—in fact I think
it would not. An interesting point coming out of the 2005 coroners'
statistics was that I noticed the number of referrals to coroners
where there was no post-mortem and no inquest was 106,000. So
who dealt with them? Was the decision made by the coroner, the
coroner's officer or a doctor that finally decided that they did
not need a post-mortem and they did not need an inquest? This
raises a question mark over how they were dealt with. But then
we know that coroners' officers are being questioned by doctors,
doctors seem very uncertain about death certification anyway and
the whole thing does not come together. Whether you should deal
with death certification in a Bill for the coroners, I do not
think we are competent to judge. But I think there is a lot of
concern about inaccurate recording of causes of deaths, particularly
in some of the specialist charities with which we have had contact.
Q236 Chairman: NSPCC?
Ms Thorpe: We would share those
concerns. There is the proposal to have the Chief Medical Adviser
who would work with the Chief Coroner and that coroners will have
some resources to buy in medical expertise, I think, at the local
level, but that is very far from the system that was proposed
in the Luce Review, where you would have a system of a medical
auditor working alongside the coroner as a matter of course, and
we believe that this would have provided that extra scrutiny and
that assistance with ensuring that death certification is accurate.
Q237 Chairman: So you strongly back
that particular Luce proposal, do you?
Ms Thorpe: Yes, with some provisos
that we would have said that it is not only the clinical expertise
that is required but also looking at the family and social factors
where child deaths are concerned, so, yes, if they had that training
and also that support available to them.
Chairman: Thank you very much for your
evidence; we are very grateful for you help this afternoon. This
is the point at which I have to hand over the chair to Mr Vaz
and invite the Minister to come and give evidence to us.
In the absence of the Chairman, Keith Vaz
was called to the Chair
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