11 Conclusions and recommendations
Pre-legislative scrutiny and the legislative process
1. [The
Minister for Constitutional Affairs asked for the Committee's
views on a number of issues at the very end of our oral evidence
sessions, leaving us no time to take evidence on these points].
We recommend that, in future, the Government makes known the particular
issues with which it requires assistance at the same time as or,
preferably, before publication of the draft Bill. (Paragraph 8)
2. The Government
cannot claim to be engaging in the pre-legislative scrutiny process
when it has published the draft Bill so late that there is insufficient
time for scrutiny to be carried out thoroughly and effectively.
We recommend that the Department for Constitutional Affairs reviews
its procedures for publication of draft legislation so that this
Committee may in future have sufficient time to conduct proper
pre-legislative scrutiny. (Paragraph 10)
The need for reform: the Shipman Inquiry and the
Luce Review
3. Coroners
undertake their statutory function in a fragmented and localised
system that has remained largely unchanged since the time of Queen
Victoria. The current system is ill-equipped to deal with the
modern expectations of society and our formal and informal evidence
has shown us that coroners are amongst the greatest proponents
of change. (Paragraph 21)
Death certification
4. Evidence
submitted to us highlights three problems with the death certification
system:
- first, the difference in certification procedures
for burial and cremation is anomalous;
- second, the complexity in the current death certification
system and lack of sufficient training for medical practitioners
are partially responsible for the very high rate of referral of
deaths to coroners; and
- third, the problem of how Shipman-style abuse
of the system might be prevented remains unsolved. (Paragraph
52)
Government proposals for reform
5. We
conclude that, because neither the DCA nor the Department of Health
is taking responsibility for death certification there is no systematic
and coordinated response to the serious issues raised in the 3rd
Report of the Shipman Inquiry and in the Luce Review. When asked
direct questions about the exact steps being taken to reform death
certification, witnesses from both departments have given evasive
and vague answers. We can only assume from their evidence that,
if anything specific is being done at all, it amounts to tinkering
at the edges of a system which has already been deemed unsafe
and unsatisfactory by two Government-commissioned reviews. (Paragraph
66)
6. We strongly recommend
that the Government revise its policy [not to reform death certification]
in order to address reform of death certification in tandem with
reform of the coronial system. It should return to the proposals
on death certification put forward by the Home Office in 2004,
ensuring that they are supported with sufficient resources. (Paragraph
71)
7. As a basic minimum,
we recommend that the Government introduce a positive statutory
duty for doctors to refer certain categories of death to the coroner
and work with the General Medical Council and the General Register
Office to establish suitable guidance and training to improve
doctors' knowledge of death certification requirements and procedures.
(Paragraph 72)
The Coronial System: local service, national framework
8. The
Government's proposals lack detail and fail to tackle adequately
the resource and structural problems currently facing the existing,
outmoded coronial system. The limitations of the local structure
of the current system, giving rise to uneven distribution of resources,
will remain. It is difficult to see how a Chief Coroner can function
effectively as a force for standardisation without being part
of a national service. A national service would almost certainly
involve significant extra cost, but the failure to introduce one
will mean that the current inequalities of resource will continue.
(Paragraph 101)
9. It is vital to
ensure that changes to the jurisdictional boundaries of the coronial
system and to the staff involved in administering it do not inadvertently
result in valuable skills and experience being lost. (Paragraph
103)
10. The Government
needs to clarify how their proposed system is intended to function
in scattered and remote areas. If it is the Government's intention
that local authorities responsible for large jurisdictions should
provide a coroner with more than one place in which to hold inquests,
we recommend that this should be made apparent on the face of
the Bill when it is published. (Paragraph 110)
Resources
11. The
Government should address the problems of under-resourcing in
the existing coronial system in order to create solid foundations
on which reforms can be built. This will require a careful assessment
of the aggregate costs of the existing system, to include hidden
subsidies, together with an assessment of deficits in particular
areas. (Paragraph 125)
12. The Government
should establish a mechanism for auditing the expenditure of local
authorities on the coronial system and ensuring that coroners
are given equivalent resources. (Paragraph 126)
13. We further recommend
that the Government should reform the structure of the coronial
system by creating a national service with centralised and adequate
funding so that all coroners are able to work to the same high
standards. (Paragraph 127)
The Chief Coroner
14. The
Government should reconsider its estimates for resourcing the
office of the Chief Coroner on the basis of a detailed analysis
of a projected daily workload. In conducting this analysis, the
Government should draw on the experience of coroners who will
be able to provide greater detail on how they are likely to deal
with the Chief Coroner on a daily basis. (Paragraph 133)
Appeals
15. We
recommend that the class of "interested persons" [with
a right of appeal to the Chief Coroner from any decision] be substantially
restricted and that limits be placed on the decisions of the coroner
which are subject to appeal. (Paragraph 139)
Death investigation
16. The
draft Bill does not deal specifically with the concern that a
coroner may decline jurisdiction on unjustified grounds. However,
the decision not to accept jurisdiction would probably be subject
to appeal to the Chief Coroner under Clause 60 of the draft Bill.
Bereaved people who wish to challenge such a decision would not,
therefore, be left without recourse under the new regime and we
welcome this. (Paragraph 141)
17. We acknowledge
that the Government has introduced some sensible reforms with
respect to death investigation procedure in Parts 1 and 3 of the
draft Bill. (Paragraph 146)
The inquest
18. We
welcome the Government's decision to keep the public inquest as
the standard form of inquest under the draft Bill. (Paragraph
154)
Medical support for coroners
19. We
recommend that Government change its policy on medical support
for coroners and return to the 2004 [Home Office] proposals, with
adequate resources being made available to coroners. (Paragraph
162)
Post-mortem examinations
20. The
National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
is currently conducting the first audit of coroners' autopsy reports,
the results of which will be published in October 2006. Without
the benefit of that information, we are unwilling to make any
firm recommendations as to the action the Government should be
taking to address both the shortage of pathologists and the quality
of post-mortem examinations conducted for coroners. (Paragraph
168)
21. We recommend that
the Government adopt a strategy for reducing the number of post-mortem
examinations performed. This may include abolition of the "14-day
rule"; provision of detailed information to the coroner and
pathologist; adoption of written sudden death reports by the police;
and consideration of a system similar to the Scottish "view
and grant". (Paragraph 177)
The bereaved
22. We
welcome the Government's draft Charter for Bereaved People. However,
we note that the raised expectations of the bereaved may lead
to severe disappointment in circumstances where serious under-resourcing
and, therefore, variable standards in service are likely to persist
as a result of inadequate funding for reform of the coronial system.
(Paragraph 185)
Coroners officers
23. We
strongly recommend that the Government acknowledges the status
and importance of coroners' officers by addressing the serious
deficiencies and local inconsistencies in their support structure.
We recommend that they be employed by local authorities, that
their pay and conditions be standardised and that they be provided
with adequate resources and training. (Paragraph 200)
Public health and safety
24. We
recommend that the Government take a bolder approach to reform
of the coronial system, embodying in legislation an enhanced role
in relation to public health and safety. This should be backed
up with significant additional resources to produce a system which
provides greater public benefit and value for money. (Paragraph
211)
Conclusion
25. We
believe that [the] complex reforms [contained in the Bill] will
require carefully planned transitional arrangements and serious
efforts to ensure that skills and experience are not lost to the
new system. (Paragraph 213)
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