Further supplementary evidence submitted
by the Coroner's Officers Association (COA)
RESPONSE TO
CORONERS REFORM:
THE GOVERNMENT'S
DRAFT BILL
1. The Coroner's Officers Association (COA)
has serious concerns about the Draft Bill on Coroners Reform.
2. Numerous public inquiries have centred
on the actions of NHS doctors (Bristol Royal Infirmary, Alder
Hey, Manchester, Isaacs and Shipman). Shipman also included an
extensive review of death certification and coroners' investigation;
and both it and Luce's 2003 Fundamental Review recommended a national
service with scrutiny of all deaths. It is therefore ironic that
the Government has decided not to proceed with such scrutiny and
that the Bill reforming the coroners service is "the best
way forward". It also suggests that the reforms proposed
in the Draft Bill on Coroners Reform will be "... complemented
by initiatives the Government is developing aimed at improving
patient safety and promoting quality in the NHS.
3. The Government's rationale for the Bill,
set out in the Regulatory Impact Assessment (RIA) of 12 June 2006
(paragraphs 7 to 10 inclusive on pages 2 and 3) diverts attention
from the serious inadequacies in death certification, the primary
object of the Shipman Inquiry's criticisms, onto the weaknesses
of the coroners service and wrongly suggests that its proposals
for coroners address those weaknesses.
4. The COA believes that the proposed Bill
clearly does not address the fundamental weakness of the system
namely, that the death certification process has not changed so
a Shipman scenario can recur; it does not correct the weaknesses
of the coroners system namely, that all deaths are not reported
for scrutiny nor does it address the chronic under-funding of
the service resulting in lack of resources and sufficient numbers
of appropriately trained coroners officers and staff within the
service.
5. The key role of the Coroners Service
is to protect society. To that end, the COA believes that an effective
coroners service to the bereaved and general public requires that
all deaths are reported to the service and that if an investigation
into a death is needed then:
— The investigation is independent,
thorough and meaningful.
— The investigators have the resources,
training and expertise to that end.
— The bereaved are kept informed and
involved in the process.
— On completion of the investigation,
the inquiry is brought to a conclusion as speedily as possible.
6. The COA is dismayed that there is no
mention or acknowledgement of the role of coroners officers in
the Draft Bill, when it is acknowledged by the Coroners Society
that coroners officers are the eyes and ears of the coroner, locally
available to families and are as such, the frontline day to day
contact with the bereaved.
7. The COA, like the Coroners Society, hoped
for a national Coroners service; that coroner's officers would
come under one independent employer; and that the service would,
at last, be appropriately resourced with mandatory accredited
training and national standards.
8. Coroners officers are employed, not by
coroners, but by police authorities or local authorities to work
to the coroner. This hybrid situation has long been a cause of
friction in many areas as to who—the coroner or the employer—has
the final say in directing the coroners officer's work. A continuance
of this unsatisfactory arrangement has to be at odds with the
independence of the service and can only perpetuate the inconsistencies
in the levels of service to the bereaved.
9. Sadly, coroner's officers are to remain
with their current employers who may or may not decide to negotiate
a transfer to another employer thereby reinforcing for the foreseeable
future the uncertainty which has blighted the service and which
has been the motive for further under-investment in resources
and training.
10. According to the RIA "the Bill
is not expected to change directly or indirectly the total numbers
of coroners officers or staff for the new service". The COA
can not see how, without further investment in front line staff
and their appropriate accredited training, the new service will
be better able to serve the bereaved.
11. The COA has long had concerns about
the lack of formal training available for coroners officers and
staff which results in a variability of practice. As a result
of initiatives by the COA and in partnership with the University
of Teesside, three accredited courses for coroners officers and
staff have been developed. (See Appendix)
12. The Draft Bill does not include provision
for the mandatory accredited training of coroner's officers and
staff. Although we acknowledge the benefits of a Chief Coroner
who will, amongst his/her many other functions "prepare and
maintain appropriate arrangements for training and guidance"
of coroners and any persons assisting them, the COA does not believe
that the Chief Coroner will have the power to compel employers
to provide sufficient resources and training for coroner's officers.
This was confirmed to us at the first of the DCA's regional workshops
in London on Friday 23 June 2006.
13. In summary, on detailed consideration
of both the Draft Bill and the Regulatory Impact Assessment, it
seems to the COA that the purpose of the current proposals is
not to improve death reporting and investigation and provide a
quality service to the bereaved, but rather to divert attention
from the deficiencies in the death certification process and the
lack of scrutiny. Nothing in this Draft Bill would help detect
or prevent another "Dr Shipman".
14. The under-funding and under-resourcing
of the service is to continue; training for coroners officers
will be patchy which will perpetuate the variable standards of
practice. In view of these factors, it is perhaps fortunate for
the Government that due to the conscientiousness, care, compassion
and dedication of those working within the service that, in fact,
of the 232,000 plus cases referred to the Coroners service in
2005, that relatively few complaints about the service were received.
Mrs Christine C Hurst
Chair
Coroner's Officers Association
March 2006
Appendix
UNIVERSITY CERTIFICATE
OF PROFESSIONAL
DEVELOPMENT FOR
CORONER'S
OFFICERS'
As a result of initiatives by the COA and in
partnership with the University of Teesside, three accredited
courses for coroner's officers and staff have been developed leading
to a University Certificate of Professional Development (UCPD).
The courses:
— Bereavement and the Coroners Service;
— Medico-legal Death Investigation;
— Fundamental Medicine for the Coroner
Service,
are part-time requiring at present that the student
attends a two week placement at the university where the courses
are delivered by academics and practitioners. A variety of teaching
techniques are used most of which involve student participation
and include lectures, seminars, case studies and project work.
Assessment methods include an examination and written case study
analysis. On successful completion of each course, students are
awarded recognised UCPD credits (40 at level one).
At present these courses are held once a year
at the university, however, the frequency of these courses can
be increased to suit demand. The delivery of the courses can also
be adapted to suit the needs of the students, for example if it
is felt that students may have difficulty in leaving their employment
for the two weeks, a combination of university based and distance
learning could be developed.
There are approximately 450 coroners officers
in England and Wales the Coroners Officers Association would like
to see a rolling out of this training over the next three years
so that all coroners officers currently in the service complete
these three courses. We estimate the total course fee cost per
coroners officer would be £2,150 and the total cost per annum
for the next three years would be £322,500. Thereafter the
numbers of officers who would require training would reduce significantly
to those coming into the service.
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