Supplementary evidence submitted by the
British Medical Association (BMA)
CORONER REFORM:
THE GOVERNMENT'S
DRAFT BILL
I am writing on behalf of the British Medical
Association with regard to the inquiry being conducted by the
Constitutional Affairs Committee into Coroner Reform.
The BMA submitted written evidence to the Committee
in February this year but in order to aid our oral evidence session
with the Committee on Tuesday 20 June, we examined the Draft Bill
and have enclosed a further submission for the Committee to consider.
This submission is very much an interim response, reflecting the
recent publication of the Draft Bill. We will of course submit
a more detailed and comprehensive response by the official deadline
of the beginning of September. We hope that the enclosed submission
will be of use to the Committee in the interim.
CORONERS REFORM—THE
GOVERNMENT'S
DRAFT BILL
INITIAL RESPONSE
OF THE
BRITISH MEDICAL
ASSOCIATION
1. We welcome the opportunity to reform
Coroner Services. The BMA has been calling for reform of the death
certification system since the Brodrick report of 1971.
2. We broadly support the key proposals
for change, but we must emphasise that no system can ever provide
complete protection against those intent on covering up criminal
activity.
3. We believe the professionalisation of
the coroner service has merits; in particular, there is a need
to bring together currently fragmented functions into a single
organisational structure with the leadership of a Chief Coroner.
We welcome the fact that coroners will have adequate powers to
carry out investigations, will be independent of Ministers, and
will be responsible to the chief coroner.
4. The plans for reform of the system include
proposals to establish a cadre of full-time, fully-trained coroners
and giving the families of the deceased a proper legal status
in the inquest system. This is supported by the Association.
5. We support the statement that the changes
being proposed have to make the system sensitive to the needs
of the bereaved. The balance between the duty of confidentiality
owed by health professionals to deceased patients and the needs
of bereaved relatives needs to be carefully considered. While
"improved family liaison" is important, consideration
needs to be given to any aspects of the health or medical care
that the deceased person would have wanted to be kept private
from relatives. The degree of routine information-sharing with
relatives (who may be distant family members) is something we
would like to see clarified further.
6. The Association believes that the public
needs a very robust, independent system which is essentially legally-led,
where coroners have effective powers to listen to concerns from
bereaved families and initiate more investigations themselves.
However this requires an even greater independence of view as
well as independence from Government.
7. We cannot see how the reformed structure
could operate successfully without significant additional resources.
We agree that any new system must be affordable and properly costed
with appropriate efficiencies, but we do not believe it will be
possible to introduce these significant changes to the coroner
and death certification service for the additional funding estimated
in the draft coroners bill. There is a danger that the Government
will be perceived as "tinkering with the system" rather
than delivering a radical overhaul that the majority of medical
practitioners believe is required. The BMA's view is that the
current proposals will deliver some improvements as far as it
goes but do not go far enough.
8. The Association is disappointed that
the Government are leaving the appointment and funding of Coroners
with Local Authorities. A true national service would provide
a better and more focused system. There is need for clarity on
the local services commitment in light of the current plans to
merge some police authorities.
9. The main concern for the Association
is that it does not wish to endorse a reformed system that is
not fit for purpose. In his evidence to the Constitutional Affairs
Committee Michael Burgess (HM Coroner for Surrey) made several
references to the current lack of resources and this indicates
that there is a lack of confidence with the current arrangements.
It is clear that for many years, some local authorities and police
authorities have not provided sufficient funding for a coroner's
service and therefore many coroners have to complete their functions
with inadequate court facilities and office facilities (as well
as very limited coronial support staff). There is no indication
in the draft bill that these conditions will improve significantly.
There are numerous anecdotal reports of colleagues who find them
selves unable to investigate sudden death properly because of
financial constraint. Who should pay for the investigation which
has no real bearing on the determination of natural/unnatural
death, but which has significant implications for the family if
there should be an underlying genetic cause? At the moment, the
coroner won't, and the NHS can't, as it has no involvement, and
so frequently, the investigation is not done. Similarly toxicology—looking
for abnormal drug levels in unexpected deaths in the elderly would
have stopped Shipman, but the funds for this are limited.
10. There is concern that it will be left
to the local authority to decide how much professional and expert
medical witnesses should be paid for attendance at an inquest.
In the draft there remains the devolution of budgets to local
authorities and the likely constraints on coroners who need medical
advice. If there is to be a national approach with the introduction
of a chief coroner, why is funding not national? Why should there
remain the division between those local authorities who employ
their own death investigators and those who rely upon the police?
A small increase in coronial support staff would make a significant
impact on the amount of investigatory work that can be undertaken
by each coroner, however the explanatory notes indicate the current
number of coronial support staff is adequate. We agree with the
current Government position that post mortem examinations do not
need to be performed as a matter of course (in the case of referrals
to coroners). However, there do need to be some guidelines as
to who does them, which ones to be done etc.
11. It is extremely disappointing that there
are no plans to unify the certification process for medical cause
of death certification and cremation. The Association believes
that the opportunity of a lifetime to reform an outdated system
set up in the 19th century has been lost.
12. The Association sees no sign that the
objections of Dame Janet to the current method of immediate investigation,
certification of death and disposal arrangements have been addressed.
The DCA has scaled back the proposals considerably and this decision
may impact on the deliberations of the Scottish Executive working
party looking at these matters. In Scotland the BMA has written
to the Review Group expressing concern that a "more economical"
option has been favoured by the Scottish Executive. The majority
of doctors are unable to see how the model advocated in Scotland
can possibly work in practical terms and whilst they are still
presently engaged this may not be for much longer.
13. The Association wishes to highlight
again the insufficient training for doctors and medical students
with regard to death certification.
14. We would like to see clarification of
the qualifications of the coroner staff. In addition, we would
like to see more about what skills/qualifications the medical
examiners themselves will need to hold. The BMA needs to see more
detailed proposals for formalising the provision of medical advice
to Coroners before more detailed comments can be provided on this
draft bill.
15. To attract doctors of sufficient quality
and experience to the medical adviser role, the terms and conditions
of service should match those of NHS doctors. There should be
provision for professional support and continuing education. There
should be a role for the BMA as the employees' representative
with negotiating rights.
16. The current proposals do not appear
to include any provision for Coroners' post mortem reports to
be made available to the deceased's GP and/or hospital Consultant
(where known) routinely and free of charge. Doctors report deaths
to the coroner if the cause of death is unknown or if the deceased
was not seen by the certifying doctor, either after death or within
fourteen days prior to death or if there is anything violent,
unnatural or suspicious about the death. Death may also be reported
if due to an accident, self-neglect, industrial disease or related
to the deceased's employment, in cases of abortion, during an
operation or prior to recovery from the effects of an anaesthetic,
suicide or during or shortly after detention in police or prison
custody. The main reason doctors refer deaths to coroners is where
the death is sudden, unexpected or we are not in a position to
certify what the cause of death is. If they do not subsequently
receive a report from the coroner telling them what the cause
of death is, then they cannot learn from the experience and are
not in a position to discuss the cause of death with the deceased's
relatives. We believe this is a significant clinical governance
issue as doctors cannot find out if they are making the correct
diagnosis on patients who die unexpectedly and are therefore not
in a position to learn from any errors or oversights they may
have made.
17. While we cannot disagree that the system
must be "affordable", the decision as to how much money
can realistically be spent on any new system of death certification
is ultimately a political one. It is clear to personnel working
in the current coroner system that the service is under-funded.
This was recognised by Dame Janet Smith in the Shipman Inquiry
Report who considered that "a new improved service is bound
to cost more than the old, which in some places appears to have
been run on a shoestring". The Association would wish to
re-iterate the previous point made by Dr Michael Wilks on 12 June
2005 that the medical advisory service proposed needs resourcing,
in skills, people and money.
18. We believe that the current proposals
do provide some foundation on which to develop a more modernised
coroner service with effective medical support. It provides a
structure on which to build for the future. However as stated
previously the resources available to deliver progress appear
to be limited and the role and responsibilities of the medical
adviser appear to be unclear. The medical input is crucial to
this working and there has to be adequate provision for the type
of advice and investigation needed otherwise we will remain with
the system we have now that has its limitations. There are considerable
hidden costs in the present service that are being provided from
other sources such as the health service.
Dr George Fernie
Chairman
BMA Forensic Medicine Committee
June 2006
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