Evidence submitted by Mrs Pip Finucane,
trustee, Victims' Voice
Victims' Voice is an umbrella organisation,
which provides a "voice" for its organisation and individual
members to raise issues that arise when people are suddenly bereaved.
Individual member organisations offer specialist support and guidance
to enable people to cope with the consequent involvement of police,
coroners, mortuaries and hospitals, and the criminal justice system.
My husband was killed crossing the road near
our home in 1995 and in 1996, I started to take a particular interest
in the problems people had dealing with coroners' enquiries and
I worked on the RoadPeace helpline for three years. In 1998, I
became involved in the drafting of what became the Home Office
leaflet When Sudden Death Occurs, first published in 2000,
now available in Welsh and seven ethnic languages.
The Sudden Death and the Coroner booklet
followed, but the Home Office had declined to publish a follow-up
booklet and Sudden Death and the Coroner was first published
by Victims' Voice in December 2002. It is currently funded by
a Department of Health S64 grant, as part of Victims' Voice Sudden
Death and the Coroner Project. It is being used by police
forces and coroners officers, for training and to give to give
to bereaved people and increasingly, is being used in hospitals
and mortuaries. Liaison Forum meetings are also funded by the
grant and a "Flyer" about the Project is included with
supplementary documents to give you background information.
INQUIRY INTO
REFORM OF
THE CORONER
SERVICE
This submission is made from the perspective
of suddenly bereaved people.
1. INTRODUCTION
The first quotation in the Luce Report was from
a submission by Victims' Voice:
"The bereaved are precipitated into a devastating
situation and are having to deal with agencies and procedures
unknown to them and from which they feel totally excluded."
The last quotation was from a submission made
by the Coroners' Society:
"The present Service has for far too long
been inadequately resourced and been compromised in what it can
do. Outmoded laws and regulations, insufficient staff, lack of
resources and poor training have all contributed to the need for
reform. It will be most important for there to be a full commitment
to any proposed changes that are recommended and implemented,
including proper funding, to ensure the objectives of the system
are achieved".
The first quotation gives a clear message about
the need for information and sustained communication and the Coroners'
Society stated clearly what the Government must do to achieve
effective change.
Lack of immediate oral and written information
about post mortems and a coroner's involvement, failure to maintain
communication, time taken to release bodies and delays in inquest
hearings and the conduct of post mortems and inquests continue
to be concerns for suddenly bereaved people.
This submission deals with the information and
training issues, both of which affect how good or bad bereaved
people perceive their experience of the Coroner Service to have
been. If information and communication are good, many of the difficulties
in coping with coronial processes are eased and added distress
avoided.
2. BEFORE DEALING
WITH THE
PARTICULAR ISSUES,
CONSIDER:
(a) the order of events: sudden death; post
mortem; investigation; inquest.
(b) the circumstances of the death: for
example, violent; road crash; disaster; in custody or an institution;
infant death; suicide; at work; at home; in hospital; alleged
clinical negligence. All present different problems for the coroner
and the different investigating agencies involved.
(c) the front line public personnel involved:
police (CID, road policing, transport); coroners' officers; hospital
staff—A & E, ICU, mortuary, bereavement, chaplain.
3. INFORMATION
(a) Again and again, the failure to provide
immediate information is raised. Why is this such an issue? Because
from the moment you are told of the death, information becomes
crucial to helping you cope. And, post mortems need to take place
as soon as possible.
(b) It is the responsibility of the coroner
to inform next-of-kin of their rights. The coroner's officer will
normally do this, but how soon bereaved relatives are contacted
by a coroner's officer and given information is uncertain. It
will depend on how soon a coroner is informed of a death, staff
availability, workload, and day of week—coroner's officers
are not generally available at week-ends; many local authorities
and police forces will not pay for week-end work or call-out.
(c) What happens also depends on the circumstances
of the death—relatives bereaved by murder or road death
are assigned a police Family Liaison Officer who now has an statutory
obligation, under the Home Office Victims' Code of Practice, to
provide specialist homicide and road death packs, published by
the Home Office and a charity respectively. Some post mortem and
coroner information is included in the packs, but each pack differs
in content.
(d) Relatives bereaved in other circumstances
in the community or hospital may be given some information before
contact with a coroner's officer, if personnel trained in dealing
with sudden bereavement are available. NHS acute hospitals are
now developing bereavement services and mortuary staff are also
seeking bereavement training. Some hospitals are centralising
the responsibility, but in others, the responsibility for bereavement
is fragmented.
(e) What happened when someone was killed
in a car crash on a Friday is graphically illustrated by N's Story,
which is attached (see Appendix). N was not contacted by
a coroner's officer after the week-end or at anytime before the
inquest.
(The treatment of N two years ago was particularly
appalling, but similar incidents still happen. The police force
involved acted to improve things, but FLO training and that of
mortuary technicians are seriously affected by lack of funding
and cut-backs.)
4. INFORMATION
LITERATURE
(a) In 2000, the Home Office (now DCA) leaflet
When Sudden Death Occurs was published, but the HO declined to
follow with a booklet to deal with the questions that immediately
arise. Victims' Voice published a booklet Sudden Death and the
Coroner—Coroner's Post Mortem and Inquests—Information
for Suddenly Bereaved People, in Dec 2002. This backs-up the difficult
explanations given at a time when bereaved people are unable to
"take-in' information and need to have written information
available.
(b) The provision of immediate information
about post mortems and coroners should be a statutory obligation
required of the Coroner Service. Literature that can be used in
all sudden death cases should be available and the DCA has been
asked if it will provide a booklet as well as the leaflet. A Charter
is in preparation to set out the rights of bereaved people and
performance standards of the Service.
5. TRAINING
(a) In dealing with the Victims' Voice Sudden
Death and the Coroner Project, speaking to coroners, coroners'
officers, police officers, hospital and mortuary staff across
the country, it is very clear that understaffing means that even
the minimal training that is available cannot be undertaken because
personnel are not released to do it. This is happening across
all agencies, is a particular difficulty in trying to raise present
standards and inevitably contributes to the continued poor response
and conduct bereaved people experience from the present Coroner
Service.
(b) In a large city jurisdiction, only one
coroners' officer out of fourteen has had any professional training
in the last five years.
(c) There are endemic staff shortages in
police, coroner, pathology, hospital and community bereavement
and trauma services. Some additional funding has been made available,
but for bereaved people and overstretched staff, it is far too
little and years late. The goodwill and dedication of staff, in
all agencies, are being exploited and for the bereaved, it means
added distress and misery and in the longer term, increased ill
health and social care needs, which in turn increase the burden
on the NHS and Social Services.
6. PROPOSALS
FOR REFORM
(a) The DCA proposals have moved some way
from the proposals in the HO Position Paper and no longer include
the formation of a national Coroner Service, in which coroners'
officers would be employed by the Service.
(b) A chief coroner, full-time coroners,
fewer districts and medical support are welcome proposals. But,
will the processes of coronial law actually become more efficient,
so long as the Coroner Service continues to be fragmented and
under-resourced?
(c) The training situation highlights the
unrealistic expectation that a Coroner Service can be efficient
where key personnel are responsible to other Services. Is it right
that the post be recruited on such terms and, perhaps more to
the point, would the best candidates for the post of Chief Coroner
want to do the job under those conditions?
(d) A national Coroner Service, with all
personnel working within it responsible to the Chief Coroner,
is urgently needed. That governments have repeatedly ignored the
need for radical reform, widely agreed as necessary, makes it
very clear where suddenly bereaved people figure in the order
of things. This time funds should be found to commit to the "proper,
effective and humane service" that the Minister, Harriet
Harman wants.
Pip Finucane
Trustee
Victims' Voice
February 2006
Appendix
The following account is of the personal experience
of N when his wife was killed in a road crash. At the time, N
contacted SCARD (Support and Care after Road Death and Injury)
for help and now hopes that by telling his story others will be
better treated and supported.
N is a 63 year old ex miner and his wife was
a secretary for the local Health Care Trust. Married for forty
years with two children, both enjoyed being involved in the lives
of their eight grandchildren. They did most things together and
their main interests were entering their Pedigree dogs into shows
around the Country and taking walks in a nearby forest.
Friday, 19 March 2004 was a dry fine day. N
was preparing a favourite meal for his wife, due home from work
at about 5.45 pm. She never arrived.
By 6.15 pm N, now beside himself with worry,
was informed by his granddaughter that there had been a crash
on the Axxx and that some of the nearby roads were blocked. He
had a dreadful feeling that something was very wrong. He immediately
rang the local Police Station to ask if they had any information
about the crash and who was involved. The Police asked whom he
was inquiring about, then replied that they would get back to
him if they found out anything.
N felt that he could not just sit and do nothing,
so he got into his van and set off to drive the four miles to
the crash site. Whilst on his journey, a Police car passed him
going in the opposite direction; thoughts went through his mind
"I wonder if that car is going to my home".
He arrived at a roundabout near the crash site;
it was blocked by a police patrol vehicle. The Police officer
came over to N's van. N asked if he knew what vehicle had been
involved in the accident. The officer asked his name and requested
that he pull over to the side. N sat for seven or eight minutes
watching the officer talking on his radio. The first Police car
he had seen earlier then arrived and pulled up to the side of
his van. N was invited to sit in the rear of the second police
car and was told that his wife had died in the crash. After a
couple of minutes, he was asked was he ok to drive? N then drove
his van back home, followed by the second Police car.
When N arrived home Sue, his daughter-in-law,
was waiting for him. N was distraught and unable to take in what
the Police were telling him; he could not believe that his wife
was dead. The police informed him that he had to go with them
to the nearest hospital to see his wife and identify her. N, who
was in an extreme emotional state, pleaded with the Police. He
felt could not deal with identification that night, but was told
he must.
He and Sue were put into a police car and driven
to the hospital where they were dumped in A & E by the Police
Officer, who then left. No-one came to them to ask who they were,
what were they waiting for, or informed them what was happening
or why there was a delay.
After an hour and ten minutes, the Police Officer
reappeared and said "Sorry mate we are at the wrong place,
we should be in the Mortuary car park." They then got back
into the patrol car and were driven round to the Mortuary car
park where they were left sitting in the car for over another
hour, in the darkness.
Eventually another car came onto the car park,
pulled up outside the mortuary and flashed its lights at the Police
car. N told the Police Officer "I can't take much more; I'm
feeling ill with shock". He said again that he was petrified
about having to identify his wife.
A man, thought to be a Mortuary technician,
then approached the Police car passenger window where N was sitting
and said, "Do you want to see her now?" The Police officer
interjected "No, we'll wait for the traffic officer".
The man then said "Personally, I think it should be left
until Monday". N said "what are you trying to tell me?"
and the man replied "Well she's not a pretty sight".
N had voiced his reluctance to view his wife
at least twice that night, but because of the comments of the
Police Officer earlier, he had been led to believe it was the
only legal way of identification.
N again voiced his reluctance, but the Police
Officer then said to N "Sorry it has to be done tonight.
It is Friday evening and it must be completed before the weekend".
They then sat for another 15 minutes in the back of the police
car.
The Traffic Officer they had been waiting for
then arrived and they were taken into the mortuary where N was
asked questions and personal details about his wife.
N was then asked was he ready and led to a side
room. He had no doubt that it was his wife though, in his words,
"it didn't look like her". Part of her forehead, which
was injured, was covered with a piece of white cloth and was still
bloody. He kissed her. He registered in his mind that a large
bunch of plastic flowers had been laid across his wife's body.
After some time had passed N asked about his wife's clothes. He
was told "you wouldn't want to see them". But later
he was given her handbag. When he opened it, he was appalled to
find his wife's glasses pushed inside, still splattered with blood.
N and Sue were then driven home by the Police
Officer. After being given a "blue binder", the Police
Officer left, telling them not to read it for two or three days.
N sat with several members of his family for
a time and they left after N assured them he would be alright.
He then spent the next six hours between 12.30 am and 6.30 am,
repeatedly redialling his wife's work's answer-phone, just to
hear her voice. His daughter-in-law stayed with him all night.
At 6.30 am, N rang the Police station to beg
them not to do a Post Mortem; he couldn't bear the thought of
it and couldn't see the need; it was clear she had died of her
injuries. He was told by the Officer who answered the phone that
"she is no longer your wife".
The following morning, Saturday, N's son arrived
and found his father distraught at the Officer's comment about
"she was no longer his wife". On the Monday, his son
rang the Police to complain and the following day an Inspector
and a WPC came to his home. The Inspector told N that the Officer
had said the wrong thing, but it wasn't meant "like that".
He also confirmed that N did not have to make a "visual"
identification.
The Monday was three days after his wife's death
and N decided to ring the hospital and plead with the senior technician
not to do a post mortem. The Senior Technician thought N was ringing
about the identification and asked N "Are you coming down
this afternoon?" N replied, "I have already identified
her, I was brought down on Friday". The Technician was astounded,
saying "You're joking, there is no way you should have been
allowed to see her like this". He further added "Those
bloody coppers and their paperwork".
Although N had protested, a post mortem was
carried out. No-one had explained that this is normal practice
after traumatic deaths and a coroner does not need the consent
of next-of-kin. But, N should have been told when and where the
post mortem would take place and that he could have a medical
representative present.
One week later his beloved wife was laid to
rest. The week following the funeral, a WPC called at N's home,
introducing herself as a Family Liaison Officer (FLO). She had
a conversation with N lasting about ten minutes.
The FLO rang him a week or so later. N told
her he had burned the blue binder that he had been given on the
night of his wife's death because the information contained said
he did not have to make a visual identification, which he had
been forced to do. The FLO said she would call again and would
bring another "blue binder". She duly arrived the following
day. As she came into the house, her mobile phone rang and ignoring
N, she answered it, saying to the caller "I won't be a minute".
N was angry at this and told her "don't let me keep you".
The FLO handed him another blue binder and left. This was also
burned. He never saw an FLO again.
N's wife had left her work at the usual time.
It is thought she decided to stop at a garden centre on the way
home as it was Mother's day in two days time. She had rejoined
the main road and had reached her carriage way when her car was
hit by a speeding coach, travelling at over 60 mph in the opposite
direction. The speed limit for a coach on that stretch of road
is 50 mph.
The coach hit Mrs N's car on the driver's door.
Emergency services arrived within minutes, but it took three and
a half hours to free Mrs N. N was told his wife had died instantly.
The driver of the coach was giving an ex colleague,
who was sat in the co-driver's seat, a lift. They had commented
to each other about the "near miss" the coach had with
another car a few seconds earlier. The driver of this car came
forward later.
N had made it clear to the Police right from
the start that he wanted to be involved with the judicial process
surrounding his wife's death. He was assured that he would be
informed. Despite all the reassurances, N received a phone call
from an officer some weeks later and was told that the driver
had been charged. N asked when the case would go to court and
he was informed that the case had been in court the day before.
It was over and done with!
The driver was fined £60 and given three
penalty points.
This catalogue of unbelievable and shockingly
insensitive and inappropriate treatment of N has left him severely
depressed, disillusioned and obsessional about his dreadful treatment
by all concerned. The ignorance of the law with respect to identification
and post mortems and the "inconvenience" of a traumatic
death on a Friday are equally shocking. The assurances of the
police to keep n informed meant nothing.
This story is not an isolated one, nor is
the sentence, which reflects the attitude of our society to loss
of life on great Britain's roads.
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