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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 902-iii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE CONSTITUTIONAL AFFAIRS COMMITTEE
Reform of the coroners system and death certification
Tuesday 13 June 2006 VICTOR ROUND CHIEF CONSTABLE PETER FAHY, CHRISTINE HURST, COUNCILLOR BRYONY RUDKIN and STEVE CHARTERIS Evidence heard in Public Questions 101 - 157
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Constitutional Affairs Committee on Tuesday 13 June 2006 Members present Mr Alan Beith, in the Chair James Brokenshire David Howarth Keith Vaz Dr Alan Whitehead ________________ Witnesses: Victor Round, Honorary Secretary, Coroners' Society of England and Wales and HM Coroner for Worcester, gave evidence. Q101 Chairman: A warm welcome to you, Mr Round. I am sorry that it is quite literally so, but our air conditioning system is not that impressive on a day like today. This is not an apology from me, but somebody should give you an apology for the fact that you are being asked to give evidence in front of this Committee when the Bill was only published yesterday, and although we were able to make a certain amount of information available to you following our own protests to the Department, the Committee is not happy that the parliamentary process should be impaired by Bills not being produced when they were promised and when the Committee is carrying out an investigation. So we quite understand any difficulties you might have of not having got round the detailed wording of the clauses. Victor Round: I am grateful for that, sir. I think it would be disingenuous of me if I did not admit that I have had a day or two, at least with the outline. Q102 Chairman: Let me provoke you with just an opening question. Why do we have to have coroners at all? Scotland manages without them, has fatal accident inquiries in very few cases - nothing like the number of inquests we have - and leaves the Procurator Fiscal to carry out any investigations that may be necessary if it is a criminal matter and to assist the family if they wish to have, for example, medical reports. There is not the perception there that you need to have an open judicial-style process for most instances of initially unexplained death. Why do we need it in England? Victor Round: I am not 100% sure, sir, if one were writing a system from the ground up, that I would recommend a judicial-style inquiry into every unnatural death. It is rather more a question, now that we have it, that people would be bitterly resentful and suspicious if we removed it. That is a terribly pragmatic answer, I know, but one of my own deputy coroners had to fight for years to get an inquiry into the death of her husband in Scotland, and it was a campaign by a lawyer which took several years to get the inquiry even to start, and we are by no means impressed, I regret to say, that in Scotland they inquire into quite as much as they should. Had it not been that that particular widow was a deputy coroner, I very much doubt whether the discoveries would ever have been made. So I think, frankly, they are too selective. I notice Mr Luce said that before you on the last occasion as well. Q103 David Howarth: I have a couple of questions about the draft Bill, in so far as you have been able to work out what it is saying. First of all, under the draft Bill the coronial system essentially has to remain local in terms of appointments and resources, but built on top of that there is going to be a new national government system headed by a Chief Coroner. Do you think that will be an effective system, particularly in terms of accountability? Victor Round: No. We have doubts that a national Chief Coroner, he or she - can I just get that out of the way and say "he" from now on - whom we welcome completely; it is a splendid idea, but we have doubts whether they are going to be any better at winning an even supply of resources than we have been. There really is a postcode lottery about resources. Well over 30 coroners now struggle to get a court in which to sit for an inquest at all, and the number is rising steadily. That is to do with local authorities' ability to supply. So unless in some strange way the Chief Coroner is able to even out that supply of staff - two of my own officers have no office. They stand in the mortuary and literally, they have nowhere to sit and type or anything else, and this is not unusual. I do not have an office. I work from home. I have no office at all or office staff. These things outside the cities are quite common, yet my local authority is really rather good to me compared with many. I do not see how the Chief Coroner is going to solve that problem. Q104 David Howarth: So your preference would be for a national system? Victor Round: We did rather hope to see a national system. We had almost got to the stage of assuming it would happen, and so we are a bit shaken to find that we still have the old battles to fight. Q105 David Howarth: The draft Bill also introduces new provisions on the commencement and the discontinuance of coroners' investigations and the duty to hold an inquest. Could you just give us your view on comparing the new regime with the existing regime in terms of the bureaucracy that a coroner would have to negotiate during an investigation, and a number of investigations. Victor Round: It is one of the good things in the Bill, I think, sir, that they really have simplified the legal support for the work that has got to be done and removed a lot of the stupid anomalies. That is some of the really welcome material. This important distinction there used to be between is this an inquest inquiry or is it not an inquest inquiry, which made vast differences to our ability to fund and investigate and everything else has all been removed, and I am sure that is to the good. It is one of the very good things in the Bill that logical approach to the job that they have built in there. I am not sure that it would actually make much practical difference to the families on the ground though, most of whom do not attend the openings of inquests nowadays, I hope, unless they feel impelled to, which would be very hard for them, but it always has been possible, with a sympathetic approach, to somehow survive the absurd legal technicalities and lighten the load for them while trudging through them ourselves. So it is nice for us to have them removed. Whether it will actually feel very different to families I rather doubt. Q106 David Howarth: Will it increase the number of inquests? Victor Round: They stay the same, as I understand it, sir. It was noticeable in the February briefing note that there was a proposal that certain inquests, and they mentioned specifically domestic suicides and matters of that nature, might not receive a public hearing. It is very noticeable that that has been dropped from the Bill, and I confess, like my predecessor Secretary of the Society, I was rather keen on removing some of those inquests, and publicly so, and I know Mr Luce was before you previously, but I think I have changed my mind. There is this issue of transparency and an awful feeling of cover-up. It is such a wonderful way to defeat conspiracy theories and fears of cover-up to say "It is a public hearing. You do not have to come along. I will read your statement instead if you like, and even you as a family do not have to come. I am still going to do it in public, and you can change your mind and drop in at the last minute if you want to." On reflection, we rely on that very heavily, and it may be that it is much better that you can see what we are up to, to put it simply, so I have actually changed my mind. Q107 David Howarth: In the light of that, the government is estimating that there will be about 60-65 full-time coroners under the new system. Do you think that number will be sufficient to cope with the number of inquests? Victor Round: I am sure it will not, sir, because inquests are getting longer and longer, and I am not complaining about that but the burdens of making the necessary inquiries dictated by Article 2 of the European Convention of Human Rights has made, for instance, an inquest into a death in prison that might have taken three days now be quite likely to take three weeks, and that has put tremendous pressure on to court accommodation, on staff, and on back-logs; some of us are reeling under them now, and really quite frightened about the future. We did think this new national service would solve this problem, and it has done nothing for it at all. I am quite certain 65 will not be enough, but of course, they have provided a fallback that we could use part-time assistant coroners, and if we use enough, one could still also maintain a rural service. I am sorry if I am jumping on a hobby horse, but I am a shire coroner, and it is a very different viewpoint. I think I saw the Minister saying in your House "We will have coroners travelling rather than families." So coroners can travel out, even though there will only be 41 jurisdictions or whatever. There are two problems with that, with respect. The first is that the coroner is then sitting on a car seat instead of sitting on an inquest, and the second is that all those courts we used to travel out to have been shut. It is like cottage hospitals. It is the same situation. It may be a good thing but it does not provide us with anywhere to go. So 65 coroners, 41 jurisdictions, is really the death knell of any kind of local service. We may just survive in some of the rural areas by having part-time coroners helping out from their local practices. It is really quite hard to get across. Some coroners in Wales actually have to drive the night before to a bed and breakfast in order to be in court in time in the morning to start the inquest, and it is a bit hard to envisage until one actually sees it happening. Q108 Chairman: Who is going to take the jobs of full-time coroners, bearing in mind that there is only a limited number of full-time coroners at present and a large number of part-time coroners, most of whom are in private practice as solicitors and might very well take the option of returning wholly to private practice, since the cross-subsidy, if I can call it that, of having the coroner's business in their offices would disappear, unless they are appointed as one of these part-time coroners? Presumably the authorities are going to have to look elsewhere for their full-time coroners than from the existing pool of part-timers. Victor Round: That must be so, must it not, especially when you consider that the DCA are aiming to reduce the structure to 40 or 41 jurisdictions, some of which will have two full-time coroners and some one? A lot of the people with present expertise will simply not want to move hundreds of miles, not be able to abandon a practice, and I am very concerned that a number of them who currently sit on tribunals of various sorts will simply increase their tribunal work, and leave the coronership completely. I think there could be a great big ability gap and I quite accept that appointments must be open to all ultimately, of course, like any judicial appointment, but somehow - and I do not see that any provision has been made for it - the experienced people have got to be kept on board long enough in the interim to keep the system going, and I do not see any provision or discussion even of that at the moment. Q109 Dr Whitehead: I would like to ask you a question about the dog that did not bark in the Bill, as it were, and that is the apparent silence on the face of the Bill about any change in the relationship with he coroner and the local authority, and indeed, no change in as much as what one might call the fudge of the relationship continues, but with a Chief Coroner who is clearly not related to the local authority system. Do you see the silence in the Bill as a merit for the future or do you see particular problems with the continuance of that unclear relationship? Victor Round: I do think there are going to be problems. There are going to be the existing problems with that unclear relationship. I saw a briefing paper from the Local Government Association saying it ought to be all with the local authority and they will control and monitor it direct on the one hand, or all with the DCA on the other hand, and they seem to be uncomfortable with this fudge. That is very alarming for us, when you think that they are our suppliers of money and people, that in a sense they do not really want us on these terms, and we feel unwanted on these terms, very much so, even though the odd personal relationship is sometimes quite good. I have to be a bit discreet about particular cases but I know of three examples where local authorities whose own performance in relation to looking after somebody who has died is under question by their coroner, and they have fallen out with the coroner about the money spent on that inquiry, and so I find the idea of us being totally responsible to the point of being monitored by local authorities quite unacceptable, because we would not be remotely independent, and although this "HM Coroner" phrase sounds terribly old-fashioned and the idea of an office to which one has some sort of freehold title is obviously out-dated, that appointment as HM Coroner is what we present to the families as "We are not in the pocket of the local authority, and don't worry, they can't dismiss us if they don't like what we're doing," and if it is ever removed - and of course, it is in the Bill at the moment, the bald provision that the office will be removed, and nothing is said about what will replace it - then we will be less independent, and that does worry me. Simply working for a local authority who do not want one and until you shout about resources do not even really notice that you exist is very bad for morale. Q110 Dr Whitehead: Would you say there is an even greater potential than hitherto of local authorities and perhaps police authorities, where they are providing some or all of the funds, saying in the future "We provide the money. We are not satisfied with the degree of accountability there is. Therefore we won't provide the money" or "We will try and attach strings to the money" in a way that would de facto place accountability for your work in the hands of local authorities? Victor Round: I have never come across specific strings being placed, I must admit, but it takes an awfully strong personality to go for a particular local authority department and then at the same time go cap in hand to another department in the local authority saying "I need this much extra money to do this inquest in which the local authority is involved" and indeed, the High Court have on at least one occasion had critical things to say about a local authority that literally did that. They have a duty to indemnify us for what we spend and in some cases, we have even been in the bizarre situation of lending money to a coroner because of the financial difficulties he was in because his local authority would not pay up. We literally lent the money, which is a bizarre situation. Q111 Chairman: You had a whip-round of other coroners, did you? Victor Round: We lent the money out of the Society. Q112 Keith Vaz: The new Chief Coroner is going to be something of a superman or superwoman, having to deal with a huge amount of responsibilities, looking after all the coroners, dealing with training, dealing with complaints, trying to sort out appeals and, apart from all that, he or she is going to have to report on a regular basis to the Lord Chancellor, and maybe even having to give evidence to our Committee. Do you think this is a reasonable workload for one individual? Victor Round: I am sure it is not, sir, but I understood it differently. I thought that that Chief Coroner was going to have a number of assistant Chief Coroners to do, if I can call it crudely, the leg work, dealing with a lot of the appeals and that sort of thing. I thank you for that list. I think there is another item that the Chief Coroner will have to do that just has not been envisaged yet. At the moment, unlike all the other judicial officers, we supply our own information, case law, case support, updating system and all that, again voluntarily. It is done by the Coroners' Society, and we do it out of our own subscriptions to the Society, which are repaid by the local authorities, but we do it ourselves. The Chief Coroner, who is the one who will be setting standards and keynotes and giving information, will surely be the one to do that. Nobody is really the boss of coroners at the moment. It is a mixture of me and the President today and various other secretaries in the Society. We use the website that way, but we would have no place doing that; the Chief Coroner would have to run it all. So he would have to take that on as well. Q113 Keith Vaz: Yes, and presumably you would envisage a large amount of resources to assist the Chief Coroner. You have talked about a number of Assistant Chief Coroners. Presumably, you would need not just financial assistance by way of funding but also personnel. There would need to be quite a robust and strong office supporting that person, would there not? Victor Round: Yes, sir. It is also expected to move extremely fast, and I have no doubt that is a good thing, because if one is going to appeal against the decision to have a post mortem or to refuse it, for instance, then of course, the decision by its nature has to be very, very rapid indeed, but to have the resilience to react at that speed, there have to be staff able to turn round and drop everything. Quite how the coroner drops everything and does his or her side of the appeal, I do not see at the moment how that could possibly be done. But we are told by the Bill that is how it will be, and unless there is some sort of filter system, I do not think either the Chief Coroner or we will cope. Some other level is needed. Q114 Keith Vaz: The draft Bill also contains a new and much wider definition of interested person. How do you think that these interested people will affect the way in which the investigations will be progressed, especially if they disagree as to how the process should pan out? Victor Round: They do it now from time to time, sir, so we are used to handling disagreements between interested people, and we console ourselves with the thought that these people are all obviously properly interested. Who would want to exclude them? But at the moment we have the assistance of two things. We have the natural emotional hierarchy in a family, which tends to elect a boss, a leader, a family spokesman, and if it is a split family maybe two of them, but we cope with that regularly, and also then the legal hierarchy provided by the Administration of Estates Act and so on. That would appear to be removed by the Bill, as far as I can see, and one of the additions really alarms me, and that is the friend of long standing. How a friend of long standing can be equated as a properly interested person with members of the family mystifies me completely. A friend of long standing to look after the deceased's interests because the family do not care would be a splendid thing and of course, we would welcome it, but the Human Tissue Act has, if you will forgive the phrase, a pecking order, a hierarchy, and that is recent legislation on the subject. I would have thought one could almost adopt the pecking order in the Human Tissue Act, otherwise you do, I am afraid, particularly with mental patients, have friends of long standing popping up all over the place, and nowadays we say to them, "Look, the family are in charge here, not you" and I would have hoped we would still be able to say that. Q115 Keith Vaz: Do you think that the volume of appeals are going to increase as a result of the regime set out in the draft Bill? Victor Round: I think "increase" is putting it very mildly, sir. The range of things that can be appealed, which witness one might call, what questions you could put to that witness, whether that witness will have the right to refuse to answer questions as self-incriminating, that whole range of things, because of the way it is currently set up and not restricted in regulations, would be able to stop inquest after inquest in mid flight. That does not happen in other courts. What happens in other courts is that you say to your clients - or I did when I was in practice - "Wait to the end. You may still get the result you want, so this won't matter then." PMs I accept are quite a different business; whether or not you have a PM needs a quick response, but so often the things that are vitally important or feel vitally important to people on day one or day two of an inquest diminish into nothing when you get to the verdict, and at the moment it seems to me the Chief Coroner system could get flooded with appeals very quickly indeed. Q116 Keith Vaz: One of the bizarre descriptions of what happens at the DCA, which is a pretty bizarre Department, as far as I can see, is the way in which coroners are currently trained, which seems to be very much on an ad hoc basis. There is some kind of list somewhere. Somebody rings somebody else up and says, "Would you like to come and be trained?" Under the new system, of course, the responsibility rests with the Chief Coroner. Do you think this is the right place to put these responsibilities? How do you see the training of coroners and the support staff being done? In other words, should it be done by the new coroners service people, but then let them get on with trying to make sure that people are properly trained? Victor Round: I would suggest it is much better to keep it inside the new coroners service but by that I meant with the Chief Coroner, which is having it both ways, because the coroners really do not have time to train themselves. That is what we have been struggling to do and even though the budget has recently increased and training is getting a little bit better, it is still basically coroners training coroners, and there are a number of things wrong with that. If you will forgive the analogy, if you want to charge a 12-volt battery you do not put 12 volts in; you put in about 17. One wants somebody bigger and better than oneself if you are going to raise your game, to switch the analogy again. So I am in favour in general terms of a Chief Coroner saying, in consultation with the Advisory Council and so on, "This is what you ought to be trained on. This is the sort of thing." But we have turned to the Judicial Studies Board with some success in this respect, and I think if the Chief Coroner had the help of the Judicial Studies Board - and again, it is yet more work for the Chief Coroner but we will not have much time to do it - I think that is the right home for it, and I hope the Chief Coroner would come and talk to us direct as well. Q117 James Brokenshire: Just following on on that issue on training, obviously, you have talked about the pressure that would be put upon the Chief Coroner in terms of time and also the time that would need to be freed up from existing coroners. How would you see that actually working in practice? It is all very well for the Chief Coroner to set out standards and to set out perhaps the issues that a coroner should be trained on, and if you do not literally have the time in the day to do the work that you need to do, how do you find the time to do the training? Victor Round: Again, I think it must come back to delegation. Having seen the job as it was written, I had envisaged that there would be a number of Assistant Chief Coroners, one of them would be Assistant Chief Coroner, Training, another might be Assistant Chief Coroner, Appeals, and so on. Unless it is divided up that way - and I think it was envisaged it would be a High Court Judge as Chief Coroner - I cannot imagine us having the benefit of enough High Court Judges' time to cover it all. Q118 Chairman: You do not need a High Court Judge to organise training though, do you? You would have a Director of Training. Victor Round: I do not see a problem, sir, unless I have misheard your question, with the High Court Judge directing what the training should be and coming and making keynote speeches and so on, but I am quite sure he or she would not have time to get down to the detail. But if he or she could turn to an Assistant Chief Coroner and say, "Now, you sort this out with the Judicial Studies Board", make attendance at training courses compulsory, introduce something like continuing professional development with points or whatever it is, and introduce massively more training than we have at the moment. But we cannot do it any more. We really do not have the time. Q119 James Brokenshire: Is there also another resource issue here? To actually find the individual coroners at the local level, their time, they would need presumably to take time away from their general duties, you would therefore need to have assistant coroners deputising for them, and there is a cost implication in that which will presumably need to be borne by the local authorities in that circumstance, given that the existing system is to be retained. What sort of impact do you see that as having in terms of actually implementing proper training on the ground? Victor Round: It is a problem already, which is why virtually all our training is done at weekends, because we cannot get away from work, or rather, we cannot get coroners to attend during the working week, and the only way we can get them away from their jobs is to say it is at the weekend, and then they come. In fact, we are just experimenting for the first time with trying to train coroners during the week, and we are wondering whether they will leave their desks to come and do it. It is a very new thing for us. Otherwise it has always been arrive Friday night, leave Sunday afternoon, and then straight back into inquests on Monday morning - unpaid of course and without a break, and you will find, sir, I think that the same problem applies to coroners' officers, because police forces do not like to release coroners' officers for training courses because they then have to put somebody else in place. It is exactly the same problem. There it is not so much the money as the actual able man- or woman-power to put in place. Some local authorities are very good about letting us pay deputies while we go off on courses and things, because other courses we have to go to are not at weekends, but our own specific training courses are nearly always in our own time, for that reason. Q120 James Brokenshire: From what you have said, obviously, with new people likely to come into the service in terms of fulfilling the full-time coroner's role, training is going to be quite an important issue. Victor Round: It is, sir. What happens at the moment is sometimes quite bizarre. There is nothing like new blood, and it really does improve the strain; there is no question about that. But one or two appointments from outside the coronial service have been made by the local authority and then they say, "Where do I go for my training now?" "Oh, well you might get a place on a training course for four days in six months' time. Meanwhile, you start your inquests in a few weeks." Q121 James Brokenshire: Let us move on to another issue, and perhaps the glaring omission from the Bill, which is in connection with death certification. You will be well aware of the Luce Review, and its recommendations that there should be a direct link between death certification and the coroners service. You will no doubt be aware that Dame Janet Smith has also been quite trenchant in her comments on the fact that there should be this inextricable link between death certification and the coroners service. The Home Office originally seemed to take that on board but clearly these provisions contained in the Bill make no reference to that whatsoever. What do you think will be the consequences of this decision? Victor Round: If I could start by saying I also notice, sir, that Mr Luce on the last occasion referred to that absence as a great hole in the road. I think we have to mention Dr Shipman at some stage. These reforms, with respect, have just nothing to do with the Dr Shipman problem at all. They do not impinge upon it at any point. One reason why they cannot is that nothing has been done about modernising the death certification system. It is dropped behind us. I remember one of you asking on the last occasion something like "Is it worth going on with this bit?" given that death certification is not being modernised and tied up at the same time?" and I think the answer is since we are reviewed or re-analysed every 30 years cyclically, and it really has in the last century been that, and nothing happens, we had better just take what reform we can get, even though we know that the death certification system does render us much less able to do the job. There is no statutory definition of what doctors or registrars must report to a coroner. That is a headline lack. With respect to things that have been said about improving matters by training coroners, it really is no help at all to be brilliantly trained if you do not know the particular patient lived or died because nobody has reported the matter to you so you cannot apply your skills to the case anyway, and we are still in that situation. Q122 James Brokenshire: I was quite struck by what you said in terms of the impact of this Bill being the death knell of a local coroners service. Do you think that that therefore increases the risk of a Shipman-type incident, because coroners are more taken away from the local level and therefore are not likely to be plugged into those local networks and therefore will not detect even a hint of whether there may be a problem? Victor Round: It would be so tempting as part of my campaign to latch on to that, sir, but I do not think it is quite fair, because the real eyes and ears of coroners are actually their officers, their all-important coroners' officers. As long as their strength is kept up and their morale is kept up and they are trained and improved, those are our eyes and ears, and so as long as they are locally available to families, I think it would be unfair to pretend that, just because the coroner is miles away, families will not be able to communicate with them. We had this plan - we were so excited about it - that we would create a one-stop shop where the family could come in with their paperwork and if it suddenly turned into a coroner's case, it would be all right; behind that door is a coroner's officer, maybe not working for the registration service, maybe working for a totally different unit, but as long as the family see it as all in the same building, and they can get rapid access, maybe that does not matter too much. One could get there eventually alongside this legislation and I think that would solve the communication problem to some extent. As long as there is good local access to groups of coroners' officers who are themselves in close touch with the coroner, families should be able to communicate their concerns about a particular death. Q123 James Brokenshire: Your response is heavily caveated on, in essence, the retention of good coroners' officers at a local level. Do you think that there is any risk as a consequence of the changes that have been put forward in this Bill that that might change in some way? Victor Round: Yes, sir, oddly enough, not so much because of the changes in the Bill as because of the lack of changes in the Bill. Who can blame the Local Government Association for saying, "Look, are we providing this service or are we not? We are sort of half in, half out." Then they have exactly the same situation vis-à-vis the police, where some police forces take the view "We will provide coroners' officers. It helps our CID side enormously. It means we have our ear to the ground. We can pick up on all sorts of drugs deaths and drugs information." The new untoward incidents in hospitals inquiries that they conduct and so on are much better done with police-employed and involved coroners' officers, to my mind, but there are a few areas where coroners' officers are supplied in whole or in part by local authorities. Very few local authorities are willing to take that on and I know coroners are now faced with the two most important people to us of all, the local authority and police, arguing about who is going to provide and finance the people we rely on to work with. We are in this strange situation of directing their day by day work, they are our eyes and ears, but we do not pay them or supervise them. We have no controls over them. We are entirely on our own. The lack of change in the Bill - it does not even name coroners' officers, as far as I can see. So it is not the changes introduced; it is the failure to introduce changes that will, I think, really endanger the continuance of the bit of pride they have built since they have formed a Coroners' Officers Association on their own and so on; a bit of self-worth will be bled away again. Q124 James Brokenshire: So it is almost like an indirect impact that might highlight the lack of changes on the death certification side, and whilst it is indirect, it might actually exacerbate the need to have stronger provisions in death certification to avoid something like a Shipman type case. Victor Round: Yes. There is another avenue, of course, which does not get mentioned very much but one of the plans - and I think it was implicit in the fundamental review, and it certainly would have been in Dame Janet Shipman's plans - was that there would be one body release system, whether burial or cremation, which we for historical reasons do not now have. If that system were enormously strengthened and trained, then one could see the beginnings of some part in the medical examiner checking system. We wanted that. We wanted to be able to turn to them for help and send families to them and everything else, and if society does not want to spend the money, I cannot recruit the doctors, so be it, but in some way something has got to be done because registrars do not quite know whether to refer cases to us or not, and they do not have the training or the expertise. Crematorium referees do but their staff do not. Doctors themselves at the moment are untrained in death certification, and have been for 30 years, and they do not know what to report. There is just a possibility, I suppose, that in regulations under the Act one might be able to name reportable deaths; I do not know. It is a very big hole at the moment that still doctors do not know what to report. If this were passed tomorrow, they would know no better than now what to report to us. Q125 James Brokenshire: Therefore, if the doctors do not know what to report, other people do not know what they should be reporting and therefore there is still a big gap out there about people who might manipulate and use the system. Victor Round: Mr Luce's hole in the road is still there, yes. Chairman: Mr Round, thank you very much indeed. In only 40 minutes I think you have demonstrated the value of pre-legislative scrutiny by Select Committees, with their witnesses giving them such good help. Witnesses: Chief Constable Peter Fahy, Association of Chief Police Officers; Councillor Bryony Rudkin and Steve Charteris, Local Government Association, and Christine Hurst, Chair, Coroners' Officers Association, gave evidence. Q126 Chairman: Welcome. You have obviously all listened to the proceedings before this, so you are already reminded of some of the issues. Can I just throw at you as well a general question. You are all familiar from various standpoints with the coroners and inquest system. Do we really need such a system or does it involve us in formalised procedures which in a number of other jurisdictions - they do it in Scotland - people do not find necessary except in a much smaller number of cases. Does anyone have any thoughts about? Chief Constable Fahy: If I can start, I think that if the system is to continue as it is now, that is a very good question to ask. I think there is an opportunity, or there could have been an opportunity in terms of strengthening the system, strengthening a lessons learned approach and clarifying the processes and the roles of all the people involved in the system for the coroners system to be of real worth and real value. I think the consent at the moment is that it is an opportunity missed, and therefore I think you are right to question the continuing ability of a system like this, unless it has access to all the information, unless it has well trained people out there making inquiries, so it gets the best possible picture of the issues behind deaths, behind accidents, and lessons can be learned, good service can be given to the families involved and hopefully we can try and prevent those deaths that can be prevented in the future. Q127 Chairman: It is a bit of a steamroller cracking a nut sometimes, in that it invokes a whole series of procedures which may be absolutely essential in some sorts of cases and entirely appropriate, but cumbersome and perhaps even distressing in a lot of cases where a more limited and informal inquiry might be sufficient. Councillor Rudkin: A service to the public is what local government would see as being the starting point. If you say "Do we need this service?" well, maybe not that service but we need a service, and you are right to say "How does it have to feel for everybody?" Not everybody needs the really intense end of investigation. Everybody needs a service, and we in local government would certainly see the customer care end of that as being one of the most important aspects for us, to make sure that it is seen to be done properly but that it does it in a way that people feel comfortable with. Christine Hurst: From a coroner's officer's point of view, we are the interface with the families, with the bereaved, and I think the bereaved actually do get a lot of reassurance when we are involved. We can then explain to them what the procedures are going to be and what inquiries we are going to make, and I think it is the appropriate questioning, the questioning that the coroner's officer gives to the family, and the appropriate investigation or inquiries that we make for them that gives them the reassurance. Q128 James Brokenshire: I would like to come back to the issue of death certification and your thoughts on that. I know ACPO in their written submissions to this Committee said that no system can be perfect but given that the Government has decided not to include death certification within the Bill that we now see before us, do you think that it strikes a good balance between safeguards against Shipman-type incidents on the one hand and public safety on the other? Chief Constable Fahy: No. You have heard some of the concerns from Victor Round about the fact that there is a lot of lack of clarity about the roles and responsibilities of various people in the system, and so there is a real need, I think, for a major piece of work to try and clarify those issues. I know coroners' officers spend a huge amount of time answering queries from doctors themselves as to what they should be saying, as to whether they can issue a certificate. I do not know whether you are aware that doctors can issue a certificate without actually seeing the body. So there is a big problem about all sorts of people involved in the system. The roles and responsibilities are actually unclear. The system only really survives because of the seriousness of it and the fact that on the whole, people will try and do their best in the circumstances, but for instance, the responsibility of people who attend the scene of a death, the responsibilities of the ambulance service, the doctor, the police officers, on the whole are fairly unclear. So in terms of that issue about death certification, what is necessary is a whole-system approach and as many safeguards as possible. That comes from a good system of data capture, data analysis, and opportunities for families and other people to raise concerns. As has been said, the coroners' officers play a vital role. They are the foot soldiers here. They know who are the doctors they need to be wary of, they know the circumstances, they know the suspicions and the circumstances in which they need to ask further questions, but it is really about having a number of safeguards within the system, and really, even if there were, for instance, two doctors each time for a death certificate, yet that was still done on the basis of just a paper exercise, clearly, that would not be much of a safeguard. I think a lot more work needs to be done to be absolutely clear about what are the processes and what are the situations in which a doctor can issue a certificate or not. At the end of the day, the system has to rely on doctors, on trust in the medical system. At the end of the day, you are relying on a doctor to give an opinion one way or the other, unless you are going to do a post mortem and toxicology in each case. So really, where we are disappointed is that there is still a need for much more detailed piece of work to actually clarify the roles and responsibilities. I think also, to deal with that issue the Chairman asked about the steamroller to crack the nut, well, actually in some cases, yes, a lot of the processes probably could be simplified and clarified but we need to do that piece of work because the problem is, as is outlined in the reports, that there is a huge variation in the way that the coroners service operates across the country. Q129 James Brokenshire: It certainly sounded from the evidence given by our previous witness that a lot of the pressure falls on the coroners' officers and that that will obviously remain post the implementation of this new structure. I do not know, Mrs Hurst, whether you have any comments on what you use in terms of the current practical situation and the implications of what this might mean moving forward, given that in essence nothing is changing here. Christine Hurst: That is basically it. I do not think there would be any move forward at all. The Coroners' Officers Association believe that all deaths should be reported to the coroners service and we agree with Dame Janet Smith that it would go some way to remedying the defects within the death reporting system, but that would also enable the coroner's officer to make appropriate inquiries with the doctor, with the bereaved and with all parties concerned, thereby giving them the opportunity to raise any concerns that they have. We also think that if all deaths were reported to the coroners service, that would also eliminate any doubt that doctors have as to what cases should be reported to the service. We also believe that if you have a system where every death is reported to the service, it would alleviate a lot of alarm and distress that some families feel when they find that their loved one's case has actually been referred to the coroners service. It can be quite alarming for them, and we have to spend quite some time reassuring them why we are involved. I think the reporting of all deaths would also facilitate a programme that could be interrogated, and that then would highlight any anomalies and detect any trends, and maybe the likes of Shipman might be brought to the fore a lot sooner. I know at the present time in my own area we are looking at a number of nursing homes and there is a certain amount of deaths that have come from one nursing home, and we are focusing on that particular nursing home. Q130 James Brokenshire: Obviously you heard some of the comments that Mr Round made in his previous session, and the points I was probing as to whether inadvertently the lack of change and some of the tensions that exist at the moment might exacerbate or make the problems worse in some way. Would you share that view or would you have any other comments? Christine Hurst: The Coroners' Officers Association really did want some change, and we are very disappointed in the lack of any change really with regard to coroners' officers. We are now, I think, losing a lot of experienced officers, and there is no formalised training for officers. The COA in partnership with Teesside has formulated some accredited training courses but there is no support for the officers to go on that; there is no resilience in the service for them to be allowed to go on that. There are a lot of problems, and we are getting experienced officers now leaving. There are only about 450 officers in England and Wales dealing with 232,000 deaths, so it is quite a heavy workload that officers have. I can only see that, if we are losing experienced officers because of the poor morale that they have now and the lack of support by some employers for them, with resourcing and training, then it has got to impact. We will have new people coming in, they are not going to be trained, and that has got to have an impact on the bereaved. So yes, I think lack of change. Q131 James Brokenshire: I do not know if your colleagues from the LGA have anything to add in relation to this, whether you have any comments on what you have heard. Steve Charteris: Peter raised a fundamental issue that seems to be avoided in the draft Bill, the issue of the tripartite relationship between the coroner, the local authority and the police. The clarity in the responsibilities is essential for the service to move forward, and this does not seem to assist. It seems to leave everything to local agreement where that can be achieved. We can see nationally that this has always been the case, and some areas have managed to develop local agreements but others have not. Q132 James Brokenshire: I am sure we are going to come on to probe some of the structural arrangements in all of this. One interlinked point relates to the provisions that are contained in the Bill which seem to give the power or the right for a coroner to report a matter to a person who has power to take action in relation to a particular incident, and indeed also to report facts on to the Chief Coroner. You might suggest that that may be a way of trying to raise alarm bells in some way if there is some problem that has been identified. Do you think that that type of approach - I will direct this to you, Mr Fahy - goes far enough to meet ACPO's concerns about the use of information generated by the coronial system for public health and safety purposes? Chief Constable Fahy: I am not sure there is enough clarity behind that particular proposal to be absolutely sure. What has happened is that really, over the last ten years the whole world of partnership working at local level has developed enormously, and the point I was trying to make on the evidence really is that the coroner is not connected really to that at all. So at the moment he can issue recommendations and write letters and actually nothing happens. It is a huge opportunity missed. There are all sorts of issues which could be looked into in terms of particularly things like deaths from domestic violence, deaths from drug overdoses, obviously child deaths, where there could be important lessons learned which are not being fed into the system. So I think it needs to be a bit more structured than the way it is termed in the Bill to make sure that there is, as I say, a more robust process, making sure that we are learning those lessons and that there is clarity about how the coroners system feeds into all these different streams, local area agreements, safer and stronger communities groups and, as I say, this huge network of partnership working which has evolved and which at the moment the coroner is completely outside. Councillor Rudkin: Directors of public health in the health system where we had health authorities and PCTs would make annual reports that would have exactly those sort of flavours towards them. There might be some particular trends with child deaths that local authorities could pick up on and could certainly do something with and could learn and could actually spread good practice amongst themselves. There are models already in the partnership working that has been described where we do listen to people who would talk to local authorities and talk to the police and say, you know, these are things we can do collectively, but I do not see how this... and coroners could be vital in that. It could be very helpful to everybody but I do not see how that actually fits into this. For health, for example, there is health scrutiny that exists, so local authorities can scrutinise health bodies and learn lessons, and there does not seem to be that kind of accountability. Steve was saying about accountability; we do not feel that that is embedded in this in a way that could be useful and practical to everybody. Q133 James Brokenshire: Just to follow that through, because in essence, the key word here is "may"; it is not "shall". Certainly, from my understanding of the way that fatal accident inquiries operate in Scotland, at the end of the inquiry what would happen is that the sheriff would actually specifically report on precautions by which the death might have been avoided and any defects in the system that caused or contributed to the death. Would you welcome something actually being physically codified there so that in essence coroners are required to set their minds to that type of approach so that it is actually on the record and therefore the information can be used whether it is reported on or not? Councillor Rudkin: I think, yes. I would be guarded in so much as it goes back to the questions you were quite rightly asking about training and wanting to make sure that there was some kind of standardised approach so that one did not have a maverick coroner who particularly went down one alleyway with one issue. But if there were to be some regularisation of training and approach, I can see that there would be value in highlighting certain trends and actions, and again, that is where good practice comes in, so that if you knew somewhere else somebody had made a recommendation that was of use, you could pass that on, and it would seem to me that that would also be part of training, sharing good practice and improvement. I can see the merit in it, yes. Chief Constable Fahy: It is hard to underestimate really the huge amount of material that coroners actually gather. For instance, for every fatal road accident there will be a huge file and a huge amount of evidence about that particular accident. In a lot of cases it will not go into the criminal court system for various reasons, and I think it is opportunities like that that are sometimes lost because the coroner is perhaps not tied into all the other work the various agencies are carrying out on road safety in general. That is some of the weaknesses. We are just too close to a judicial approach to this. It has got to be very firmly, I think, a lessons‑ learned approach, where the coroner is able to connect into the different agencies and to try and make sure that lessons are being learned, and could be in a powerful position to knock heads together to make sure that is actually happening. Q134 James Brokenshire: Obviously, the Chief Coroner has a role in collecting information from the regional coroners under the new system that is proposed here, so there is quite a lot of data, as you have rightly highlighted. How do you think that needs to be used or shared or in some way passed on in order to have some of the wider public health and safety issues that you have rightly alluded to in terms of things happening on the ground? Chief Constable Fahy: I personally see that happening at a national level as quite difficult. I have to express some confusion about how it links into all the other systems collecting data in things like accident and emergency departments, where clearly they will collect huge amounts of data as to how accidents are caused and injuries and things like that. I think the value of that role is more actually at a local level. There may be some national trends to be picked up but it is probably more about how agencies are working at a local level in terms of perhaps picking up people that may have problems with depression that may lead to suicide, or issues about the agencies not working together well enough on road safety issues, whatever it might be, to the way the agencies are working together to try and prevent deaths in domestic abuse. That is more likely to operate at a local level but really at a high enough local level, shall we say, which again is tied into the partnership working. That is difficult, because obviously everything is changing in terms of local government and police and everything else, but certainly at the moment, at the sort of county level, certainly in shire areas, which at the moment is where most of the key agencies join up. Councillor Rudkin: We do have models of sharing good practice. I absolutely agree about the local. I can think of a local road safety issue in Suffolk, which is very particular about a road where there had been a spate of accidents, and what we do locally together, fire service and other agencies, together, but actually, local government is getting better about sharing good practice amongst itself. The Local Government Association takes a lead role in that. So whilst there are some things that are local, the local can become of national use in terms of informing on a different area, and we are getting much, much better about being ambassadors for ourselves and helping each other, and I would see that kind of local knowledge being translated into national use elsewhere as being a key to actually getting more added value from a coroners service and collecting all that data that you have referred to. Q135 James Brokenshire: Obviously, this all comes down to time and resource and also maintaining that local link, but in essence what you are telling me is it should be very much bottom up in terms of the use of the information rather than top down. Councillor Rudkin: Ultimately, though, it could save lives and therefore it could save money to all sorts of parts of the system. Therefore, although it has a cost, I think we would also want to take on that challenge of eventually turning that round, so that in fact there were fewer deaths in some of those areas we talked about. That has got to be a better and more efficient use, apart from also the human cost, that has to be better for everybody. Steve Charteris: The coroners are naturally feeding a lot of different information into different agencies. I know in Hertfordshire we are feeding that information into suicide audits. There are lots of different forms of information that we pass to other agencies. It just feels as if there is no national approach to that. I know recently coroners expressed concern that they were being asked to supply data to so many different agencies and the time constraints, etc, were causing problems. There is information being passed, but it is not nationally organised. Q136 Dr Whitehead: The Government in the Bill is suggesting that there will be additional costs of the new system, particularly with the new responsibilities for maintaining proper accommodation for coroners, for example, and they have suggested, I think, that estimated costs will come to start-up costs of £14.5 million and additional running costs of £5 million per annum. How do you see that from the LGA's point of view, particularly in terms of those costs falling on local authorities, whether or not the Government agrees in theory to underwrite them? Councillor Rudkin: I think to begin with we would question that. We can provide the detail of this but we would say that actually only £9.4 million of that would go to local authorities, including police authorities if you put the two in together. So we are not convinced by what we have been told about the money there. I think we could also point to other examples: the new licensing system which has been set up, which also falls into my brief at the Local Government Act, is something where I think as the year has gone on, the new legislation was introduced in November, and obviously time has passed and the cost of that. We are seeing a heavy use now of extended licences at the moment during the World Cup, and I know there are questions about what the real cost is. I think anybody who tries to predict in advance is doing better than predicting football scores, frankly, because I do not think that we know and that we can say, and we would certainly want to question that. Of course, there are variations. The truth is that because, I think, local authorities have felt that reform was coming for such a long period of time, some authorities, police authorities and local authorities together, have perhaps not invested the money that they should have done because they have been waiting for something else to happen. Therefore there have been deficits. I have seen evidence of deficits in my own region. We must take responsibility for that but it is actually a part of the system about waiting for change really. We would certainly want to question that. We will look in more detail at those figures, and we would be happy to come back with what our members say, what our constituents say. Q137 Chairman: Are you going to do serious cost estimates on what the Bill proposes - not your idea of what the perfect system would be but what the Bill is actually proposing - bearing in mind that, as I understand it, quite a lot of the part-time coroners have an administrative support system which is really on the cheap, because it is a part of their practice offices, and if you were to set up an office wholly devoted to a coroner's duties, new costs would be involved? On the police side not all costs are charged out to coroners. Therefore, there is quite an exercise to do, which your two organisations are probably best placed to do. Councillor Rudkin: Indeed, and there is an awful lot of - the Chief Constable in Suffolk described it to me as not so much good will but custom and practice in terms of the money that the police in Suffolk have put into it, and at any one time a police authority could turn round and say, "Actually, we are not going to do that any more." We are all under budget pressures. Q138 Chairman: Or "You are going to have to pay us for it." Councillor Rudkin: Yes, quite, and I have to say that with the amalgamation of forces and the review that is going on, I have no doubt that in looking at the base budgets of different constituent authorities that there will be some questions asked if it is found that a particular authority has a particularly generous kind of arrangement and somebody else is giving not very much. This will be part of the discussion, frankly. Q139 Dr Whitehead: So bearing in mind that there may be quite a lot of additional expenditure which you are not too clear about the funding of, and indeed, I think ACPO has in its evidence to this Committee suggested there ought to be a clearer form of funding upon local authorities, your evidence to this Committee suggests either that the coroners service should be brought fully into the judiciary or should be integrated as part of a local authority, I presume on the lines that accountability should follow financial responsibility. Which of those do you think is the preferred outcome as far as LGAs are concerned, if you had an ideal clean sheet of paper to write a draft Bill? Councillor Rudkin: I suppose for the LGA we would have to say that, as we do believe in local delivery of service and this bottom up approach that was used, I would personally want to go for the local authority approach because I also think that gives an accountability that people recognise and understand and is there. But I think you have hit the nail on the head in as much as what we want is something that is clear and is obvious and in terms of the finance is something that we can be accountable for and we can control. I do not mean that in the control freak sense of the word but in so much that we would have greater powers than we do over the moneys that are spent. My board has not discussed this so that is just my personal view but on the basis that I think we are into local service delivery. Given that it is local authorities with the police with the kind of partnership working models that we now have, which are now complex and sophisticated but actually very good and very good for the public, I think that is what I would welcome. Q140 Dr Whitehead: Do you think there might be a concern that should coroners' officers effectively be directly accountable to a local authority system, where the coroners' office is investigating a death that has occurred perhaps of someone in local authority care... Councillor Rudkin: I think there would be proper checks and balances. At the moment, if there would be a death that would need another social services authority, for example, to investigate, we already have those kinds of checks and balances, as indeed do the police when investigating anything that involves one of their own, and I think with proper recognition of those factors, that is not insurmountable. Q141 Dr Whitehead: The Government has said in the Bill that local authorities should be represented on the Coronial Advisory Council. Does that impress you much? Councillor Rudkin: It sounds like I ought to be impressed, does it not? I think we would still want something a little more real than that. We would rather have something directly there. We understand that is an advisory body representing a broad range of interests, and I do not know quite how we would feel that that was enough, frankly. Q142 Dr Whitehead: The Government has also in Part 4 of the draft Bill, within the new governance system with the Chief Coroner, included investigation of complaints which could result in a referral to the Office for Judicial Complaints. Do you think that perhaps could go part of the way towards meeting some of the concerns that you are expressing? Councillor Rudkin: I think it is a bit out of touch. If we are wanting people to have the one-stop shop kind of arrangement where everything is dealt with in one place, as was referred to, I think, again, a complaints system that is a different complaints system to others, because actually people's complaints are usually very complex, are they not? They are not going to relate to just one part of a service. I think we would want to have something that was a better and simpler governance structure and that made more sense to people who are bereaved and therefore need things to be as simple as they can be for them to negotiate. Q143 Dr Whitehead: On the matter of bereaved people, do you welcome the provisions in the government's draft Bill about arrangements for involvement of those bereaved in the coronial system and do you think perhaps in terms of what you have already said about the efforts local authorities have made to achieve a greater degree of co-operation between providers in different parts of the system that that perhaps could be something that could be a genuine way forward as far as local authorities are concerned? Councillor Rudkin: I think we need to make it better. Anything that makes it better for bereaved people... As a local councillor, I have been in County Hall when bereaved families have arrived, and I have been ashamed, frankly - not of the way in which they were handled, but, if you like, the system that there was. There was nowhere even for them to have a cigarette because we have a no smoking policy in the building, and just a real lack of understanding of what facilities people require. I think that anything that makes it easier and better for people in what must be the most difficult of circumstances has got to be an improvement. My colleague here from Hertfordshire can tell you that they have done a lot to actually look at that customer care end. There is good practice out there about what people are doing to make sure that people have a better experience - one that nobody would want but that it is a better experience and that their engagement and involvement is meaningful to them. That is a bottom up thing, is it not? It is not just about saying "You have been involved but how meaningful was it for you to have been involved and is it part of your grieving process and helpful to that? Q144 Chairman: If you, any of the three bodies represented here, do some work on costings, the Committee would be very interested to see it. Councillor Rudkin: We are good on costing. We have done the licensing costings and we are very used to gathering information from our body. We would be happy to do it. Q145 Chairman: Did your estimate on licensing prove near the mark? Councillor Rudkin: Please, do not ask. Q146 Chairman: Just a test of your credentials in these matters. I want to turn to a number of matters relating to coroners' officers. The ACPO position is that you would like to see a national solution involving a transfer of many of the inquiries into sudden deaths carried out presently by operational police officers to coroners' officers. Does that not have the problem that many cases of sudden death, suspicious circumstances, are only uncovered as a result of proper investigation, and that some police forces regard this investigation of sudden death as a core function, not one to be transferred? Chief Constable Fahy: We will be very clear. If there is any suspicion about any death, we would want to be told immediately, and whatever happens, we will still have a heavy involvement in sudden deaths, in terms of deaths in the street, all sorts of cases, but there are lots of other inquiries into cases like suicide which at the moment are passed from the coroner's officer to operational officers to carry out those inquiries. It is in those sorts of cases that it would be preferable if that could stay within the coroners service. As I say, we would have no problem at all about crossing the gap into criminal activity and absolutely we want to be involved, but I do not actually see a problem with that. It occurs in a number of areas, and this is the difficulty about the differences in the coroners service across the country, but we think overall that if the coroner is directing the inquiries, then he or she should have the staff to carry out those inquiries unless they require that police expertise, but as I say, I would want to be very clear that if there are any suspicious circumstances, we would want to be involved right form the start, and whatever system comes up, we realise that, as now, out of hours, out of office hours, at weekends, all sorts of cases, police officers will continue to be in many cases the first people on the scene of a sudden death and still have very heavy involvement in those cases. Q147 Chairman: You normally are the first people on the scene in those circumstances where a body is found. There may be no evidence of anybody else being involved. In the smaller jurisdictions, would I not be right in saying that the coroner might not involve the coroner's officer at all, because all that would do would be appointing another of your officers to take over the information which the first officer on the scene has obtained and therefore many of the coroners in the smaller jurisdictions would rely on your officer to do the whole thing? Chief Constable Fahy: Yes. In a lot of cases that will still be the case. A police officer will have attended, will have got the basic information, will have done the identification, will have filled in the forms, and will then pass to the coroner's officer... Q148 Chairman: The coroner's officer in a smaller jurisdiction may be another police officer who is actually... Chief Constable Fahy: Even in the bigger jurisdictions it is often another police officer, certainly somebody employed by us. It is distinct roles. Obviously, in the ideal world, we would prefer the coroners service to have a 24-hour service and so they turned up at all these sudden deaths, because we end up having to go to things like death on arrival at hospital. If somebody is brought in dead on arrival at hospital, then often a police officer will have to attend to do the identification, to notify next of kin, to deal with any property, despite the fact that that hospital is full of medical staff who we feel could be doing that job themselves. But we have to do it because there is no doctor there that can issue a death certificate. We have to be realistic about the finances that are available and that there is not going to be a new coroners service that is going to take on that sort of responsibility and that will still lie with the police service. Q149 Keith Vaz: The draft Bill talks about the improvement of standards in the service, but it makes very little changes to the circumstances of the coroners' officers themselves. Were you surprised at this lack of tinkering with such a central figure in the relationship between the bereaved and the service? Christine Hurst: Certainly the Coroners' Officers Association were very disappointed, and I would go so far as to say dismayed really at the lack of recognition of the role of the coroner's officer, which is quite an important role with the families - a very important role with the families. We are the interface with the families, as I mentioned before. The lack of any comment with regard to coroners' officers has taken us somewhat by surprise, to be quite honest, because we had hoped that the system would be reformed and that coroners' officers would come under a unified national system that would give us the pay and conditions and the appropriate recruitment and resources to do our job and also with sufficient officers to manage the workloads that we have and, most important of all, a standardisation of practice as well. Q150 Keith Vaz: Chief Constable, do you agree with that? Chief Constable Fahy: Absolutely. Coroners' officers play an absolutely vital role. It is not a job for a police officer. It increasingly requires a very high level of medical expertise to understand the medical certificates, to be able to question doctors, to be able to answer questions from doctors. It really is a very, very skilled role. So it is more than just dealing with families; it is a vital role, and the system is extremely ramshackle across the country. It is a mixture of police officers, retired police officers, police staff members that we have been able to employ, but it is incredibly ramshackle and has only really survived because of the fact that we have kept on being told by government that they are going to sort it out. This has been really for the last seven years, and so police authorities have just kept on trying to support the system because we believed that the Government was going to sort it out. Q151 Keith Vaz: So it is a missed opportunity. Chief Constable Fahy: Well, I do not think we can afford to miss the opportunity, to be quite honest. I have already had discussions with the Local Government Association and we are going to take this forward in any case, because we cannot afford to miss the opportunity. The coroners' officers are too important. There are training issues which need to be sorted out, and also this key issue about there is a lot of work that needs to be done on just clarifying the roles and procedures and trying to make sure that we capture the best practice across the country to try and make sure that the system is working as efficiently as it possibly can. Q152 Keith Vaz: Cllr Rudkin, do you concur? Councillor Rudkin: Absolutely. I think there is good practice. We do need to share that, and the disparate nature of how it has operated, even within one county, where we now in Suffolk have one coroner but we used to have four, with different standards, different terms and conditions, and it just is not simple for people to understand and follow. I am meeting the Association of Police Authorities tomorrow and high on the agenda is the discussion about the reform of the police service and how that fits back into it. This is the point at which we have to discuss it because if other things in the jigsaw are going to be altered, then we have to discuss it now otherwise we will lose that opportunity. Chief Constable Fahy: London has seven coroners' districts. I have just been talking to a colleague from the Metropolitan Police and each one of those works in a slightly different way, so they cannot actually use their staff to move between those coroners' districts because the practices are different, and that clearly is very unsatisfactory. Q153 Keith Vaz: Now that the Government's policy is clear, do you foresee any of your various employers providing more resources to help with this system? Chief Constable Fahy: The police authorities' view would be that we are facing reductions in other areas. On the whole, we have tried to preserve the number of coroners' officers, under some pressure, and I regularly get calls from coroners asking me to intervene with various chief constables to see if I can persuade one of my colleagues to release more. So I do not think, with all the other pressures that you will be well aware of on the police service, we can say that we would put more resources. On the other hand, we do think there are a lot of opportunities to try and run the system in a more efficient way. Councillor Rudkin: Local government finance is in the same position. We do try and do things differently and more efficiently and we have taken on best value and all sorts of other agendas as well, and we do try and use the money that we have as creatively as we can, but I think we would be hard pressed to find any more. Christine Hurst: By leaving coroners' officers as they are, we believe the DCA has lost a real opportunity to modernise, standardise and professionalise death investigation, and one of the comments before with regard to coroners' officers taking over the role of police officers at the scene of death, yes, I think that is perfectly feasible, but we need more staff to do that, we need appropriate training to do that as well. At the moment officers do not get any formalised training at all. It is on a shadowing basis whereby the new coroner's officer is taught by the outgoing coroner's officer, so there may not be any will or commitment there for that coroner's officer to pass on any good practice. There may be poor practice, and that is promulgated basically down to the new officer. It is a downward spiral, to be quite honest. Unless we get appropriate training and resourcing, I cannot see that the service could cope with that. Chief Constable Fahy: I would also point out that if you are going to have a system which is going to have more appeals and more active encouragement for the public to raise concerns and complaints, clearly that is going to generate more workload, which will inevitably fall either on police forces or on the coroners' officers themselves. Q154 Chairman: The issue of training, of course, will become the responsibility of the Chief Coroner, will it not? Christine Hurst: The Coroners' Officers Association are not quite sure about that. I think the Bill does not say anything about it being responsible for training of coroners' officers. We are in a situation at the moment where we are employed, but we are not owned, if you like by the same employer as the coroner. The DCA at the present time has said that they cannot influence any of our current employers to provide us with more resourcing, to provide us with training, and I cannot see, as we will not come under the Chief Coroner, how he or she will have the power to say to our employers "You must do this" or "You must do that." Q155 Chairman: He might have the power but not the resources. The power to provide a training programme. That would be a question of releasing people to go on the training programme. Christine Hurst: That is another thing. The fact is that we are in very short supply, our workloads are very heavy, our inquiries are far more complex than they used to be, there is lack of support and officers are now actually feeling stress and leaving the service. That is putting an even bigger burden on the coroners' officers service. Q156 Chairman: Here we have a situation where everybody agrees that the system needs reform, all the witnesses we have seen today think that the Government's proposals do not go far enough to meet the various requirements for reform, the existing funding bodies, local authorities and police, do not have any more money to find for it, we all know that the DCA's budget does not have any more money to find for it, so we are embarking on a very necessary reform inadequately because we cannot afford it. I do not see where we go from there unless we can find offsetting reductions in costs by running some parts of the service in other ways. Is this not a doomed exercise? Christine Hurst: It would appear so to me. Councillor Rudkin: We would try to be more positive. It is like licensing again. The challenge is there to do something better and to do something differently, and I think with more flexibility, and I would say this, if local authorities were to have more power, they would be in a position to look for some of those savings and to make some of those efficiencies. We have done them in other parts of local authority services, because we have had to and because it has been a good thing anyway, but we feel that this does not actually give us those hooks and those controls. We work much more closely with the police these days. Local area agreements mean that all parts of the service, including the hospitals - I was horrified to see the costs that are charged by hospitals for storing bodies. There have to be better ways of us negotiating some better deals with our health partners. Q157 Chairman: Some jurisdictions own their own mortuary. Councillor Rudkin: Why not? We could do things like that if we had more control. This is why I referred to control. Those are the things that we could explore. But we feel that does not actually give us the opportunity to do that, and therefore, to maximise the resources that we have. That is the disappointing thing, because, you are right, we could set up mortuaries. That was exactly the question I asked, "Why aren't we doing this?" when I was shown the figures in Suffolk, because it seemed to me to be - not a business opportunity but something we could do that would benefit people. If we do not have that power and that control, then we cannot. Chief Constable Fahy: I would agree. I personally think there are a lot of opportunities for efficiencies in the system. Some of those would be hard decisions to make but I think there are opportunities out there to do things in different ways. It also would be about, in police jargon, a more intelligence-led approach, to try to be the basis of better information gathering and analysis to decide what are the cases that you really need to concentrate on. I think that might be that in certain cases, like certain suicides, there would be fewer inquiries, because at the end of the day, you are never going to work out what is in somebody's head just before they decide to do something. In other cases, you will probably want to do more inquiries. If there was enough resourcing and support and it was a more intelligent approach, I think there is an opportunity to concentrate resources in the right areas, and I think that would involve things like questioning the need for so many inquests and things like that. There are lots of opportunities. Police officers spend a lot of time sitting around waiting for undertakers to turn up to remove bodies. All sorts of things, with a more modern approach, there would be opportunities, but we need really the DCA to encourage that work and to almost invest in some of that work so that we can see what a better prospectus is. Steve Charteris: This is reliant upon local agreements and that is really where it seems it falls down nationally. I know I sound like an advert, but in Hertfordshire we have gone a long way under the current system, and so I do believe that there can be things done to improve the service to the local community, even as the draft Bill stands. In Hertfordshire we had a best value review six years ago which identified the fundamental issue which the draft Bill does not seem to address, which is this tripartite relationship, and who is actually responsible for which part, whether it be the police, the coroner or the local authority. On local agreement, we noted that that was the problem, so to bring coroners' officers first of all to the local authority, the coroners' admin staff into the local authority to be employees, base the coroner with all their own staff within the centre, provide court facilities on one location. Those are all steps forward, but it required us having agreements and partnership with the police and the trusts, and having a coroner who was forward-thinking and willing and open to be scrutinised by his own local community for the good of the service, and willing to adopt some practices which are not necessarily what other areas want to adopt at the moment. We think it has been a success. We are one of the few services that have actually allowed ourselves to be externally scrutinised both through the ISO process and also from the bereaved. I think you will not find many examples where we have actually surveyed the bereaved who have been dealt with by our services and learned from that. I think there are things that can be done under the current legislation and also what is highlighted in the draft Bill. But it would assist if the draft Bill had incorporated some guidance on this tripartite relationship, who is responsible for which part. Chairman: Thank you very much. You have given us anything great deal of food for thought and I hope you have given the Government a great deal of food for thought too. Thank you. |