You are here: Parliament home page > Parliamentary business > Publications and Records > Committee Publications > All Select Committee Publications > Commons Select Committees > Constitutional Affairs > Constitutional Affairs

UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC902-iv

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

CONStITUTIONAL AFFAIRS COMMITTEE

 

 

REFORM OF THE CORONERS SYSTEM

 

 

Tuesday 20 June 2006

DR MICHAEL WILKS, DR JOHN GRENVILLE, DR ANNE THORPE

and DR ANDREW DAVIDSON

 

DR GINA RADFORD

Evidence heard in Public Questions 158 - 209

 

 

USE OF THE TRANSCRIPT

1.

This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.

 

2.

Any public use of, or reference to, the contents should make clear that neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.

 

3.

Members who receive this for the purpose of correcting questions addressed by them to witnesses are asked to send corrections to the Committee Assistant.

 

4.

Prospective witnesses may receive this in preparation for any written or oral evidence they may in due course give to the Committee.

Oral Evidence

Taken before the Constitutional Affairs Committee

on Tuesday 20 June 2006

Members present

Mr Alan Beith, in the Chair

Jessica Morden

Julie Morgan

Dr Alan Whitehead

________________

Witnesses: Dr Michael Wilks, Chairman, Medical Ethics Committee, Dr John Grenville, General Practitioners Committee, Dr Anne Thorpe, Chair, Central Consultants and Specialists Committee Pathology Sub-Committee, and Dr Andrew Davidson, Forensic Medicine Committee, British Medical Association, gave evidence.

Q158 Chairman: Dr Grenville, Dr Wilks, Dr Davidson and Dr Thorpe, welcome. I am sorry to have kept you waiting for a moment. I also apologise that you appear to outnumber us. The Company Law Reform Bill is sitting at the same time as this Committee and a number of our Members also serve upon that. But we have retained a group of high-quality Members and we look forward to questioning you. You will be aware of the background to this inquiry. It began before the Government produced its draft legislation which you will have had an opportunity to consider. Perhaps I may start by asking you about it in very general terms from your standpoint. I do not know whether any of you have worked in Scotland. In England we have a coroners system that we are setting out to reform, but Scotland manages without any such system; in other words, it has no requirement for a formal inquest other than in the rarest cases where a fatal accident inquiry takes place. The procurator fiscal simply explores whether any criminal proceedings are appropriate or whether the family needs any help in getting information about how the death took place. That is just a prelude to my question as to whether we really need such an extensive system or we can manage without it?

Dr Davidson: You will see from my cv that I have experience of working both sides of the Border. I should like to make two brief points on the Scottish system before I answer the final question. First, there is no 14-day rule in Scotland, which I believe impacts on the percentage of cases referred to the procurator fiscal which is lower than the percentage of cases referred to the coroner.

Q159 Chairman: Just explain to Members what the 14-day rule means.

Dr Davidson: Essentially, it means that if the doctor treating the patient has not seen the patient 14 days before death the matter must be referred to the coroner because the registrar probably will not accept a certificate on that basis. That does not apply in Scotland and, therefore, perhaps it gives doctors a little more leeway in terms of providing cause of death and medical certificates of death without referring the matter to the procurator fiscal. Second, in Scotland of those cases that are referred a smaller percentage is submitted for post-mortem examination. That is principally because the investigation is much more detailed in terms of the production of a police sudden death report of which I have experience. In Scotland usually a very helpful three or four-page typed report is provided to the pathologist and procurator fiscal prior to a decision being made about whether or not a post-mortem should be performed. I believe that that decreases the number of post-mortems performed. The more information there is available prior to that decision being made the less likely a post-mortem examination. I believe that those two factors account for why fewer cases are referred and why of that number fewer are the subject of a post-mortem examination. In terms of inquests, Scotland perhaps does not have enough of them. It may be we should meet somewhere in the middle. My figures are old and date from the mid-1990s. They indicate that there were about 140 fatal accident inquiries a year. The figure may now be higher.

Q160 Chairman: It is still a very small percentage?

Dr Davidson: I believe so. In terms of England and Wales, I believe that inquests are now up to about 28,000 or so. I believe there is a happy medium here. Both systems have got it somewhat wrong in that in England there are too many inquests and in Scotland not enough.

Q161 Jessica Morden: Before we get into the detail, what is your broad view of the Government's draft Bill?

Dr Wilks: Coming from a position where for decades we have argued for reform of the coroner system, particularly in relation to death certification and cremation, we are a little disappointed. We see this as an opportunity half-grabbed. There are a number of general comments to be made. One is that if one looks at the various reports which have led to the draft Bill all of them have had "death certification" in the title but the draft Bill does not. That is a shame. We go further and say that it is also a shame and a huge missed opportunity not to have integrated into the proposals reform of death certification and cremation certification. We are also concerned that, although the position of chief coroner is welcome, that individual will preside over a system which under the proposals is fairly fragmented. Therefore, the chief coroner is appointed, reports centrally and covers coroners who have local jurisdiction, responsibility and appointment. Within that system there is potential for the kind of non‑communication that we have in the present system which has led to situations like Shipman. It remains to be seen whether co‑ordination of these various strands will be possible within a service that is a bit fragmented in its proposals. The lack of death certification and cremation certification integration is to be regretted, although we are not necessarily in support of all the recommendations relating to detailed death certification changes. Although they represent a gold standard they may be difficult to achieve unless resources are put into them, but perhaps we will come to that later. Another comment I make concerns a matter that is not in the Bill but obviously is part of this Committee's remit: the question of medical examiners and advisers. To us this is very important. We have a general concern that that medical advice will be found out of the local coroner budget. We believe that that may lead to a lack of informed advice and this matter ceasing to be a priority in an already stretched budget, which we note from the proposals would not be significantly increased. Finally, we have significant concerns about where people of the right skills, skills mix, training, authority and experience will come from to act as medical examiners. We have some proposals as to where they could come from, because there is an emerging discipline of forensic and legal medicine in this country which we believe needs significant support. At the moment it is quite difficult to see where people of the right experience and background will come from to provide the cadre of medical examiners as envisaged by the Government's proposals.

Q162 Jessica Morden: The Government has already stated that it will fund a chief medical adviser for advice and guidance with, as you mentioned, medical assistance for coroners at local level, but it makes no provision for a medical examiner system that is fully integrated into the coroners system. Do you believe that this is an improvement in the medical support that we see at the moment? Do you believe that it is sufficient medical input?

Dr Wilks: I believe that in the context of a medical adviser or examiner having more investigative powers, which it is envisaged the new coroners will have, that has to be a good thing, but I just make the point that the type of skills that a medical examiner would need to have in order to provide proper scrutiny of the process of the review of certification would be an awareness of situations that were perhaps not quite right in the experience of forensic medicine, the judicial and criminal processes and obviously experience in suspicious death. Unless resources are put into training those people, identifying them and developing a specialty in that area there may be some difficulty manning this part of the service to produce maximum or any effectiveness. In recent times the Royal College of Physicians has set up a new faculty of forensic and legal medicine, of which I am very proud to be a foundation fellow. The faculty will be developing training programmes for forensic medical practitioners such as myself on the whole aspect of legal medicine. It might help if the faculty were given some responsibility for helping to grow this specialty and provide advice on the core skills.

Q163 Chairman: One of the matters we have looked at is that in Sheffield, for example, there is a situation where the coroner, his officers and staff and the pathologists are all located in the same building. Is that a model that city jurisdiction, at any rate, could usefully follow elsewhere?

Dr Davidson: Perhaps I may deal with that question as the forensic pathologist here. That is an ideal. I think you will have to ask the Sheffield coroner and the head of Sheffield pathology department whether it works efficiently.

Q164 Chairman: We have asked them.

Dr Davidson: It should. In theory, communications should be better since the people are in the same building, although that does not always work. The other important group is hospitals. It would be quite useful if the coroners' offices and officers were closely linked with hospitals, because a significant number of referrals to the coroner come from the hospital system. That is another area where one can look at close communication and the question whether one has coroners' officers based in hospitals or in medico-legal centres. Probably the two are appropriate. It was regrettable that the review of forensic pathology services did not take on board some of the recommendations made in submissions that ideally there should be six to eight medico-legal centres around England and Wales providing, if you like, centres of excellence around which training could be planned. The idea is that there would be full-time autopsy pathologists within those centres of excellence and coroners might well be linked into them as well. They would be responsible for postgraduate training in pathology, revalidation and the continuing professional development of pathologists in that region. I think it is a shame that the resources were not available to provide those centres of excellence because it might have gone a long way to solving this problem.

Q165 Dr Whitehead: Dr Wilks a little while ago said he was concerned and disappointed that the Government had decided not to reform the death certification system. What do you believe will be the consequences of that decision in terms of the new legislation?

Dr Wilks: I should like to ask John Grenville to deal with that, if I may.

Dr Grenville: I think we are clear that the gold standard would be the automatic referral of all cases to a properly constituted coroner service. That would have the effect of reassuring everybody - the public, the profession and politicians - that deaths are being properly certified, recorded and, where necessary, investigated. That would be the gold standard. We realise that it may not be possible due to resources, particularly money and workforce, but it would not be too difficult to design systems that did not quite reach the gold standard but took into account the various levels of resources that might be available. We are, however, quite clear that the current system is unacceptable. We need a unified system for the certification of deaths for the purposes of burials and cremations, for instance. I do not believe it is reasonable to have a system whereby burials are subjected to less rigorous scrutiny on the grounds that the body can always be exhumed. I do not believe that that is a reasonable stance to take. The reform of the coroners system as suggested in the draft Bill is good as far as it goes, but without proper reform of the certification system it probably will not achieve its ends. Members of the public and bereaved people will probably still be left with the feeling that there is a gap somewhere in the system.

Q166 Dr Whitehead: The Government has said that it is still considering reform in the area of death reporting and certification. Do you think that in terms of the possible progress of the draft Bill, and presumably its passage into legislation, that uncertainty would undermine the reforms in the Bill as proposed, or do you believe it is possible to continue to consider different reforms alongside those other changes?

Dr Grenville: I have considerable concerns. If one reads the Shipman inquiry report one sees that the Government has been saying it intends to undertake reform since the 1925 inquiry. One wonders just how long we would have to wait. But the problem is that a new system will have to try to bed in and start to work and it will develop its ways of working. It would be much easier to reform the whole system at once and find altogether new ways of working than to change little bits of the system, allow them to settle down and develop their own ways of working and then change another bit of the system, which may mean that the first one has to change again.

Q167 Dr Whitehead: Would you include in that the fact that there is no corresponding statutory duty on doctors to refer a death to the coroner and that in the reforms no such duty is proposed?

Dr Grenville: As I have said, the gold standard would be an automatic referral of all cases, so that would not be a question.

Q168 Dr Whitehead: With respect, the gold standard might alternatively be referred to as a utopian standard.

Dr Grenville: Yes, it might.

Q169 Dr Whitehead: I invite you to speculate where a statutory duty to refer deaths to coroners might sit short of the gold standard?

Dr Grenville: I think it is very difficult because death comes in so many forms. If one does not draw up a list in other than the most general terms of those cases that should be referred it is very difficult. I note that Dame Janet said she and her team found it impossible to draw up a list. One of the problems I have as a general practitioner is how certain I have to be of the cause of death. I could give a certificate with an indication of the certainty I felt as to that cause of death. There are some deaths where I am absolutely certain of the cause; there are others where I am absolutely certain that it is a violent and unnatural death and needs to be referred to the coroner. There is a range in between. It may be possible to set up a system which helps doctors to decide, depending on their level of certainty or uncertainty and with someone to talk to, whether or not a particular case needs to be referred to the system.

Q170 Dr Whitehead: You say that there should be a positive statutory duty to refer particular deaths to the coroner?

Dr Grenville: Certainly, if we become aware that there has been a violent or unnatural death there is absolutely no reason for us not to have a statutory duty. Although we do not have a duty, in theory we could complete an MCDC which says that this is a violent or unnatural death and the registrar will refer the matter to the coroner. It does not happen in practice but it is the theory. We could tidy up that theory.

Q171 Dr Whitehead: Is the idea that perhaps that is a useful public safeguard something that might be seen as approaching gold-plating, inasmuch as it could be argued there are rather few circumstances in which a doctor, provided he is reasonably competent, will fail to refer to the coroner a death that ought to be referred?

Dr Grenville: I think that for many doctors the difficulty with the current system is: what level of certainty is required? There is also the difficulty that under the current system referral to the coroner is very likely to lead to a post-mortem examination which the relatives may be keen to avoid. A doctor may certify at a lower level of confidence as to cause of death if the family suggests that it really does not want a post-mortem. If the doctor can say to the family, "There is a degree of uncertainty here and I will refer it to the coroners service and it will be able to make a full investigation, including discussions with you, and decide whether or not a post-mortem needs to be held", the family will understand that, but at the moment he says, "I will refer it to the coroner." In many areas that means uniformed police officers and, almost invariably, a post-mortem. That is not a good way to help bereaved relatives.

Q172 Chairman: I was going to ask whether you thought doctors were influenced by the fear of bringing all this upon the bereaved unnecessarily, simply because a certain kind of certification would prompt that?

Dr Grenville: I think many doctors do feel that way, and certainly many families, particularly those who have had experience - it is surprising how many families in the current system have had experience of the coroner system - have views when another death occurs.

Q173 Chairman: Dr Davidson, would the existence of something like the Scottish view and grant procedure make that situation easier, because it means there are many cases where although it is referred they do not have to go to the full post-mortem?

Dr Davidson: I believe that the English and Welsh systems could take advantage of that in limited cases. I work in Glasgow. In approximately 10% of referrals the procurator fiscal will put a note in the letter to us saying, "Would you consider a view and grant in this case?" We would perform an external examination of the body. If we found signs that perhaps were not consistent with the story or slightly suspicious we would phone the procurator fiscal and ask if we could do a full post-mortem. He would say yes. If we found nothing suspicious we would do a view and grant and write out a medical certificate of death. The ability of the pathologist, if you like, to write a certificate of death was helpful in such cases and avoided the need for a post-mortem in, say, 10% of cases in Glasgow. It differed in other jurisdictions in Scotland. Some people used it less and some more.

Q174 Julie Morgan: I want to return to the question of training. Is the current training of doctors in death certification and reporting adequate?

Dr Wilks: Anything sub-gold standard might have layers in it. One of our disappointments about not including death certification in the proposals is that it is a missed opportunity to improve the quality of death certification because it is crucial for a whole variety of tasks, including epidemiological patterns of morbidity and mortality. The opportunity is there to improve the quality of death certification, and one aspect is the training of doctors in how to do that. I ask my colleague Dr Thorpe to comment on that.

Dr Thorpe: I work in a district general hospital and am aware of death certification by junior doctors. I believe that about half of all deaths are certified by hospital doctors, mostly junior ones. When they start their first job they do not feel they have been properly trained in how to complete a medical cause of death certificate. They are often advised by people who themselves are not trained but have more experience, such as older people in the team or the patient affairs officer. I am sure this is a big gap that needs to be filled.

Q175 Julie Morgan: Do you think that lack of training is a contributory factor in the relatively high level of reporting to coroners in this country in comparison with others?

Dr Thorpe: It is certainly the case that if juniors are uncertain, as they often are because of lack of training, they will feel the need for a comfort blanket by speaking to the coroner's officer. I am sure that a lot of things come into the coroner's office which with better training on how to certify death would not do so.

Q176 Julie Morgan: How do you believe training should be delivered?

Dr Thorpe: Ideally, it would be part of the undergraduate curriculum and reinforced by further training during early postgraduate years. A lot of things are required by death certification. I suppose that in the normal hospital situation where one is not trying to pick up criminal conduct the main purpose is to obtain accurate statistics from an epidemiological standpoint that can be used in health planning and so on. That is where it is very useful to have accuracy. But a good deal of the discussions on the draft Bill and the reports which have led up to it are in terms of picking up wrongdoing, which is a completely different function of death certification that is being talked about. That requires thinking along different paths.

Q177 Chairman: There are also medical errors?

Dr Thorpe: Indeed.

Q178 Julie Morgan: How important is the advice of coroners' officers to doctors in filling out death certificates and making a decision about whether or not to refer the matter to the coroner?

Dr Thorpe: It is very influential, because coroners' officers do this all day every day and become very practised at knowing how their particular coroner likes things managed. They advise junior doctors a good deal.

Q179 Julie Morgan: Therefore, that is a major part of the process?

Dr Thorpe: Yes, it is.

Dr Wilks: Under the new system there could be an extremely crucial central figure in collating information, reporting to the coroner and linking with the medical examiner and, crucially, the family. We see a very strong role for the coroner's officer, but it has not been one that has developed into a particular career structure with particular set skills. We would like to see that developed.

Dr Davidson: There need to be more coroners' officers. It has been suggested that there would be the same number of such officers. We do not see that working if we want them to collate all the available information prior to an informed decision being made about the necessity to perform further investigation, such as an autopsy. I would probably expand the role of coroners' officers. They could eventually develop into the American model of scene examiners; they could go to the scene of death and examine it. A lot of these people would probably be ex-nurses or ex-police officers with experience of talking to bereaved people and getting information from them, looking at scenes, suicide notes, pills and so on, and taking that information back to the coroner and/or medical adviser. An informed decision can then be made about the best means of disposal of that body, shall we say, in legal terms.

Q180 Julie Morgan: Turning to the autopsy rate in England and Wales, this is also very high compared with other jurisdictions. Why do you believe that is so?

Dr Davidson: I would go back to my answer to the first question. I referred to the 14‑day rule and the amount of information that is gathered prior to that decision being made. This is crucial. The Royal College of Pathologists has said many times that one of the main problems is the lack of information provided to the coroner and so to the pathologist before the decision to perform a post-mortem is taken. For instance, there is nothing like a typed sudden death report in England and Wales. Sometimes in non-suspicious deaths we will receive, if we are lucky, a typed history from the coroner. Usually, it is a handwritten scrawl. I have experience of cases such as road traffic collisions where all the history I get prior to the post-mortem is: "Deceased involved in road traffic accident. Taken to hospital. Died." That is almost useless and it does not serve the family well to have a post-mortem done for that reason. Neither the coroner nor the pathologist is served by that lack of information. Part of the problem is that coroners' officers do not on the whole get out of their offices. Some do but not many; a lot of them are deskbound. They do not get out and chat to the relatives; usually, the relatives have to go to them.

Q181 Chairman: The problem with the 14-day rule will become worse because of the number of doctors who will not have seen the patient either because it involves a doctor with an increasingly large practice or it is outside the nine-to-five contract, or whatever it is - if you forgive me for saying so - and an agency doctor is involved?

Dr Davidson: That is another minor factor. I suppose that another problem is that doctors are post-Shipman slightly worried that relatives might accuse them of doing something improper. That encourages them to refer more cases to the coroner so as to be seen not to be doing anything improper. Dr Grenville may want to comment on whether or not the changes in the GP contract or the way general practice works have an effect.

Dr Grenville: I am not convinced that it is the changes in the GP contract but the way that we look after patients. There is much more teamwork and there is a much wider team nowadays. While the doctor may be co‑ordinating things he may not be seeing the patient on a day-to-day basis. The district nurse and the community matron may be the ones who go in and see the dying patient. This is particularly so in cases where patients have long-term illnesses that are in the terminal phase. The doctor will try to get there, but he may be on holiday. However, the care will continue. The doctor will be the central point and have the record. He may be the person who is best able to synthesise what has gone on and come up with a reasoned opinion as to the cause of death. In this sort of situation it should be fairly obvious anyway, but he may well not have seen the patient in the past 14 days.

Q182 Chairman: So, there will be more referrals and more autopsies?

Dr Grenville: Under the present rules, yes. We need to be able to get round that and say that information is important, not sticking to the rules. If we believe that we have high-quality information in a reasonable way then we can make high-quality decisions. Just having stuck to the rules does not necessarily mean that the decisions will be of high quality.

Q183 Julie Morgan: Is there a lack of trained pathologists in England and Wales?

Dr Thorpe: Perhaps not everyone here knows what a histopathologist is. Autopsies in this country are done by histopathologists who do two things. They are concerned with the diagnostic reporting of biopsies and surgical specimens and they are also trained how to carry out autopsies and interpret the findings. There are about 1,600 histopathologists in the UK. According to figures provided by the Royal College of Pathologists, this year there are about 200 vacant posts, which is approximately 14%. That in itself indicates there is a shortage. Another factor to consider is the age distribution. About 40% of histopathologists are 50 or older. You may wonder what the implication of that is. Since Bristol and Alder Hey the number of hospital-consented post-mortems has dropped dramatically. My hospital is probably typical, in that we used to do about 200 a year and now we do about 20. The training opportunities have dropped. The college put a figure on how many post-mortems a trainee should do per year, which is currently about 20. When I and my colleagues trained it would have been very unusual for someone to do less than, say, 60 or so a year. Obviously, there was no need for any guidance about numbers. Therefore, younger pathologists and ones coming through training get their first consultant post with a good deal less experience in carrying out autopsies than we did. I suspect that fewer of them will be willing to put themselves in the medico-legal position of carrying out coroners' autopsies, attending inquests and possibly being questioned by barristers as to their findings when they are not really very experienced. I believe that the age distribution is an indication that something will be a problem later on. Within the Royal College of Pathologists there is an active discussion about the concept of "autopsy-light training" in which trainees can self-select themselves into groups that want to become confident in autopsies and those who really do not want to go down that route but stick to diagnostic surgical pathology. Clearly, that will further reduce the pool of pathologists who are willing to undertake this role. There is a problem of manpower which I believe will get worse.

Q184 Julie Morgan: Is this having an effect on the death investigation system?

Dr Thorpe: I do not believe that it has started to have an effect on what might be called run-of-the-mill coroners' post-mortems. There is certainly an effect on specialist types of coroners' post-mortems, particularly paediatric post-mortems and ones requiring skills in neuropathology and complex trauma cases. I am sure that Dr Davidson can think of more examples. I am sure that there will be a much bigger problem than we are aware of now.

Q185 Julie Morgan: The BMA has accepted the concerns expressed in the Luce review about the quality of some coroners' post-mortem examinations. Would the new provisions in the draft Bill allowing bodies to be moved to areas where there is appropriate expertise address the concerns about quality?

Dr Thorpe: From my point of view, that is a good development. Maybe others want to speak about quality. One thing that struck me about the proposed role of the medical examiner or medical assessor proposed by Tom Luce and Dame Janet was that that was an opportunity for somebody to audit the work done for the coroner by the pathologist and make sure that the standards set by the Royal College of Pathologists were broadly adhered to. My sadness about the local medical advice now being on a rather ad hoc basis is that it is not specified that a person would be responsible for assuring the quality of post-mortems in a coroner's jurisdiction.

Dr Davidson: To comment on the issue of quality, it would certainly help if bodies could be moved to certain specialist areas but I would not like to see it as a wholesale option. Part of the problem is that it can be difficult to identify exactly the problem until one has started the post-mortem. I can accept that certain cases can be identified. Paediatric cases are an obvious example, but there are other cases where one does not really know which expertise is required until one starts the examination. For the vast majority of cases I do not believe that the bereaved families want bodies moved a great distance away to a specialist in a big centre. I believe that is of limited value. Anecdotally, there are concerns among pathologists about the quality of a significant minority of post-mortem examinations. The scale of that significant minority we cannot judge. The NCEPOD, which used to be the National Confidential Enquiry Into Peri-Operative Death but is now the National Confidential Enquiry Into Patient Outcome and Death, started in 1989. As the title suggests, it looked at peri-operative deaths and found that in about one quarter of cases the pathology was regarded as poor or unacceptable. The outcome of those reports over the years improved that figure somewhat but not by much. The Royal College of Pathologists proposed to NCEPOD two years ago that it would do an audit of coroners' autopsy reports. That is the first time it has ever been done. That report will be published on 18 October of this year. I was an adviser to that study but I cannot speak about any of the findings because it is embargoed until then. I have seen a first draft. I believe many of the recommendations may be of very great interest to this Committee. It may be that you can approach NCEPOD for perhaps sight of a draft or an earlier release perhaps in confidence.

Dr Grenville: As to quality, we should remember that that does not end with the post-mortem examination. A report is generated. I think the quality of the whole system could be improved considerably if the coroner's post-mortem report was routinely made available to the patient's registered GP. Clearly, most cases are reported to the coroner because the cause of death is uncertain. The GP is one person who needs to learn what cause of death has finally been decided upon and why so he can use that information to learn from it or change practice where necessary in future. It is part of organisation and memory and the continuous learning process.

Q186 Julie Morgan: What about helping relatives to understand the implications of a report? Do you think that is the role of the GP?

Dr Grenville: I believe that it is vitally important. The contention is that the new coroners service will be able to do that and that the new service will be a point of contact with the relatives. I think that very many relatives will still want to come to their doctor and be able to discuss it. I find it so much easier to discuss with relatives what exactly has happened if I know all the information. I sometimes find myself in the position of saying that this or that may have happened because I have not seen the post-mortem report and the relatives say that, no, that did or did not happen because they have been told it by the coroner's officer. It puts everybody in a very difficult position.

Q187 Jessica Morden: I want to ask about the appeals process in the draft Bill which makes provision for the bereaved and others to appeal about anything at any stage in the process. Do you think that this will work? What difficulties can you see? What is your view on it generally?

Dr Wilks: In general, we believe that proposals to improve the understanding and knowledge that relatives have and their involvement in this very painful process can only be a good thing. We have lived through the backlash of Alder Hey and Bristol where, obviously, things were done by doctors which were thought to be in everybody's best interests but turned out to be perceived as extremely damaging simply because there was not enough communication. That was a dreadful event that was a very important learning process for the profession. We believe that to think of it as an appeal tends in a sense to bring in a rather confrontational element. While obviously an appeal process is important, we hope that if the main provisions of the draft Bill are designed to improve the involvement of families with better communication - we have talked about the GP and the coroner's officer - to help relatives understand exactly what has happened and has been done it will reduce the level of antagonism and misunderstanding that may take place so that appeals will be less common. What would be more common would be good communication and understanding. But at the end of the day if there is a serious concern on the part of relatives that something has not been properly investigated that appeal process should be in place. Part of the concern about public engagement must come from a real fear that another Shipman may be out there. What we say is that no reforms, whether of the medical regulatory system in which Dame Janet Smith has been engaged or the coroner and death certification and cremation procedures, will reliably and conclusively stop another Shipman, but what we can see in this draft Bill and other initiatives, such as those relating to medical regulation, is the potential for much better practice around a whole variety of different areas of patient care - medical quality and proper death certification and cremation certification - if our suggestions of a bit more boldness are taken up. I do not think we should see all of this as being focused on stopping another mass murderer. I think that there are huge spin-offs for good medical practice and good new processes coming out of this Bill as well as some of the changes that have happened post-Shipman.

Chairman: Thank you very much indeed. We are very grateful for your help.


Witness: Dr Gina Radford, East of England Regional Director of Public Health, Department of Health, gave evidence.

 

Chairman: We welcome Dr Radford of the Department of Health. We are very glad to have your help.

Q188 Dr Whitehead: When the evidence of the Department of Health was received by the Committee it was not entirely clear how the department was involved in the death certification and investigation systems. Can you explain how the department is involved?

Dr Radford: I will do my best. The Department of Health is not responsible for everything around death certification by any means. As the Committee will know already, the legislation by which doctors complete medical certificates is the Registration of Births and Deaths Act. That is owned by the General Register Office which is part of the Office for National Statistics. That department owns the legislation dealing with death certificates and the legislation under which doctors complete them. Doctors complete medical certificates of the cause of death as a personal statutory duty. That is a personal role that they play under the Act of 1953. Therefore, issues to do with their conduct in respect of this are subject to regulation by the General Medical Council. First, we have the ONS with responsibility for death certification itself and the legislation concerned with that. The GMC is concerned with ensuring that the conduct of those doctors in completing certificates is satisfactory. Finally, in terms of the Cremations Act, which accounts for up to 70% of disposals, that is legislation for which DCA is responsible. As for the majority of the statutory responsibility, it sits outwith the Department of Health.

Q189 Dr Whitehead: But the Government has apparently changed its view since it put forward its 2004 position paper. Is it fair to say that the Department of Health and the DCA work together on death certification and how to move it forward?

Dr Radford: We have always worked together. When it was under the auspices of the Home Office we worked very closely with that department in terms of producing the position paper which was then published. Since the responsibility for coroners was taken over by DCA we have also worked closely with DCA officials.

Q190 Chairman: Is that why the view has changed?

Dr Radford: That the responsibility should change to that of DCA? I cannot say. Clearly, the content of the proposed Bill is subject to ministerial views, so that is not something on which I can comment.

Q191 Dr Whitehead: But any change in death certification was not included in the reforms put forward in the draft Bill?

Dr Radford: Absolutely.

Q192 Dr Whitehead: Do you think that may have something to do with the fact that nobody appears to have, as it were, clear responsibility for what goes on?

Dr Radford: There are a number of processes that contribute to the satisfactory completion of a death certificate and a body being able to be released to be either cremated or buried. We sit within the current regulatory framework. At the moment there are different regulatory responsibilities depending on the element that we are talking about, whether it be the Cremation Act or regulation in terms of satisfactorily completing the necessary paperwork so that bodies can be released or the required detail on a death certificate and the processing of that certificate.

Q193 Dr Whitehead: But, as you set out very succinctly, there are what might be called a number of different poles of responsibility, none of which trumps any other one. Is that a fair assessment of the process that you describe?

Dr Radford: Yes. There are different elements of the process.

Q194 Dr Whitehead: Can the fact that there are no reforms in the draft Bill be construed as perhaps a requirement for the resolution of those particular poles? Indeed, the DCA has said hat it is doing further work on the question of death certification and, therefore, reforms may be in the "too hard" tray, as it were, for the time being?

Dr Radford: We are certainly working with DCA to look at what other aspects, particularly around death certification, may be necessary to strengthen death certification in the light of the recommendations of both Shipman and Luce and the comments that clearly we have received and the context within which we are now operating. I can say that most definitely there is other work in progress.

Q195 Chairman: Dame Janet said to this Committee that she did not think the Government's proposals as they then were - they have not changed in this particular respect - went any way to stop another Shipmen. You were given the task of working on the Government's response to Shipman. Surely, your department would say that it had a major stake in making sure this is put right. Is not the department involved in the policy lead here with the health aspects and the registration process? From the way you describe the process everyone can conclude that nobody is responsible.

Dr Radford: Certainly, the whole process of death certification needs to be seen in the context of a much broader reform agenda that Shipman and Dame Janet highlighted in terms of issues to do with improving overall quality - quality of care and health care - and clearly death certification is one element of those. We have been working across the broad front of health care reform for a considerable time, as you will know, and quite significant changes have been made in terms of quality and patient safety improvements that have been made in the health care sector. Clearly, as to death certification we are working on issues with DCA in terms of what else can be done outwith the draft Bill to take account of some of the concerns raised by Dame Janet and others.

Q196 Dr Whitehead: In your view, would that involve further legislation or simply a reshuffling of how things are done?

Dr Radford: One of the issues on which we are in discussion with DCA is whether this will require further legislation or we have satisfactory legislation in place which will allow us to improve the system in a way we would wish to.

Q197 Chairman: I find myself quite uneasy. This is a fairly serious matter which involves a major initiative on the part of the Department for Constitutional Affairs but it seems just to pass the buck to you by saying that death certification is for health, not DCA, and so it is not doing too much to incorporate it. Am I misinterpreting what is happening here?

Dr Radford: That is perhaps an unfair summation of its position. Clearly, its draft Bill does not cover death certification as it is set out at the moment, but that does not mean there is not work ongoing in terms of what else can be done to improve the process of death certification to address some of those issues. But at the moment that is not, as you rightly point out, within the draft Bill that is before you.

Q198 Chairman: One matter for which the department is responsible is the training of doctors. Earlier this afternoon we had quite a good deal of discussion about that. This is looking at it from the other angle, not Shipman; that is, all the other problems which arise for those who have to go through the coroner and inquest systems. Do you think that training may develop in a way which means, as indicated earlier, that we could have fewer reports to coroners because doctors are more confident about what they are doing?

Dr Radford: We are very much aware that to make sure people are appropriately trained is and has been for some time an issue, but we need to realise that training comes at different stages of a medical career. First, there is the undergraduate training which goes on in medical schools to make sure that before they qualify as doctors people have an understanding of death certification. The content of that training is the responsibility of the medical schools. A recent survey by the Council of Heads of Medical Schools showed that at all the medical schools which replied to that survey medical students are being trained in death certification, so medical students are receiving training in terms of how to fill in a death certificates, what the statistics are used for, the reason we need to have accurate death certificates and so on at that stage. But clearly that is not sufficient of itself. We then talk about postgraduate medical education. That is under the control of the Postgraduate Medical and Education Training Board set up in September of last year. Training for doctors in issuing death certificates is now a requirement of postgraduate training. There is a requirement in postgraduate training to ensure that doctors are competent because the training is based on competence, not just "tick box" ability, to issue death certificates. Finally, there is continuing professional development which is lifelong in terms of making sure that practitioners throughout their medical careers are competent and up to date in terms of things like death certificates. As you may be aware, last year ONS published some renewed guidance to all doctors, which also accompanied the CMO's newsletter, reminding them how to fill in death certificates, setting it in the context of how the information from death certificates is used. But you are absolutely right that there is an ongoing need to ensure that people who fill in death certificates are competent to do so. Clearly, one of the issues is that some doctors do not fill in death certificates necessarily very often. Some do and some do not. To keep that competence up to date and fresh is important. Clearly, that is an ongoing issue, not a new one. How does one keep competence in a task that perhaps is not performed on a daily, weekly or monthly basis up to date and to an appropriate standard?

Q199 Chairman: Post-Shipman did the department consider a random check of death certificates to see from the results whether competence was being maintained generally? I am not talking of an individual doctor but across the system.

Dr Radford: Yes. You will remember from the Home Office position paper that one of the issues was to do with scrutinising all death certificates, because we are aware of the importance of devising systems that will encourage good practice, rather than just leave it to individuals, and looking at what systems we can put in place to improve the quality of death certification. Clearly, that line will not be pursued in terms of the Home Office position paper and, therefore, we are looking with DCA and others at how we may address the need to improve the quality, and also quality assurance, of death certification in an achievable and appropriate way.

Q200 Chairman: What about individual doctors where randomly one might pick out the previous half-dozen death certificates to see whether or not they appear to be competently done?

Dr Radford: We are looking at a number of mechanisms whereby we can quality assure death certificates. Whether it be a small proportion of them and in what way we can do that is one of the issues at which we are looking very closely. As you may be aware, some GP practices already regularly monitor sudden and unexpected deaths and that would also include what was ultimately put on the death certificates. Therefore, they audit their own practice both in terms of clinical care and what then happened in terms of handling the death, which includes death certification. There are already models out there which we are looking at.

Q201 Chairman: There has been talk about the statistical value of death certificates and the work of coroners as well as inquest verdicts. Is that not a case for investment from the health side in the system because it is one of the ways in which you have information that you must have to plan your other decisions properly? Is it viewed in that light?

Dr Radford: We are very clear that the information from death certificates is very important across a number of fronts: first, on the epidemiological side which helps us better to understand the patterns of diseases in populations and changes over time. It also helps to plan health services and look at the success or otherwise of intervention. We are fully aware of the importance of information that accrues from death certificates and, therefore, the importance of the accuracy of those death certificates.

Q202 Chairman: Turning to a more specific problem, where a coroner believes that action should be taken as a result of what he has discovered and the verdict he has reached he may report that matter to a person who has power to take action. Under the Bill he can also report the matter to the chief coroner. Is that enough from the public health and safety point of view?

Dr Radford: I would hope that we would be able to agree some consistent ways of working around reporting concerns in terms of preventable issues or issues that need to be further pursued. It is very important that there is consistency so we are quite clear about what that actually means in practice and to whom those sorts of concerns may be reported. I believe that that will be important for the chief coroner together with the chief medical adviser working with the appropriate organisations or individuals who may be the recipients of any concerns to agree some common practices.

Q203 Chairman: As a department have you given any thought to the implication of that part of the Bill which is about providing medical advice to coroners? It is quite understandable that the chief medical adviser should advise the chief coroner, but lower down the system it is not clear at this stage where the medical advice to local coroners purchased on an ad hoc basis will come from. Presumably, the department would have to be involved in discussions about that, and at the very least it would draw on its resources within the hospital and general practice services. The department must have views on whether this advice can be provided and how it can be made consistent.

Dr Radford: I think we need to be very clear with the DCA what sort of functionality it is expecting the local medical support to provide. We need to be very clear, therefore, about the sorts of skills required to support that function. Those discussions are ongoing.

Q204 Chairman: The department is involved in trying to develop that?

Dr Radford: Yes, because it will be important. From previous conversations with the BMA and so on, we need to be clear about the skills required and, therefore, the manpower, and also that whatever medical presence is provided can feed into the health and healthcare system.

Q205 Jessica Morden: The coroner's officer is the interface between the coroner and reporting doctor and therefore is in a good position to identify any wrongdoing on the part of the reporting doctor. Would the department look at or offer medical training for them as a group?

Dr Radford: I think we need to be clear about what we see as the role of the coroner's officer and how that sits with the new medical advice that is proposed at a local level. At this stage we are not thinking of significant medical training for the coroner's officers, but that is something about which we would be happy to have further discussions. I think it would need to be very clear as to what the purpose of that medical training or input might be and what it might look like, because we need to be clear that coroners' officers have certain functions. What particular skills or knowledge do we believe they may be missing that would need to be augmented? We need to be very clear about what issue we are trying to address and what skills or knowledge we are trying to give them or strengthen before we embark on medical training that may not be appropriate or properly targeted.

Q206 Chairman: Do you recognise that not many people outside the system, not even everybody within it, realise the range of activities of a coroner's officer, varying as it does between different jurisdictions?

Dr Radford: Absolutely.

Q207 Julie Morgan: There has been criticism about the high autopsy rates in England and Wales. Some have said that unnecessary autopsies are held, with consequential distress to relatives. Is this caused by the precision required by the medical certificate of cause of death?

Dr Radford: I think you have just heard some very good and valuable opinions as to why that may be. The honest truth is that we have only opinions, not necessarily hard factual evidence as to why that may be. As to why that may be, my opinion would be no better than anyone else's. That may well be a contributory factor, but I cannot give you a better answer than my previous colleagues.

Q208 Julie Morgan: Given the concerns expressed about the quality of some post-mortem examinations, is the department taking any steps to address this? In particular, how does it plan to address the shortage of pathologists?

Dr Radford: We have been aware for some time of the shortage of pathologists and share the concern expressed earlier. We have invested several million pounds in increasing the number of training posts of pathology and recruited quite a considerable number of people into new training posts to increase the sheer numbers and capacity within pathology, but clearly that will take a short time to work through the system so we have people who are then qualified to operate at consultant level. At the moment those people are going through the system. There has been significant investment to improve the numbers in training, because this was not a popular specialty some years ago and we ran into a shortage to which previous colleagues have alluded.

Q209 Julie Morgan: Therefore, you believe that in future there will be enough?

Dr Radford: We are certainly trying to address the shortfall as we see it.

Chairman: Thank you very much. We are very grateful for your help this afternoon.