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Westminster Hall

Thursday 8 March 2007

[Mr. Mike Weir in the Chair]

Coroners’ System and Death Certification

[Relevant documents: Eighth Report from the Constitutional Affairs Committee, Session 2005-06, HC 902, and the Government’s response thereto, Cm 6943.]

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Cawsey.]

Mr. Mike Weir (in the Chair): Before we begin the debate, I remind hon. Members that proceedings in coroners’ courts are covered by the House’s sub judice resolution. Reference should not be made to particular cases.

2.30 pm

Mr. Alan Beith (Berwick-upon-Tweed) (LD): It is a great pleasure to see you chairing the debate, Mr. Weir. You can enjoy listening to discussion of a system that Scotland manages to do very well without—a point to which I shall return.

In July 2006, the Select Committee on Constitutional Affairs published a report on reform of the coroners’ system and death certification, which is the subject of today’s debate. The Government’s draft Coroners Bill on reforming the system was not published until the day before we started our inquiry. We welcomed it in principle, but strongly criticised its details. The Bill did not make it into the Queen’s Speech. This debate therefore provides an opportunity to raise our concerns and to establish what the Government will do now.

The coroners’ system is one of the oldest features of our legal system and has probably been subject to less change than any other part of the system. Its present shape is very much what it was in the 19th century, with coroners exercising a strictly limited geographical jurisdiction in a personal capacity and drawing their very limited resources of support in a variety of ways from local authorities, police authorities or, in rural areas, the offices of their own legal practice.

The system has some strengths. The office of coroner has a recognised authority, drawn partly from its long history. The coroner is usually a locally known and respected figure who serves the same jurisdiction for a long time and enjoys support in the local community. Many coroners’ staff and coroners’ officers, who are often ex-police officers or even serving police officers, are dedicated, considerate and kind in their dealings with bereaved families.

Coroners have been at the forefront of demands for reform and very much welcomed the Government’s declared intention to embark on reform. The system is under severe strain and, in some cases, has been brought almost to the point of collapse by the limitations on its ability to cope with some major problems. The Harold Shipman case severely tested confidence in the coroners’ system and, even more, in the system of death certification and registration.

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Those two systems need to be reviewed together. The failure of the Bill to do that led Dame Janet Smith, who conducted the Shipman inquiry, to say that the Bill would not prevent another Shipman. Similar concerns were expressed in Tom Luce’s very thorough, fundamental review, which was entitled “Death Certification and Investigation in England, Wales and Northern Ireland: The Report of a Fundamental Review 2003”.

A series of terrible accidents involving multiple deaths, such as the Marchioness tragedy and the Potters Bar and Paddington rail crashes, have exposed the difficulty of relying on a wholly local system. Such disasters are not new, but public expectations of the coroners’ system in such cases are much higher now than they used to be. The London bombings led to extraordinarily complicated arrangements to deal with the fact that bodies and body parts were located in different jurisdictions.

There has been a particular problem in the Oxfordshire jurisdiction, because almost all those killed on active service in Iraq or Afghanistan have been flown back to Brize Norton, generating a need for large numbers of inquests, some of them raising important and difficult issues, such as the need to obtain evidence from allied forces abroad. Huge delays have built up, resulting in distress to bereaved families of our service personnel. The Minister has sought to help by providing the Oxfordshire coroner with deputies and administrative support, even though it all had to be done informally, with no central legal authority.

The Princess Diana inquest raises issues that cannot be discussed, for the reason that you have explained, Mr. Weir—it is sub judice—but if I may just mention in passing that we now have the oddity of one of the most experienced retired senior judges in the land becoming the assistant deputy coroner of Inner West London, I think you will understand that the case has thrown up some of the system’s problems.

Of much wider significance has been the impact of a variety of changes in the way that we live our lives and the way that public services are provided. The fact that people travel much more, for example, makes the strict geographical limits on jurisdiction unrealistic. To take another example, in the modern health service, it is increasingly unlikely that a doctor is available to sign a death certificate, perhaps at night or at the weekend, who has seen or treated the patient in the past 14 days, which is a requirement and enables the doctor to give a reliable and specific cause of death or to recognise that the case should be reported to the coroner. The way in which health services are delivered now makes it very unlikely that someone can get the same doctor in the same place.

The Government Bill set out to tackle many, although not all, of those problems. It did not tackle the issue of death certification, on which witnesses from both the Department for Constitutional Affairs and the Department of Health seemed unfocused and evasive when they appeared before the Committee. That issue was the subject of a separate statement from the Government in February entitled “Learning from tragedy, keeping patients safe”. That is a welcome step forward, which I shall consider later in my speech. The Minister held a day of consultation with a panel of bereaved people in November 2006, the evaluation of
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which was published last month. The Minister gave a written statement on 30 January about strengthening the public protection role of coroners.

Where does all that leave us? We should start by identifying what the systems of coroners and of death certification are for. I see the objectives as, first, to establish the cause of death when there is any uncertainty about it and to decide whether the death could and should have been prevented; to draw attention to public protection issues that arise from preventable deaths; to prevent and deter malpractice; and, in the case of the death certification system, to provide statistical information that can guide health policy.

A number of other countries have coroners or comparable systems to achieve those purposes, although the duties are different in several cases. In Scotland, as I mentioned, there are no coroners. Deaths of uncertain cause are reported to the procurator fiscal, who will investigate to establish whether a criminal offence is involved. He can hold a fatal accident inquiry, which is similar to an inquest, but that is done only in very rare cases. Post-mortems are also rarer in Scotland. We asked witnesses whether they saw advantages in that system, but the general view seemed to be that, in England and Wales, the system of coroners holding inquests in a significant number of cases was worth keeping and was important to families and the public.

Dealing first with the structure of the system, the Government propose to put in place a national chief coroner, to oversee and support full-time local coroners. There would be a chief medical adviser, access to medical advice for local coroners, an inspection system and national training. We said in recommendation 8 of our report that that model was not adequate, because it did not remove the limitations of the local system and because it did nothing to resolve the uncertainty about who was to pay for the service. It cannot make sense to go on with a system in which some coroners have to rely on police authorities paying for coroners’ officers or providing them without charge, while those facilities are provided to other coroners by a local authority. Such is the pressure on police and local authority budgets that such uncertainty carries the risk that some funding will be withdrawn, and it offers no basis for major improvement in the service.

One coroner who provided material to us, the coroner for Essex and Thurrock, said:

Mr. Kevan Jones (North Durham) (Lab): Does the right hon. Gentleman agree that the problem is not only lack of capacity locally? There is downright incompetence in some coroners’ offices, which leads to a lot of heartache for relatives who are waiting for inquests to be heard, yet it is very difficult to remove a coroner.

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Mr. Beith: In a sense, it is right that removing a coroner, as a judicial officer, should be difficult—it is difficult to remove a judge, which requires an address of both Houses of Parliament—but it should not be impossible. There should be adequate means of dealing with the low levels of performance that can arise in virtually any profession and that all other professions have had to find ways of dealing with. Similarly, in the case of coroners’ officers, training has been provided very sporadically so far, because it has not been built into the system properly. In respect of both coroners and coroners’ officers, the present system does not deal effectively with the situation that the hon. Gentleman describes, of which a number of us are aware as a result of cases in various parts of the country.

Simon Hughes (North Southwark and Bermondsey) (LD): Let me pursue the same issue for a moment. I tried to support victims’ families and survivors after the Marchioness sank. Colleagues might know that the first coroner in that case was the subject of an appeal and that another coroner was appointed, because there was great dissatisfaction with the first coroner’s performance. That was not the first time that such a case was brought. Should there not be a mechanism short of address by Parliament to allow a coroner about whom there is great dissatisfaction to be removed more immediately and effectively? There is real discontent about inequality in the quality of service around the country. Some coroners in charge of their own courts have acted in a way that is entirely unacceptable for public confidence.

Mr. Beith: My hon. Friend makes an important point. The object of the Government’s reform ought to be to deal with such matters by doing what is done with the judiciary. If a judge is thought not to be the right person to deal with a case, perhaps because he does not have relevant experience or because he has interests that would make doing so inappropriate, another judge can be found; it is a national judiciary. There is no similar system with coroners’ jurisdiction. That is why Ministers have to send High Court judges and senior barristers to be deputy coroners in Oxfordshire. I refer not to the competence of the coroner in that case, but to the overwhelming nature of the task with which he was faced.

There is no central system by which to move coroners around to deal with particular cases. Neither the Minister nor anyone else has the power to do that. There are perhaps two aspects to this issue. I have talked about removing a coroner from office on the grounds of misconduct or unsuitability, which should be difficult, but a national system should be able to fit a coroner to a particularly difficult case and deal with someone who is not capable of handling a certain level of case. I have concerns about the proposed system.

I want to give a very different illustration of the pressures caused by the current system. In rural areas, in my part of the country, it is common for the police officer who happens to be on duty when and where a death occurs to assume the role of coroner’s officer for that case, but it is not certain that chief constables will always be ready to agree to such an ad hoc arrangement. Neither is it certain that the relevant officer has the necessary training to act as a coroner’s
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officer. He might simply be a local constable who was on duty when a death occurred. The complications of getting someone else to serve as the coroner’s officer have hitherto prevented any other solution.

Mr. Tom Watson (West Bromwich, East) (Lab): I am grateful to the right hon. Gentleman for producing a fabulously comprehensive report. I am here at the behest of my local coroner, Mr. Robin Balmain, who wrote to me on this subject. His letter says that he never sends an officer to investigate a death because of the pressure of work—they are all deskbound—and that

Does the right hon. Gentleman have anything to say on that?

Mr. Beith: The hon. Gentleman vividly illustrates some of my points—namely, that the system is under severe strain and that coroners are well aware of that and want change, because those difficulties are a constant in their daily lives. Unless we have a system in which both coroners and the resources and staff available to them are properly co-ordinated and of a sufficient standard, we will not solve the kind of problems that he describes and things that should be done will be left undone.

There is another side to all this. Sometimes the system is caught up with things that probably do not need to be done. There are inquests and investigations into cases that frankly do not merit them because there is no uncertainty. The current problems can be solved without a limitless commitment of resources, but the fundamental problem is the lack of a national system.

Our views on this issue were shared by most respondents to the consultation. The Government, in their response, assert their belief that the local system is the “most effective reform model”, but I do not believe that. I think that they believe it is the only model that the Treasury will accept; that is what lies behind this. I believe that there is a better model that they cannot get the Treasury to accept.

If the Government are determined to proceed without creating a national and nationally funded structure, the only alternative is for the provision and administration of support for coroners to become a much more clearly defined local authority responsibility, without dependence on police authorities and with clear responsibilities for the recruitment and training of coroners’ officers and staff. However, local authorities would need additional resources to do that, so police authorities might lose some resources.

Under such a system, coroners would need to retain their independent status and would look to the chief coroner on legal and disciplinary matters. They could rely on nationally agreed levels of support from their local authority or group of authorities. That system is second best, but it is more or less where the Government are heading—and with nothing like enough clarity about who will be responsible and who will pay the bills. While all that is being considered, people who work in the system face severe uncertainty about their future, and experienced people might leave to develop their careers elsewhere, because they simply do not know whether they will have a future in a substantially modified system.

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The Committee also pointed out that, although we agree with the introduction of a system of full-time coroners, it will not be possible to retain an accessible service in some rural and remote areas without the support of some locally based deputies. People should not have to travel huge distances to inquests. It is not simply a matter of the proposed coroner for the northern counties driving to Whitehaven or Berwick—journeys of hundreds of miles—to hold an inquest; it is about having accessible coroner’s offices in those communities. That way, families have a point of contact, coroners and their staff can talk things through with families, and unnecessary delays with burials and cremations can be avoided. There are further problems in communities close to the Scottish border, where a coroner’s removal order is required to move a body out of the jurisdiction for burial or cremation. Having a locally based coroner’s office is invaluable to deal with such orders.

At one stage, the Government appeared to accept that there would be a need for part-time deputy coroners, but in her response to the consultation, the Minister said that

I ask her to reconsider, because I think that there will be a gap.

I am also curious about the figure that has been given of 60 to 65 full-time coroners. First, does that allow for some part-time deputies? Secondly, why 60 to 65 coroners? Has the Minister done a calculation? If so, will she share it with the Chamber and the Committee? Has she added up the number of man hours worked by full and part-time coroners in the system and calculated them to equal the work of 60 full-time coroners? Or is that figure simply a rough calculation along the lines that there are about 60 million people in the UK and we should have roughly one coroner per million? That is what it sounds like.

It is recognised that coroners need medical support. We have recommended a return to the Government’s 2004 plan for a medical examiner to support the coroner in each area. The Government’s more recent proposal, however, is that apart from the chief medical officer’s guidance on policy and practice, it will be for coroners to obtain medical advice locally. Our recommendation was rejected and the Government turned their back on the earlier proposal.

There is considerable anxiety about resourcing and independence under the present proposals. Clearly, medical advice must be given by someone independent of the hospital trust, practice or service that dealt with the circumstances leading up to the death, but coroners who buy in help locally might have difficulty in securing such independent advice. It is not clear how that advice will relate to the proposed new system for medical examiners who deal with death certification.

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