Examination of Witnesses (Questions 1-19)
RT HON
HARRIET HARMAN,
MP AND LORD
HUNT OF
KINGS HEATH,
OBE
8 MAY 2007
Q1 Chairman: Minister of State, Lord
Hunt, welcome this afternoon. You will know of the Committee's
close interest in this matter of the future of the coroners' system
and of the debate which we had in Westminster Hall on the earlier
report. You have sent us some further evidence which, I am afraid,
only arrived within the last few hours—statistical evidence—which
the Committee has not been able to absorb properly in that time.
If you rely on it we might draw attention to the fact that we
have not had time to study it. Our initial look at it, and that
of our advisers, suggests there may be things we want to query
about that paper. Can I start by asking you both, just very quickly:
in the case of the Ministry of Justice, as it is about to be,
you are in the process of significant change and massive new responsibilities.
Is this issue of reforming the coroners' system going to get pushed
back down the queue, as it in one way already has, in the legislative
timetable? I will start with Harriet.
Ms Harman: No, I do not think
the fact that the Department for Constitutional Affairs is going
to become the Ministry of Justice will mean that there is less
of a focus within our department on coroners. A great deal of
work has gone on. We have got a sense that we have got a practical
set of proposals which will make a big difference. Even whilst
we are waiting for that Bill to find its legislative slot practical
changes are getting under way. So I think there is a workstream
for preparation for the Bill and there is a workstream even to
make some changes before the Bill comes in, and it would not be
right for that to be stopped because I think it is very, very
important work.
Q2 Chairman: Can you give us any
indication of the sort of thing that you can get on with? For
example, we have seen that in the case of the Oxfordshire inquests
you put additional resources at the disposal of the Oxfordshire
coroner. What sort of thing can you do without your Bill?
Ms Harman: There are two things
in particular, and one is the question of learning lessons from
inquests. Obviously, there are two important reasons for the work
that the coroners do: one is to answer the questions of relatives
as to why somebody has died, and the other is for the public interest—to
learn lessons. If there are lessons to be learned there is a provision
called Rule 43 which says that if a coroner believes that action
should be taken they can announce that they are reporting the
matter in writing. Now, there are a number of problems with the
way that operates at the moment. We can sort out one of those
problems, the rest will have to wait for legislation. One of the
things is that we are going to surface that; we will have a rule
change whereby when a coroner is going to make a Rule 43 recommendation
about how, perhaps, practice in the health service should change,
or how practice in the prison service should change, as a result
of a death that has come before them, people can know that the
Rule 43 recommendation has been made and they will see the response
from the public authority, so that lessons will not only be seen
to be learned by that local authority—the particular one—but,
also, more widely. This is a very, very important tool, this Rule
43, and it seems to me that it is not doing what it was supposed
to be doing. Sometimes authorities do not respond, but nobody
knows they have not responded; sometimes an individual authority
will respond but the lessons are not learned more widely in the
system. That is something, by making a rule change, which makes
it all public so that it is on the Coroners' Society website or
on the Ministry of Justice website, depending on what is decided.
Those Rule 43 recommendations go up there and then the authority's
response or non-response is there and available to see. When we
get to the Bill there will be a statutory requirement to respond,
so we will have to wait for that, but at least people will be
able to see whether or not there has been a response. The other
thing that I think we can be making some progress on is the business
of a Chief Coroner and the potential for having a shadow Chief
Coroner in anticipation of legislation. One of the things that
I have been feeling increasingly uncomfortable and concerned about
is that we have got different coroners' jurisdictions in all the
different local authority areas and we have got ministerial responsibility
in the Department for Constitutional Affairs, but it is only for
policy. So if there is something that needs sorting out and there
needs to be some sort of intervention to sort out a problem, you
either say: "We don't have operational responsibility: this
is an independent judicial office holder—nothing we can
do" or else the Minister intervenes and treads quite a difficult
line. I am constitutionally an interventionist but I do not think
it is a good idea for a Minister to be intervening in situations
where you are dealing with someone who is a judicial office holder.
I think the coroners have been very forbearing when I have attempted
to intervene to try and help sort out problems, but it really
ought to be a Chief Coroner doing that, looking at the picture
across a piece and taking a leadership role—like the Lord
Chief Justice does with judges. There is a possibility that we
could do a shadow Chief Coroner. We could get on with developing
the policy and a shadow Chief Coroner could take that leadership
role.
Q3 Chairman: Lord Hunt, in your department
you have got a major crisis over the registrars' computer system
and we have, in our observation, been far from satisfied that
the two departments work together very closely. We will come to
that in more detail when we come to the medical examiner issue.
Is it at the back of the queue in your department as well?
Lord Hunt of Kings Heath: I am
not sure I recognise the word "crisis", but perhaps
I should pass on that one. It is an important aspect of the post-Shipman
work. We have done a lot of work since Dame Janet reported, strengthening
clinical governance, particularly work on the revalidation and
re-licensing of doctors so that we can be assured that doctors
continue to have the experience and skills to continue to practise
as a doctor, and the issues around certification should be seen
in that context. We hope to publish a consultation paper on certification
issues in the next few weeks—in June, hopefully—so
we are committed to taking this work forward.
Q4 Jeremy Wright: Can we talk a little
bit about death certification? I want to ask you both about the
reasons for the course the Government is intending to take in
this regard. You will both know that this Committee has taken
the view that death certification and death investigation should
be within the boundaries of one service, the coroners' service.
That clearly is not the position that the Government has taken.
Can you explain to us why you think it sensible to have the investigation
of deaths separately from the certification of deaths?
Lord Hunt of Kings Heath: Shall
I kick off, and then Harriet might want to follow it up? There
is joint government departmental responsibility now for the issues
that you are questioning me about: the DCA and the Ministry of
Justice, clearly, in the future, and the Registrar General, under
ONS, in terms of registration and the statistical information
that is collected. The Department of Health has a big role to
play in the oversight of doctors, in ensuring safety and quality
of doctors in the way they perform, but, also, there is a much
stronger role in clinical governance assuring the health service
and other professionals it employs actually are being safe in
what they do. Then there is a wider public health element of looking
at health statistics in terms of determining the future health
policies of a particular district. Information statistics around
deaths are an important component of that. So, given that there
is this joint departmental responsibility, it surely makes sense
to make the most of that to add value by working together. I do
think that there is a strong case for the NHS to have a significant
involvement in the areas of certification.
Q5 Jeremy Wright: Do you want to
add to that?
Ms Harman: I agree. I think, in
a way, that health is always going to have to be involved because
they have an interest after death in respect of things that have
happened before the death and in respect of public health patterns.
Obviously, there is an argument about boundaries, where boundaries
are drawn, but it would never be the case that the Department
of Health would not be involved; of course they have to be involved
and they have to be involved in considering issues after death
as well.
Q6 Jeremy Wright: Does it not make
it more difficult to implement reform in this area if you have
to get those reforms approved not just by one department but by
two, which is effectively what we are looking at here: that if
you want to reform the area of the investigation of deaths within
the coroners' service there will be knock-on effects with medical
examiners and the certification of death? Would it not be much
easier to do all of that within the boundaries of one government
department?
Ms Harman: I do not think so.
You would want to be sure that the health service and the Department
of Health were fully agreeing with whatever we were doing about
that anyway. It has not been my view that somehow the Department
of Health are holding this up. The Department of Health have a
joint Programme Board which DCA officials sit on, and that meets
monthly. So they do operate in a teamly way. I would feel concerned
if somehow this was completely taken over by the Department for
Constitutional Affairs, and the Department of Health was kind
of excluded from it. We need their involvement; they need to be
involved.
Lord Hunt of Kings Heath: Can
I just add to that? If you look back at Dame Janet's report, one
of the conclusions is that there was a lot of information held
about Dr Shipman in different bodies and different organisations.
Part of what we are trying to do is to enable us to be able to
pull together information so that you can pick up patterns. If
you can pick up patterns not only might you, in the case of a
doctor intent on doing harm, pick out those patterns at an early
stage to deter or detect but, also, there is a key advantage in
pulling those patterns together because of what you can learn
about clinical practice in general. If there are identified problems
you can take action to make care safer in the future. Wherever
you decide to place responsibility there are always going to be
boundary issues. The key question is: given that different departments
have different responsibilities, are we making them work well
together so that we add value? My contention is that the work
that we have been doing has been going well but we are determined
to make sure that there is a co-ordinated response to the challenges
that have been set and that we are determined to make this work
in the future, which we are.
Q7 Chairman: Can I just clarify something
you said there? You talked about the responsibility which your
department has but we were rather concerned that your department
seemed to be washing its hands of much of this matter. We had
one official who said to us: "The Department of Health is
not responsible for everything around death certification by any
means. As for the majority of the statutory responsibility it
sits out-with the Department of Health."
Lord Hunt of Kings Heath: Clearly,
if one looks at legislation, legislation around death certification
is covered in the Births and Deaths Registration Act 1953, but
when you look at the key players in certification they are doctors,
and the Department of Health and the National Health Service have
general oversight of those doctors. I am clear that ensuring that
there is a very strong relationship between the clinical governance
processes within the health service and the role of the coroner
is very, very important, both in terms of ensuring that in the
case of individual deaths the system works effectively but, also,
that in terms of detecting Shipmans of the future, or indeed patterns
of health care and morbidity and mortality, closer working together
is essential in that the Department of Health must have a lead
role to play.
Q8 Jeremy Wright: Coming then to
specific examples of where that co-ordination might play out,
can we look at the comparative positions of medical advisers to
coroners, who are provided for in these proposals, and medical
examiners, who are, if you like, another element of testing in
the process of death certification. It would seem that when you
come to choose a medical adviser, if you are a coroner, you are
asked by the Government to ensure that the person you pick has
a degree of dependence from the medical bodies which may have
been responsible for the last stages of care for the deceased,
but if you look at the position for medical examiners they are
likely to be closely connected with the hospital trusts. Why the
difference?
Lord Hunt of Kings Heath: As far
as the medical examiners are concerned, we think that they are
best placed in the clinical governance teams of primary care trusts.
We will clearly be consulting on that in the summer and will look
at the views we get back, but that is our preliminary assessment
of the best place for medical examiners. The clinical governance
approach which is being newly developed in this country is all
about a systematic approach to ensuring safety and quality of
care for patients. In the White Paper we produced in February
about the re-licensing, revalidation of doctors, doctors are going
to have to be re-licensed once every five years. The re-licensing
will be based on quite a lot of different information, but a key
component will be annual appraisals undertaken under the auspices
of clinical governance teams. The whole clinical governance process
is about a thorough and robust approach to assuring that doctors
are practising in a safe and qualitative way. It does seem to
me that having medical examiners from that particular stable is
a guarantee, both of rigour in the approach and, I would certainly
say, independence.
Q9 Jeremy Wright: You say you will
await feedback on this, but is it not blindingly obvious that
some of the feedback you will get is that relatives of the deceased
will find it more difficult to accept that there has been an independent
assessment of the quality of care given if that assessment is
coming from someone within the Trust, which is the position on
the current proposals? That, surely, is why it was thought sensible
that when coroners look for medical advisers they look for someone
who is not in that position. Surely, there must be a conflict
there, and it goes to the root of what we have been saying: that
it is important to co-ordinate these things within one organisation
instead of having the possibility of different approaches in two.
Lord Hunt of Kings Heath: I do
not really agree with you. For the reasons stated, the link between
the work of the coroner and medical examiner links very, very
strongly to the clinical governance work within the primary care
trust. I would be very, very surprised if the independence of
that process was called into question. I would also suggest that
if the medical examiner was not placed within the health service
clinical governance approach—was independently placed—there
is all the risk of professional isolation, when what we want here
is a system which actually makes the flow of information as constructive
and as positive as possible, so that we do deal with some of the
major issues that Dame Janet raised in terms of the paucity of
information that was actually being able to be centralised.
Q10 Jeremy Wright: Can I ask, then,
what happens if the medical examiner connected to the trust and
the medical adviser to the coroner disagree over the need for
an inquest? What happens in that situation?
Lord Hunt of Kings Heath: Of course,
it will be a matter for the coroner to make the judgment. I am
sure Harriet would wish to comment in more detail. My understanding
is that the role of the medical advice that is available to a
coroner, which could come from a variety of sources, not necessarily
an adviser, is to give advice on specific cases. The role of the
medical examiner, as you know, is to check through each medical
certificate on cause of death and they have to give their approval
to the registrar before a death certificate can be issued. The
medical examiner, of course, can refer cases, and will refer cases,
to the coroner. The coroner will have to make the decision. In
so doing, as I understand it, the coroner can call on further
medical advice. I do not think it is so much a matter of conflict
but of different roles, which should complement each other.
Q11 Chairman: Would a trust be allowed
to let a medical examiner combine another role in the trust with
that of medical examiner?
Lord Hunt of Kings Heath: They
might do so. I would not want to give you a hard and firm answer
because we are preparing a consultation paper at the moment and
we will clearly want to explore some of those issues in that consultation
paper. Clearly, conflict of interest situations will be relevant
to that—I understand that—but I would not want to
completely rule out the fact that some part-time medical examiners
may be appointed and that they might be practising clinicians;
they may be doing other jobs that are wholly appropriate. It is
difficult for me to say there is a certain situation in which
that ought not to take place, or those where it will.
Q12 Chairman: Is it not absolutely
inherent that there will be a conflict of interest in a situation
where it is the trust that might be sued if something is found
to have gone wrong with the medical treatment and the medical
examiner is employed— perhaps a double-hatted employee—with
other responsibilities in the trust, where even his own salary
let alone his own status within the trust is inexorably bound
up with the decision he is going to have to take?
Lord Hunt of Kings Heath: Clearly,
we will want to avoid direct conflict of interest situations,
but if you think about the structure of the National Health Service,
we are saying that medical examiners should be based within the
clinical governance group of a primary care trust. If we are talking
about GPs, in the main these are independent contractors.
Q13 Chairman: But primary care trusts
can run hospitals, and some do.
Lord Hunt of Kings Heath: Some
primary care trusts do run some services, yes, which is why I
was being cautious in my response to you and why, certainly in
the consultation paper, we will be looking to ensure that there
not conflict of interest issues that arise and are dealt with
promptly. The problem with a blanket decision that a medical examiner
cannot be employed by a primary care trust is that if you do that
you lose all the benefit of those people being part of the clinical
governance team, which is so important to assuring quality and
safety in the future.
Q14 Chairman: Given the ambivalence
that there was about who was responsible and to what extent for
this whole system, as between the two departments and ONS as well,
are you confident that you have the resources to do what is required
within the system as a whole when there was doubt as to whether
DCA had the resources to deal with it?
Lord Hunt of Kings Heath: The
issue of resources is clearly a matter that has to be firmed up
in the future. Am I confident that we can come to a position where
the NHS is in a position to employ high-quality medical examiners
to provide the high-quality service? Yes, I am.
Q15 Julie Morgan: The Luce Review
and the Shipman Inquiry both took the view that death certification
procedures should be the same, regardless of how the body was
being disposed of. Will the new death certification proposals
result in a single procedure for both burials and cremations?
Lord Hunt of Kings Heath: The
answer to that is yes. The role of the medical examiner will be
the same in relation to burial or cremation. They will have to
look at every death certificate and they will have to either refer
to the coroner or give clearance to the registrar to be able to
issue a death certificate.
Q16 Julie Morgan: So there will be
no crematorium medical referee any longer?
Lord Hunt of Kings Heath: No.
Julie Morgan: So you have accepted
the recommendations of the different reviews. Thank you very much.
Q17 Dr Whitehead: When we reported
originally on the service we were concerned about the question
of resourcing and the variation in resourcing of the coronial
service between various local authorities, and the outcome of
the reforms, which is that there will be a Chief Coroner but the
local resourcing and Constitution for individual coroners will
be retained. In the Westminster Hall debate there was discussion
about the question of the variation of resourcing between various
coronial services, and you, Minister, said that there was not
any evidence, as yet, that the difficulties in various areas,
you suggested, are the result of resourcing problems. We did indicate
that there was, we thought, some evidence as far as the Committee
is concerned, but you also indicated that you would be investigating
the variation in resourcing in the coronial system. Are your inquiries,
for example, taking into account the contributions that we suggested
were made by police authorities, hidden subsidies provided by
solicitors who sit as part-time coroners, who give their services
free of charge, and things such as that, or are you relying on
more, shall we say, basic statistics in your investigations?
Ms Harman: This was a very important
point that Members have raised in this Select Committee but, also,
raised in the Westminster Hall debate. One of the things we are
seeking to address is the fact that there is not a national framework
which is able to look and see what is going on in each area and
how well resourced it is. I suspect that there are some areas
which are doing very well despite inadequate resources, and I
suspect that there are some areas which, despite adequate resources,
are not actually delivering the service that there needs to be.
We have responsibility in the Department for Constitutional Affairs
for policy. There is nobody who is operationally responsible for
ensuring that the coroners' system is working in each individual
area in the public interest and for the sake of the bereaved.
That notwithstanding, we have been investigating and trying to
find out what is going on. I do apologise for giving those tables
very late in the day (which is entirely my fault) but they are
just really to show some of the work we have underway, which are
the tables which look, for example, at the average time it takes
before something comes to an inquest. One of the main concerns
of relatives is delay, and there is an issue about whether or
not resources are affecting delay. We have been looking at how
many inquests are held by each coroner and how long they are taking,
on average, for each of their inquests, and how old are the oldest
cases. Then we are updating our information about finances: 90%
of the coroners' officers' finances come from the police—90%
of the coroners' officers are provided by the police—so
it is a question of discovering from the police authorities what
that represents in money terms, and, also, discovering from the
local authority what their resource contribution is to the system,
and then matching it so that we can see, per inquest, what the
variation is in the amount of funds going to each inquest. This
is something that it will be appropriate to have under scrutiny
by the inspection system when we get legislation and we have an
inspection system, because there is no inspection system for the
coroners' system. There is an inspection for the court service,
for police, for everything else—Ofsted for schools—but
there are not any inspection systems. So an inspection system
would surface that sort of information. The Chief Coroner would
surface that sort of information. In the meantime, we are trying
to get hold of some statistics which we do not actually have any
power to require, but people have been, helpfully, giving us this
information and trying to make sure that we can make sense of
it. That is what we are doing. We are under way. So I have given
you the length of time statistics and the number of cases per
coroner, and the resource statistics will follow along from that,
for what they are worth.
Q18 Dr Whitehead: Will those be made
available to us or to other interested parties?
Ms Harman: Yes, but they will
come with large health warnings on them, because all you need
is a few very, very difficult complex, technical, long-running
inquests and then you can get the bulge in the figures. So we
have to be quite sensitive about how we produce this information.
Q19 Chairman: It is a reason for
not using averages, is it not—for using a mean figure rather
than an average figure?
Ms Harman: Except that we do want
to look, in each coroner's jurisdiction, at whether or not the
average in that coroner's jurisdiction --- If it is a large jurisdiction,
you can compare large jurisdiction with large jurisdiction—
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