Joint memorandum submitted by the Department
for Constitutional Affairs (DCA) and the Department of Health
(DH)
This paper responds to the Constitutional Affairs
Select Committee's request for supplementary information following
their inquiry in to coroners and death certification during 2006.
SECTION 1: BACKGROUND
1.1 The Government's reform of the coroner system
is underpinned by three main aims:
An improved service for bereaved
people and others who interact with the system;
The introduction of national leadership
and improvements to enhance the local nature of the system; and
More effective coroners' investigations.
1.2 Specific changes to meet these aims are:
Charter for the Bereaved, setting
out services coroners will provide and a new appeals system.
Leadership from a new Chief Coroner,
including the introduction of new national standards.
Introduction of new independent coronial
advisory council.
Improved medical expertise from a
Chief Medical Adviser to the Chief Coroner, and grants to coroners
to buy in appropriate medical advice in their areas.
Guidance for medical professionals
setting out the types or characteristics of cases which should
be reported to the coroner.
New coroner areas with most coroners
whole time appointments.
Improved training provision.
Greater prominence given to public
protection role of coroners.
Improved powers for coroners to get
information to help their inquiries.
Removal of rigid boundaries which
hamper effective investigations, and impede efforts to tackle
delays.
Inspection arrangements for the first
time.
1.3 The Government has consulted extensively
on these and the other more detailed proposals since the draft
Bill was published. As far as coroners in particular are concerned,
four regional conferences to explain the Bill were held last June
and July, which were attended by 90 coroners, plus a further 15
deputy or assistant deputy coroners. More generally, DCA officials,
led by an SCS member, meet on a two monthly basis with senior
representatives of the Coroners Society to discuss issues of mutual
interest, including reform issues. Additionally, officials regularly
visit coronersin 2006, 47 such visits were made.
1.4 On death certification, the Government
accepts the Shipman Inquiry's conclusion that the existing arrangements
for scrutinising the medical cause of death (MCCD) are confusing
and inadequate. It has identified the following potential weaknesses:
Although there are checks by two
successive doctors in cremation cases, the scrutiny is not always
sufficiently independent of the doctor signing the MCCD and is
not subject to effective quality assurance;
There is no independent medical scrutiny
of the MCCD at all in the case of burials, unless the doctor signing
the MCCD specifically refers the case to the coroner, or the registrar
refers to the coroner before registering the death; and
There is no routine system for analysis
for local clinical governance purposes of the information on MCCDs
or on the additional forms completed for cremations, and no explicit
link to clinical governance processes in hospitals or in Primary
Care Trusts.
1.5 The Government therefore plans to consult
on creating a more rigorous, unified system covering both burials
and cremations, but outside the coroner system, the purpose of
which will remain to investigate violent or unnatural deaths or
those of unknown cause. The proposals on certification, which
are currently being worked up and which will take account of the
parallel proposals on medical advice to coroners, are:
MCCDs, for burials and cremations
alike, would be subject to scrutiny by an independent medical
examiner attached to the clinical governance team in the hospital
trust (secondary care) or PCT (primary care);
Where the medical examiner was not
satisfied that the MCCD told the full story or felt that there
were other unusual circumstances, he or she would refer the case
to the coroner for further examination, along with his or her
reasons for doing so;
The medical examiner would have full
access to medical records and would be empowered to discuss the
circumstances of the death with the doctor signing the MCCD and
with the family of the deceased;
The clinical governance team would
collate information from MCCDs and would use this to analyse trends
and patterns, looking out for unusual features such as those revealed
by the pattern of deaths in the Shipman case; and
The clinical governance team would
ensure that all unexpected deaths were treated as significant
events and followed up in individual and team clinical audit.
These proposals were announced by the DH Minister
of State for Delivery and Performance [Andy Burnham] and the Chief
Medical Officer at the launch in February of Learning from
tragedy (Cm 7014), a paper summarising the Government's action
in response to the recommendations of the Shipman Inquiry.
1.6 The Government does not propose that this
new medical examiner will act as an intermediary between the medical
profession and the coroner in the generality of cases. The Coroners
Bill will provide for regulations which will set out the deaths
which medical professionals should refer to coronersas
now, most of these will be cases where it is not possible for
the registrar to register the death and issue a certified copy
of the register entry before a coroner has had the chance to investigate.
SECTION 2: RELATIONSHIP
BETWEEN THE
DCA, THE DH AND
THE GENERAL
REGISTER OFFICE
(GRO) WITH RESPECT
TO RESPONSIBILITIES
IN RELATION
TO DEATH
CERTIFICATION
2.1 The DCA, the DH and the Office for National
Statistics (of which the General Register Office is a part) work
together on death certification issues. There are a number of
processes that contribute to the completion of a death certificate,
and a body being able to be released to be either cremated or
buried. The legislative framework is clear that cremation certification
lies with the DCA, and responsibility for providing doctors with
medical certificates of cause of death (with instructions on how
to complete them) and for the registration of deaths lies with
the Registrar General (through the Births and Deaths Registration
Act). These responsibilities complement the Registrar General's
remit, which is to record life events and compile statistics,
including those for mortality, population and morbidity. The DH
has an interest in the professional regulation of, and training
for, doctors, and an interest in the statistical data on births
and deaths needed for NHS planning and public health policy.
2.2 To update each other on progress, officials
from all three Departments meet regularly to discuss both strategic
and specific issues. On the latter, ad hoc meetings take place
as and when the need arises. On the former, a Coroner Reform Programme
Boardwhich met quarterly and was chaired by a member of
the SCS and attended by officials from all relevant Departmentswas
established in 2004 to provide direction, to discuss cross Government
issues, and to monitor progress. DH and DCA ministers are kept
regularly informed about progress in these discussions and in
addition there was a meeting in May 2006 between Andy Burnham
and Harriet Harman to review progress in responding to the challenges
posed by the Shipman Inquiry.
2.3 It was decided, in early 2007, to suspend
the Programme Board until the legislative position became clearer.
In its place, and to both improve current services and to maintain
the dialogue and momentum on wider reform issues, a Coroners Service
Stakeholder Forum was established. The Forum, also chaired by
a member of the SCS, consists of members of the previous programme
board, including DH and ONS, together with representatives of
the main stakeholder groups who have an interest in the management
of the coroners' service and its future reform. These groups include
the Coroners Society, Local and Police Authorities and members
of coroners' service user groups.
2.4 The Stakeholder Forum has two main purposes.
First, it will consider, discuss and identify solutions to issues
that have an impact on the delivery of the current service. Second,
the group will, where appropriate, consider important reform issues
and emerging reform policy proposals. The Forum will meet quarterly
and the first meeting will be held in May.
2.5 In addition, and for some years, officials
from the DCA (and before that the Home Office) have met approximately
every 2 months with senior representatives from the Coroners Society
to discuss issues, including reform, relating to the operation
and Constitution of the service. These meetings will continue.
2.6 The DCA and DH have also met jointly with
the British Medical Association and with the Royal College of
Pathologists to discuss death certification issues.
SECTION 3: SPECIFIC
CONSULTATION BETWEEN
THE THREE
DEPARTMENTS IN
RELATION TO
THE PROPOSAL
FOR AN
INDEPENDENT MEDICAL
EXAMINER TO
SCRUTINISE DEATH
CERTIFICATES
3.1 DCA officials are represented on the DH
programme board which developed the government's response to the
Shipman Inquiry and is now responsible for its implementation.
The programme board meets monthly. In addition, DCA and DH officials
have had a number of ad hoc meetings to discuss and develop the
current proposals, with almost daily telephone and e-mail contact
in the final weeks leading up to publication. Further meetings
are being held to work up more detailed proposals in a consultation
paper to be published shortly by the Secretary of State for Health.
3.2 Coroners have not, so far, been specifically
invited to comment on the proposals. Their attention was drawn
to them at the time of the publication of Learning from tragedy
in February, but coroners have not chosen to comment through the
normal channels, including at a meeting between senior members
of the Coroners Society and the Minister of State in DCA [Harriet
Harman] on 19 March. We will consult them formally both before
finalising the consultation paper and through the consultation
proposals themselves.
SECTION 4: COORDINATION
BETWEEN THE
THREE DEPARTMENTS
TO USE
PUBLIC HEALTH
ISSUES DERIVING
FROM THE
CORONIAL SYSTEM
4.1 Mortality statistics based on the information
provided to registrars of deaths by coroners following inquests
have always been an essential tool of public health. This statistical
information includes mortality rates by cause, age, sex, occupation,
social class, primary care trust and local authority of residence
and place of death. They are used extensively across local and
national Government and the NHS to identify priority issues and
population groups at risk, develop national policy and local implementation
strategies and to monitor their effectiveness. However, there
is very little co-ordination of more detailed and extensive information
emanating from coroners" investigations, whether about health
or any other protection issue affecting the public. This is a
significant weakness in the system which reform will address.
DCA Ministers have a policy responsibility for coroners but no
operational responsibility, although in recognition of the need
to do more to provide a national perspective ahead of reform,
the Minister of State [Harriet Harman] has assisted coroners to
tackle specific problems, such as the delays in holding inquests
into military personnel killed in Iraq.
4.2 The Minister is also working with coroners
to improve their public protection role in advance of reform.
The Coroners Society is developing its website to ensure that
all reports to organisations (to prevent future similar fatalities)
under Rule 43 of the current Coroners Rules are accessible to
all coroners, and to senior DCA officials. This will enable trends
to be identified and for action, or lack of it, taken by public
authorities to be monitored.
4.3 This power will be enhanced following reform.
It has been moved from the rules to primary legislation (clause
12(3) in the draft Bill), and the Minister announced on 30 January
that she was going to enhance the power in the following ways:
The organisation to which the report
is made will have a statutory requirement to respond to the coroner;
There will be a requirement for the
Chief Coroner to include in his or her annual report to Parliament
a summary of the reports made by coroners; and
The Chief Coroner will have a responsibility
to check what action has been taken by authorities to whom a report
has been made, and oversee the operation of the system generally.
4.4 The initial Bill proposal has been fully
consulted on, not just within Government and with coroners, but
others, like the voluntary sector, with an interest. It was as
a result of the consultation processwhich supported this
measurethat the Minister decided to enhance the proposal
in the way described in paragraph 4.3. The announcement was cleared
by colleagues across Government through the usual process, and
coroners were forewarned, although not specifically consulted
given that the changes of substance were almost entirely related
to the role of the Chief Coroner.
4.5 Information from coroners' determinations
already flows into information used for public health and planning
purposes in aggregated form, through the statistics collated by
the Office of National Statistics. Thus, coroners' decisions have
a very direct relevance to monitoring the incidence of suicide,
for example, to judge progress in reducing incidence in accordance
with national targets. Ministers expect the reforms, especially
the creation of the role of the Chief Coroner, to promote consistency
of practice amongst coroners which should improve the accuracy
of information. The proposed changes to arrangements for death
certification are a key component in the move to drive up accuracy
of statistics on causes of death. The improved accuracy of information
from coroners will benefit work by the range of health and social
care organisations with responsibilities for examining causes
of death in individual cases and understanding the underlying
epidemiology. These include Primary Care Trusts, Drug Action Teams,
the National Patient Safety Agency, the Medicines and Healthcare
Products Regulatory Agency, the Healthcare Commission, the Commission
for Social Care Inspection, the National Confidential Enquiry
on Perioperative Death, Confidential Enquiry on Maternal and Child
Health, the Health Safety Executive, the Health Protection Agency
and Local Safeguarding Children Boards.
4.6 The reforms also provide an opportunity
to promote greater co-operation between coroners and public health
practitioners, at both local and national level. As mentioned
in paragraph 4.3, a coroner's power to bring issues to the attention
of relevant authorities is being strengthened. The improved leadership
of the coroners' service, which is a central part of coroner reform,
is expected to promote effective relationships between coroners
and public health officials in Regional Public Health Groups and
public health observatories. This should mean that trends in a
locality that are identified by the coroner can be passed on and
investigated, as appropriate. The Chief Coroner will also be able
to make a contribution at a national level, for example in advising
where coroners identify emerging public health issues with national
implications.
Rt Hon Harriet Harman, MP, Minister of State, Department
for Constitutional Affairs
Lord Hunt of Kings Heath, OBE, Minister of State
for Quality, Department of Health
April 2007

CORONER STATISTICS
All 2006 data (oldest case and charts at B,C &
D) have yet to undergo quality assurance checks so are classed
as provisional.
A. Oldest case and average time to complete
[* denotes where an estimated average has not
been given, as fewer than 20 inquests were completed in 2005 on
deaths in England and Wales].
No | County and district
| Deaths reported to coroners in 2005 on which inquests were or were to be opened
| Oldest outstanding inquest case (as at 31/12/2006)
| Estimated average time (weeks) to complete inquests (2005) for deaths in England and Wales
|
| ENGLAND AND WALES
| | | |
1 | Avon (former county) |
600 | 18/04/1998 | 26
|
2 | Bedfordshire and Luton |
219 | 08/03/2005 | 14
|
3 | Berkshire (former county)
| 288 | 17/02/2003 | 19
|
4 | Birmingham and Solihull
| 950 | 01/02/1997 | 17
|
5 | Black Country | 290
| 23/07/2004 | 18 |
6 | Blackburn, Hyndburn and Ribble Valley
188
| 25/04/2005 | 17 |
7 | Blackpool/Fylde | 14
| 22/07/2004 | 158 |
8 | Boston and Spalding |
70 | 15/09/2005 | 18
|
9 | Bournemouth Poole and Eastern Dorset
165
| 08/05/2001 | 14 |
10 | Bridgend and Glamorgan Valleys
| 262 | 14/10/2002 | 30
|
11 | Brighton and Hove |
194 | 06/07/2006 | 13
|
12 | Buckinghamshire | 171
| 05/09/2005 | 22 |
13 | Cardiff and Vale of Glamorgan
| 323 | 23/04/2003 | 33
|
14 | Carmarthenshire | 96
| 25/09/2005 | 12 |
15 | Central and South East Kent
| 180 | 19/07/2001 | 27
|
16 | Central Hampshire |
154 | 05/08/2003 | 17
|
17 | Central North Wales |
262 | 20/11/2005 | 21
|
18 | Ceredigion | 28
| 09/12/2004 | 23 |
19 | Cheshire | 6
| 07/01/2004 | 27 |
20 | City and County of Swansea
| 140 | 15/07/2002 | 36
|
21 | City of London | 26
| 12/03/2003 | * |
22 | Cornwall | 354
| 15/04/2002 | 29 |
23 | Coventry | 168
| 15/07/2005 | 17 |
24 | Darlington and South Durham
| 138 | 31/01/2004 | 28
|
25 | Derby and South Derbyshire
| 334 | 01/07/2003 | 19
|
26 | East Lancashire | 158
| 17/09/2003 | 29 |
27 | East London | 455
| 22/10/2004 | 26 |
28 | East Riding and Hull |
272 | 22/03/2005 | 34
|
29 | East Sussex | 306
| 03/02/2004 | 27 |
30 | Eastern Somerset | 98
| 18/04/2000 | 8 |
31 | Essex and Thurrock |
437 | 02/01/2002 | 41
|
32 | Exeter and Greater Devon
| 381 | 10/04/2003 | 21
|
33 | Gateshead and South Tyneside
| 148 | 02/03/2003 | 22
|
34 | Gloucestershire | 344
| 22/03/2004 | 25 |
35 | Great Yarmouth | 41
| 14/02/2006 | 28 |
36 | Gwent | 159
| 19/10/2003 | 11 |
37 | Hartlepool | 71
| 02/08/2006 | 15 |
38 | Herefordshire | 82
| 11/10/2004 | 20 |
39 | Hertfordshire | 415
| 29/07/1997 | 19 |
40 | Inner North London |
573 | 24/10/2004 | 29
|
41 | Inner South London |
532 | 21/07/2001 | 25
|
42 | Inner West London |
466 | 30/04/2004 | 12
|
43 | Isle of Wight | 56
| 03/11/2004 | 45 |
44 | Isles of Scilly | 2
| None outstanding | * |
45 | King's Lynn | 88
| 29/06/2006 | 12 |
46 | Leicester city and South Leicestershire
| 453 | 23/10/2001 | 24
|
47 | Liverpool | 469
| 16/05/1999 | 10 |
48 | Manchester city | 515
| 01/04/1998 | 33 |
49 | Manchester North | 357
| 02/04/2003 | 19 |
50 | Manchester South | 503
| 25/03/2004 | 27 |
51 | Manchester West | 461
| 25/02/2003 | 27 |
52 | Mid and North Shropshire
| 99 | 12/07/2003 | 26
|
53 | Mid Kent and Medway |
202 | 11/09/2003 | 28
|
54 | Milton Keynes | 111
| 01/07/2004 | 17 |
55 | Neath and Port Talbot |
69 | 03/04/2005 | 24
|
56 | Newcastle upon Tyne |
344 | 18/01/2003 | 20
|
57 | North and East Cambridgeshire
| 80 | 27/10/2005 | 25
|
58 | North Derbyshire | 258
| 30/09/2005 | 14 |
59 | North Durham | 229
| 16/04/2004 | 22 |
60 | North East Cumbria |
99 | 16/10/2003 | 32
|
61 | North East Hampshire |
121 | 26/06/2006 | 12
|
62 | North East Kent | 228
| 31/01/2002 | 17 |
63 | North East Wales | 290
| 13/02/2004 | 24 |
64 | North Lincolnshire and Grimsby
| 114 | 15/01/2001 | 42
|
65 | North London | 434
| 04/08/2004 | 17 |
66 | North Northumberland |
133 | 09/08/2003 | 25
|
67 | North Tyneside | 222
| 10/10/2003 | 20 |
68 | North West Kent | 171
| 19/06/2001 | 20 |
69 | North West Wales | 130
| 01/10/1999 | 27 |
70 | North Yorkshire Eastern District
| 133 | 12/10/1998 | 21
|
71 | North Yorkshire Western District
| 140 | 26/09/2002 | 29
|
72 | Northamptonshire | 250
| 01/03/2000 | 27 |
73 | Norwich and Central Norfolk
| 242 | 24/01/2005 | 22
|
74 | Nottinghamshire | 458
| 02/10/2002 | 13 |
75 | Oxfordshire | 446
| 20/09/2000 | 38 |
76 | Pembrokeshire | 82
| 09/08/2005 | 19 |
77 | Peterborough | 90
| 09/02/2005 | 26 |
78 | Plymouth and South West Devon
| 426 | 16/07/2002 | 17
|
79 | Portsmouth and South East Hampshire
| 297 | 10/09/2001 | 41
|
80 | Powys | 81
| 04/08/2004 | 23 |
81 | Preston and South West Lancashire
| 379 | 28/11/2003 | 21
|
82 | Rutland and North Leicestershire
| 179 | 24/01/2004 | 18
|
83 | Sefton, Knowsley and St Helens
| 244 | 18/08/2003 | 22
|
84 | South and West Cambridgeshire
| 228 | 10/02/2006 | 19
|
85 | South Cumbria and Furness
| 146 | 02/08/2002 | 18
|
86 | South London | 342
| 01/01/2004 | 21 |
87 | South Northumberland |
120 | 12/09/2002 | 18
|
88 | South Shropshire | 29
| 08/02/2002 | 31 |
89 | South Yorkshire Eastern District
| 303 | 03/09/2001 | 16
|
90 | South Yorkshire Western District
| 437 | 15/08/2005 | 18
|
91 | Southampton and New Forest
| 218 | 17/11/2002 | 17
|
92 | Southend-on-Sea | 148
| 15/01/2003 | 21 |
93 | Spilsby and Louth |
59 | 08/08/2004 | 24
|
94 | Staffordshire South |
356 | 29/09/2004 | 21
|
95 | Stamford | 17
| 21/11/2002 | * |
96 | Stoke-on-Trent and North Staffordshire
478
| 28/05/2002 | 17 |
97 | Suffolk | 267
| 24/04/2003 | 17 |
98 | Sunderland | 348
| 21/07/2004 | 15 |
99 | Surrey | 382
| 31/08/1997 | 28 |
100 | Teesside | 348
| 10/12/2003 | 28 |
101 | Telford and Wrekin |
64 | 03/03/2003 | 22
|
102 | The Queen's Household
| 0 | 31/08/1997 | Not applicable
|
103 | Torbay and South Devon
| 130 | 26/06/2005 | 20
|
104 | Warwickshire | 240
| 18/10/2002 | 27 |
105 | West Lincolnshire |
111 | 25/05/2004 | 25
|
106 | West London | 759
| 01/09/2002 | 22 |
107 | West Sussex | 374
| 21/09/2005 | 14 |
108 | West Yorkshire Eastern District
| 578 | 26/10/1998 | 28
|
109 | West Yorkshire Western District
| 435 | 26/10/1998 | 25
|
110 | Western Cumbria | 70
| 27/08/2003 | 23 |
111 | Western Dorset | 89
| 03/08/2000 | 19 |
112 | Western Somerset |
143 | 19/02/2004 | 19
|
113 | Wiltshire and Swindon
| 255 | 22/07/2003 | 33
|
114 | Wirral | 269
| 01/06/2004 | 16 |
115 | Wolverhampton | 157
| 01/06/1998 | 21 |
116 | Worcestershire | 292
| 16/07/2002 | 16 |
117 | York City | 88
| 31/03/2005 | 28 |
B. Distribution of length of Inquest

C. Origin of Oldest Case

Note: Although only about 2% of coroners cases
are deaths abroad they account for about a third of oldest cases.
D. Number of jurisdictions with outstanding inquest cases
from each year
May 2007
|