Coroners and Justice Bill

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Q 98Mrs. Moon: On the system that is in use in Australia, two studies, coming out of Manchester and Oxford, have dealt with psychological autopsies, where the individual is the focus. So it is not a case of moving away from the individual and their death at all, but of exploring that person’s death much more, to provide an understanding about why the person is dead and to look at the common links. Do you think that it would be appropriate for the psychological autopsy system, which I am particularly interested in, to sit behind the coroners’ system?
André Rebello: At the moment, in my jurisdiction, we have co-operated with researchers looking back through inquest files for trends. They have looked at death by self-harm, which I have not been able to say is suicide, and they have come to different conclusions, for epidemiology purposes, to prevent harm.
I do not know. All I know is that at the moment we have got to determine who died, when or where the person died and by what means, and, in some cases, in what circumstances the cause of death arose. We can hear evidence and decide the facts. If there has to be some bridging between trends in different types of cases, that is not in the Bill and not in the current law. This would be something new. Whether that would be beneficial or not, I do not know. I presume that the Office for National Statistics and the General Register Office pull together some of these things, otherwise we would not have any information for politicians to make decisions on. There must be something pulling it together somewhere.
The lessons that we have learned and the provisions that we have now in respect of rule 43 do not have any teeth. We can write letters raising issues and we can get a reply, but there are no teeth for situations where people do nothing—apart from public humiliation—if the incident recurs.
You are talking about something that is completely new, which is not in the current law and is not in the Bill. The chief coroner might be asked to appoint a deputy chief coroner to overview several inquests. That would be a new structure and it is not there at moment. I do not know whether it would be worthwhile because it is beyond what the coroner does now.
Q 99Mr. George Howarth (Knowsley, North and Sefton, East) (Lab): I want to ask three questions: one to Deborah Coles, one to Mr. Rebello and one to Alison Cox. First, to Deborah Coles, have I misunderstood or are you mixing up two separate objectives? On the one hand there is an inquiry into the cause of death and on the other an inquiry into the systems themselves. That is what you appeared to be saying a few moments ago.
Deborah Coles: No. The example I gave was death in prison. Obviously inquests into those cases have to be article 2 compliant, so there is the opportunity to look at the broader circumstances beyond just the means by which the person died. So that involves an examination of policies and procedures. For example, the deaths at Styal raised a lot of concerns about the treatment of vulnerable women who were drug dependent. The majority of those women took their own lives by hanging themselves. The means of the death were quite clear. We knew how they died. It was the broader circumstances that were of key concern. That involved a lot of issues and looking at potential system failings. Those article 2 cases look at broader issues than the means.
Q 100Mr. Howarth: Thank you. Mr. Rebello, you made the point, and I agree with you, that even in cases where there may have been multiple deaths in one incident, each case is different. Each inquest should be about a different death, even though the overall event may have caused all of the deaths. That is an important distinction to make. There have been exceptions to that. There were a series of mini-inquests into the Hillsborough deaths which meant that they were doing eight per day. Although there was an inquest into each death, it was a shortened version. As the Liverpool coroner you will know that that caused a great deal of anguish, particularly given the insensitivity of the conduct of the coroner in those inquests. Do you think these new arrangements will do anything to improve those sorts of inquest or do you think there is scope for some further improvements for cases where there are multiple deaths arising from one incident?
André Rebello: Stefan Popper lived and worked in a different era. I suspect that what he did would have happened in nearly every jurisdiction at that time.
Mr. Howarth: I am sure he was well intentioned.
André Rebello: I am absolutely certain he was well intentioned. The other thing I would say is that my deputy acted for 96 families in the Hillsborough inquests. There were not batches of inquests. When the inquests were opened the coroner had to receive evidence of identification. You can do that in lots of different ways. You can give everyone an appointment and have one person at a time hearing evidence about who that person was, register all the particulars so that you can issue an interim death certificate and a certificate of disposal for burial or cremation and then adjourn the case until the full evidence can be heard. Or you can deal with them in batches of eight at a time. When a coroner was dealing with cases, particularly in those days, people did not stop dying. Other people were dying at the normal rates.
On a Monday morning in Liverpool, 60 deaths can be reported to me from the weekend. I will have spoken to the police. I work 24/7. I work in the middle of the night and still work the next day. Even when I am on holiday I am working. When the coroner is faced with 96 or more deaths that occurred in one incident, the number of people who normally die in the weeks it takes to deal with those will remain the same. From a pragmatic point of view, I understand that a decision might have been made in order to continue giving a service to everyone else.
Today, that might be dealt with very differently, in the sense that coroners are enabled and encouraged, particularly by the Coroners’ Society, to appoint additional assistant deputy coroners. In those days, the advice from the Home Office’s coroners’ unit, the predecessor of the Ministry of Justice’s coroners’ unit, was that the deputy and assistant deputy coroners could only work if the coroner was not working. That was the advice given by the Government. Therefore, if Stefan Popper was in court and working as coroner, no deputy or assistant deputy coroner could deal with the other cases, and that is what caused those problems. Today, you would appoint additional assistant deputy coroners to deal with work while you give time to each family to deal with the opening of the inquest.
When looking at by what means and in what circumstances those deaths occurred, you cannot hear the evidence 96 times with 96 separate juries, because you will get 96 different versions of the means and circumstances. The witnesses will give evidence differently each time and the different juries will come to different conclusions, even if they have heard the same evidence. You have to hear the bulk of the evidence for all the deaths that occurred in one incident at once, but when you open the inquest, you can open it for each individual. Today the trend would be to open the inquest for each individual, but of course those were very different times and I am sure that today coroners have moved on an awful lot.
Q 101Mr. Howarth: I accept that the procedure was unsatisfactory, and I attended a day at those proceedings—
André Rebello: Unsatisfactory, but it was the norm throughout the country.
Q 102Mr. Howarth: I still think that you have not addressed the particular issue of the appropriateness of the way it was conducted. The Taylor inquiry had already concluded that the cause of the disaster was inadequate policing, yet undue attention was paid to the alcohol intake in each individual inquest. Given that the cause of the accident was already known, that was largely irrelevant. It is as much about the perception of the coroner in those circumstances as about the procedure itself.
If we need to level the playing field and ensure that the coroner gets the justice and balance right, we have to achieve a level playing field. Part of the coroner’s role is to ensure that there is a level playing field. I am probably far more proactive when people are unrepresented than when they are represented, in an attempt to level that field, but if we are to deal with that issue, legal aid should certainly be available for inquests. It is only in the individual cases when submissions can be made with regard to the scope of the inquiry that things you raise can be dealt with. I cannot go back in history and deal with something that has occurred.
Q 103Mr. Howarth: All the legal aid in the world would not resolve the problem that if a coroner starts with a particular prejudice in his or her mind, it will affect the conduct of the case.
André Rebello: There was and still is a right of appeal with regard to a particular decision. I am not sure whether this is the right forum in which to deal with that appeal. We do not have all the facts and I cannot address the issues you are raising. I have no papers from the case before me. I understand where you are coming from. What you are saying is alien to my jurisdiction and to what I do. You are more than welcome to come along and sit in at any time you like.
Deborah Coles: On recognising the distress that inquests cause to such families, we were involved with many of the families and some of the academics involved in Hillsborough. What failed to happen there was proper family representation and an agreement on the scope of the inquest from the outset. That would have meant that it would not focus on aspects to do with the insensitive treatment of those families. In a sense, the bereaved were blamed for what happened. That is completely unacceptable.
Having said that, we have seen the same things happen in other cases. The system works best when families are represented and when there are pre-inquest reviews. Discussions about scope and what the inquest will look into are then agreed beforehand. That gives lawyers representing the families the opportunity to prepare them. Families recognise that there will be occasions when deeply sensitive, personal and distressing information needs to come out in public. The issue is about preparing the families for that. The relevance of that information and how it assists the process of finding out what happened must also come out publicly. Ideally, it will prevent such things happening in the future.
Q 104Mr. Howarth: I have a quick point to put to Alison Cox. From your point of view, are there any improvements that ought to be made to these provisions? If that is a rather big question to answer today, you may by all means submit a memorandum.
Alison Cox: I will do that, but I do not think that the question is too big. To me, the aspiration of the Bill is fantastic. The revised draft has made a big difference. The whole thing is dependent on the issue of appeal. I am aware that the appeal process is to do with the coroner’s verdict. That is important to cardiac risk in the young and sudden cardiac death. However, point 54 suggests that there is a wider opportunity. It is a question of the quality of the coroner. André and I have had a short conversation about this. There is a legacy of coroners embedded in the system who struggle to keep up with the standards that we would expect in 2009.
The issue is how the appeal process can be facilitated for bereaved families for whom, following a sudden cardiac death, it will take two years to register that that person has died. I would like some kind of evaluation or registration form that they can fill in which will feed into the question of whether the coroner understood their situation, was empathetic and showed sensitivities in many ways, such as how the media were dealt with. There is enormous scope for coroners to be seen by the families either as legends or as doing less than they could and should have done. Whether you can use the appeals process to register whether an inquest has been dealt with in a way that bereaved families feel to be right is very important in overseeing the ambitions of the service.
Q 105Mr. Bellingham: I have a quick follow-up question on something that has already been covered. Could paragraph 6(1) of schedule 4 on action to prevent other deaths be improved where it says that
“the coroner may report the matter”
when something is revealed that gives rise to concern? Should it not be an obligation to report the matter to a person who may have the power to take action? Under the schedule, that person must make a written response. What I should like to see is some follow-up, perhaps in the form of a report to Parliament. Perhaps one of the deputy chief coroners could have a specific role in collating such reports and ensuring that there is follow-up and accountability. We have touched on that matter already, but will you elaborate on how that could be improved?
André Rebello: We could not do better than follow the Victorian Institute of Forensic Medicine’s “Fatal Facts” bulletin in which all the equivalent rule 43s are pulled together. I get a monthly communiqué from Victoria setting out all the trends that have occurred, how they have been responded to and things of that nature. That will cost money and will need people to work on it. Parliament has the opportunity to invest in the system.
Q 106Mr. Boswell: Would that also cover cases of epidemic or systemic problems? I am thinking of mesothelioma, and not simply cases in which there might be some implied delinquency on the part of anyone.
André Rebello: There could be a report that pulls together inquest findings, provided that there is a requirement for the inquisitions to be communicated not only to the registrar general through the Register Office, but to the chief coroner, so that someone in the chief coroner’s office can write a report about inquest trends.
Deborah Coles: The other strength of the Victoria system is that there is a national database of coroners’ inquest findings, so that if a coroner is conducting an inquest into a restraint-related death in custody, he or she could access the recommendations and reports that other coroners have made.
In response to the question about coroners, I think that the Bill should impose a duty on the coroner to make a report when there are issues of concern with regard to preventing other deaths. Moreover, we need sanctions against authorities that fail to respond to any report. There is not much point in coroners writing reports if they are not going to get proper responses. Likewise, we should like to see enshrined in the Bill some kind of mechanism for the monitoring and scrutiny of such reports, to ensure that action has been taken to address the issues that coroners have raised. As I said to Ms Moon, that is something that is sadly missing from the Bill and would go towards the death prevention that we were talking about earlier.
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Prepared 4 February 2009