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. André
Rebello: That is a new point that you did not raise
before. Clearly, I cannot second-guess how a coroner would deal with
that case because that coroner is of course independent and has
judicial discretion. The safeguard—Deborah Coles mentioned this
point—is to
ensure that families are enabled and represented. It might not be
popular, but when I am holding an article 2 inquest, I find it very
strange when the family might be unrepresented or represented on a
legal aid certificate, to use the old language, and the barrister is on
£500, and if the prison or health services are involved, they
will be represented in the same case by top barristers on top pay, and
the state will be paying for everyone.
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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