Mr.
Boswell: Does my hon. Friend agree that that matter might
be of some concern to an insurance company?
Mr.
Bellingham: That is a very good point. I am thinking
perhaps of John’s grandchildren who will certainly want to check
their DNA framework and look for any history of medical illness. The
first thing that they will do is look at the death certificate and
although they might see the note in the margin, they will look
primarily at the principal cause of death on the certificate. I hope
that the Minister will address that case, which I have been given leave
to mention by the family.
I also hope
that the Minister will look at the point about death certificates and
at the other case involving Doreen Morris, the correspondence that has
flowed from that and the cumbersome process that is currently available
to a family. Families must persuade the coroner to reopen the inquest,
and it would be rare for that to happen when there has been a criminal
trial and no new evidence has come to light. Going to the High Court
requires the consent of the Attorney-General, and perhaps we could make
that process more family-friendly. There could be something in the
charter for the bereaved to address that. Either way, the ongoing
problem illustrated by those two cases will be carried into the Bill
unless something is done.
Mr.
Boswell: Briefly, I am sensitive to the points made
eloquently by my hon. Friend. I suspect that there is a wide variation
in practice relating to death certificates and the certification of the
medical causes of death, not least because those will often be multiple
and the hierarchy of the symptoms will not necessarily be
clear.
I touched on
this point when I intervened on my hon. Friend about insurance. If we
are considering systemic illnesses of an occupational or other
nature—I use mesothelioma as an example, although not
necessarily conclusively—it is important to have full and
accurate reporting on a consistent basis, so that we can get an idea
about the incidence of such
things. With
respect to everyone, the Minister included, I do not think that the
Committee is able or medically qualified to systematise everything in
terms of medical reporting. However, it is important for us to try to
get a better understanding of practice, and I hope that the chief
medical examiner will lead on that.
I was amazed
by the reticence of my hon. Friend the Member for North-West Norfolk on
amendment 359, which I have signed, and I wonder whether it goes far
enough. In suspicious circumstances—for shorthand let us call
them Shipman-like circumstances—it enables any medical
practitioner to notify the coroner of any concern over the
circumstances in which a person died. I have revisited that matter, and
it occurs to me that that might not cover the full range of people.
“Medical
practitioner” could include professions allied to medicine, and
perhaps the Minister will comment on
that. Could
somebody who cares for, or has regular dealings with, the person, and
who has reasons to enter any reservations, make them to the coroner? No
doubt it happens from time to time that somebody writes anonymously or
from cold to the coroner saying, “I don’t like what
I’ve seen”, or “I think I know something about
this”, and no doubt they could be called as a witness at the
inquest. Some might also have dealings with the police. However, I
wonder whether it is possible to extend the very modest terms of the
amendment tabled by my hon. Friend the Member for North-West Norfolk,
which I support, at least to include circumstances in which somebody
else who was close to the patient—a carer, for
example—felt that something was
wrong.
Bridget
Prentice: I have no problem with the proposition
underpinning the amendment tabled by the hon. Member for North-West
Norfolk. If a medical practitioner suspects, or has reason to believe,
that a person died a violent or unnatural death, or that the cause of
death is uncertain, we would, of course, want the case referred
immediately to a coroner for further investigation. However, I suggest
to him that his amendment is unnecessary, because under clause 17(1),
the “Lord
Chancellor may make regulations requiring a registered medical
practitioner, in prescribed cases or circumstances, to notify a senior
coroner of a death of which the practitioner is
aware.” Essentially,
that covers that same ground as his amendment. Also, it covers the
variety of people who could be described as medical practitioners,
whether nurses, doctors or so
on. I
shall turn briefly to the two cases mentioned by the hon. Gentleman.
Medical practitioners can take their concerns to the coroner, as indeed
can anyone else, including the family or registrar—I think that
that is what the hon. Member for Daventry was alluding to; they would
be covered, too. The reformed appeal system will obviously help in at
least one of the cases raised by the hon. Member for North-West Norfolk
by allowing the family to appeal to the chief coroner to look at the
inquest again. Also, as of 1 January this year—I realise that
that came after the cases that he has raised—the registration
provisions have been amended to allow fresh registration after a
coroner’s adjournment for criminal proceedings. Since 1 January,
such cases can return to the coroner and be
registered. Clause
19(1)(c) provides for an attending practitioner to issue a fresh
certificate if invited to do so by the medical examiner. The cases
mentioned by the hon. Gentleman are excellent examples of when that
could happen. If he wishes, I shall reconsider those
cases—obviously the families concerned need closure, having
suffered great loss—to see whether we can do anything to help to
rectify their situations in the meantime. I recognise his comments
about future generations looking at death certificates for their own
health reasons and so on. However, I think that the provisions
introduced this year, as well as the appeals system under the new
regulations, should ensure that those in such situations will have some
form of redress in the
future. 5.30
pm
Dr.
Iddon: I want to discuss amendment 104, which would add to
subsection (1)(e) the words
“including an
investigation into the drugs the deceased had been taking prior to his
or her
death”. One
of the reasons why we are here today is that Dr. Shipman
could write anything on death certificates to hide the truth about the
murders that he perpetrated with controlled drugs, which were readily
available to him. Dame Janet Smith has written extensively on that.
Since her report came out, controls have been tightened on the storage
and prescription of drugs such as heroin and morphine.
However, I am
still concerned about doctors writing death certificates without
investigating the cause of death adequately. I therefore strongly
welcome the fact that medical examiners will undertake that duty. It is
my understanding from the Bill and the explanatory notes that the
medical examiner will not only examine the medical notes and perhaps
talk to some of the medical staff, but talk to the family, relatives
and friends to get to the bottom of what caused a person’s
death. My
amendment refers not only to prescription-only medicines but to
over-the-counter medicines, controlled drugs available on the street
and, indeed, alcohol and other substances, all of which can play an
important role in a person’s death. Anecdotal stories have come
to me in my role as chairman of the all-party parliamentary group on
drugs misuse, such as that if a heroin addict is found in the
street—not all, but most people sleeping rough take drugs of one
kind or another—the real cause of death will probably be
ascertained and recorded properly on the death certificate as an
overdose of heroin. However, if a person in a rather well-to-do
household has become a heroin addict, their parents may not want heroin
addiction appearing anywhere on the death certificate, and respiratory
depression or anything else might appear instead, in which case we
cannot get to the root cause of the death of all
people. Not
all drugs, of course, come out of a pharmacy. People buy them on the
street, where they are often contaminated. Some heroin is purer than
other heroin. I also refer to internet sale, which is becoming a bigger
nuisance than ever. Some 10 per cent. of all medicines obtained on the
internet are counterfeit, so people who take them do not have a clue
what they are taking—it might be Viagra, but it could be
anything else. The same applies to medicines available from certain
pharmacies on the internet. I am not saying that all internet
pharmacies are bad. Some are highly regulated, particularly in Britain,
but if a person has been abroad, it is certainly another
story. In
care settings, it is not unknown—in fact, there have been
several cases—for medical staff, including nurses, to overdose
patients—generally older patients or patients who are vulnerable
in some other way—with medicines. That has happened in hospitals
and residential homes, as right hon. and hon. Members know. I am
therefore pleased that the medical examiners will be able to talk to
people and perhaps ascertain the real cause of
death. There
are other reasons why I am interested in proper medical certificates
and an investigation into the drugs that a person may have been taking
immediately or perhaps some time before their death. One of them is
that the national programme on substance abuse deaths, which is based
in the centre for addiction studies at St. George’s hospital
medical school here in London, has been collecting and publishing data
on drug-related
deaths for several years now from all the coroners’ jurisdictions
across Britain. I have a copy of one of those reports,
“Drug-related deaths as reported by coroners in England and
Wales”. Those reports
are extremely useful to the national treatment agency and to others
involved in the misuse of drugs—they are interesting to
me—because they show the rapidly changing scene in the illicit
drug market. Perhaps Peterborough is a hot spot today; next year it may
be Blackpool. The reports show which towns and cities across England
and Wales have the greatest drug misuse problems by recording such
information. However, it was difficult for St. George’s hospital
to start collecting the material, partly because coroners did not
originally comply with requests, although that has now been overcome,
but mainly because the death certificates have not always been
accurate, as I have already
explained. The
second reason why it is important to know the real cause of death and
whether drugs, illicit or otherwise, were involved—that is often
difficult to get to the bottom of, because such activities can be
covert, as I shall explain—is that epidemiologists look at death
certificates as well, and they, too, are interested in trends of why
people are dying and what is causing those
deaths.
Mr.
Boswell: I want to reinforce the hon. Gentleman’s
comment by reporting some correspondence that I received this weekend
from a constituent who is concerned about ketamine abuse—the
first time that I had ever heard of the phenomenon. Ketamine is a class
C drug, and my constituent has asked me to make representations to the
Home Office about that. My constituent makes the point that the use of
ketamine is now prevalent in, for example, my market towns and, in
terms of her daughter’s health, it is extremely damaging. I
suspect that if, sadly, her daughter were to lose her life as a result,
it would be so diffuse and difficult to pin down ketamine as the
underlying cause of the medical presentation and cause of death that it
would probably never be picked up by
anyone.
Dr.
Iddon: I accept that it is often difficult to get to the
bottom of the real cause of
death. As
I have said, I am chairman of the all-party parliamentary drugs misuse
group, which has just published an interesting report on physical
dependence and/or addiction to over-the-counter medicines, which one
can buy by walking into a chemist’s shop, and to prescription
drugs. The main body of evidence concerns benzodiazepine misuse.
However, let me stick to codeine-based products, which are the
commonest that can be bought in a shop—some of them have
“plus” or “extra” at the end of their names
and are vigorously advertised on
television. In
the evidence that we have collected, we have come across patients
taking between 30 and 70 analgesic or anti-inflammatory tablets. I do
not want to mention any brand names, but they are in our report. A lot
of the substances are co-medications, by which I mean codeine at a
fairly high dose level—12.5 mg per tablet, which is higher than
the normal dose in other products—is co-medicated with other
medicines such as ibuprofen. The United Nations international narcotics
board has already highlighted in its reports that the misuse of
over-the-counter and prescription medicines is now
exceeding the abuse of controlled drugs, such as heroin, cocaine and the
others, which is a remarkable statement. When the United Nations say
that, it is getting
serious. The
United Nations also says that, by taking enough codeine, the same buzz
can be obtained legally, at a much cheaper price than buying heroin
illegally on the street. However, the problem is that quite a lot of
tablets have to be taken to get that buzz. If taking ibuprofen at the
same time, the inevitability is that someone will suffer serious
gastro-intestinal bleeding leading to death. Unfortunately, such
activities are covert. The wife in a family may be doing that, unknown
to children and husband, and they may suddenly die at quite a young
age. It is important that we look into those problems in more detail
than ever
before. I
also want to mention poly-drug use. Let us say that someone is taking
cocaine at the same time as drinking considerable volumes of alcohol.
They may be on other substances as well, which complicates the issue
even further. However, just cocaine and alcohol will produce a very
toxic material called cocaethylene. If no one asks whether the person
was drinking alcohol or what they were doing in the night or week
before they died, those problems may not be picked up by doctors, the
medical examiner or the
coroners. The
analysis of drugs is very easy. It need not even be intrusive. One can
cut off a piece of a person’s hair, subject it to a chemical
process called mass spectrometry and readily find out which drugs are
in that sample of hair. One can go further, of course, and use body
fluids such as
blood. The
Samaritans has sent a second document to the Committee picking up that
problem: “Some
relatively important items are often not recorded, e.g. contact with
psychiatric services, date of last contact with GP, blood levels for
drug overdoses, source of drugs taken in
overdoses” and
so on. It strongly
recommends “the
development of further measures which could improve the development of
data collection for the purpose of informing research and strengthening
suicide prevention
strategies.” I
look forward to hearing what my hon. Friend the Minister has to say in
response to the
amendment.
Bridget
Prentice: It is with trepidation that I rise to speak
following my hon. Friend, who has given the Committee very detailed
information on some of the serious problems that people around the
country have in taking medication, whether legal or otherwise. I
commend what he and his all-party group do in highlighting those
problems and not only raising them in this debate but bringing them to
the attention of the wider
public. My
hon. Friend the Member for Bolton, South-East is right that the
information included by the attending practitioners on medical
certificates of cause of death is an important source of data for a
number of organisations, partly because it will give us more
information about mortality rates generally associated with particular
diseases, but also because it will be invaluable to people such as
clinicians, to those responsible for planning and managing health
services, to the general population—not just the relatives of
those who have died, but those who could be at risk of specific
diseases—and to people such as my hon. Friend and the all-party
group, who can then do further research in these areas in order to help
to persuade the Government on how best to tackle those
problems.
The
introduction of scrutiny of the cause of death by medical examiners
will, I believe, lead to a significant improvement in the quantity,
quality and consistency of the data on the death certificate. The
inquiries undertaken by medical examiners when they are undertaking
medical scrutiny will reflect different combinations of care setting,
stated cause of death and circumstance, which my hon. Friend the Member
for Bolton, South-East has referred to. That will include discussions
about the medical history and other relevant information, such as what
the person had been doing, who they had been associating with and so
on, including any medication that they had taken before death. It would
not be appropriate, therefore, to highlight any single element of those
inquiries in the
Bill. 5.45
pm I
hope that I can reassure my hon. Friend by saying that if a death has
resulted from the misuse of drugs or illicit drug use, it would almost
certainly be reportable to a coroner, in which case the coroner could
obviously call for a post-mortem. Then the coroner, not the medical
examiner, would ensure that all the conditions and events that
contributed to the death are properly recorded. The medical examiner,
of course, could recommend to the coroner the types of examinations,
such as a full toxicology report to establish the substances in the
body. I hope that the Bill, which gives both medical examiners and
coroners the power to investigate further on a much wider spectrum,
will give my hon. Friend some
reassurance.
| 
