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Whitty, L.
Wilkins, B.
Williams of Elvel, L.
5.01 pm
44: Clause 29, page 19, line 10, at end insert—
“( ) For the avoidance of doubt, it is hereby declared that Regulation 14(6) of the Non-Domestic Rating (Alteration of Lists and Appeals) (England) Regulations 2005 (S.I. 2005/659) (which provides that the alterations made to correct inaccuracies in local rating lists shall have effect from the day on which alteration is made) shall apply to any lists affecting the liability to pay BRS; and where such an alteration affecting liability to pay BRS is made, it shall in no case have retrospective effect without error or default on the part of a ratepayer.”
Coroners and Justice Bill
Bill Main Page
Copy of the Bill
Explanatory Notes
Amendments
7th Report from the Delegated Powers Committee
8th Report from the Joint Committee on Human Rights
16th Report from the Joint Committee on Human Rights
Committee (1st Day)
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Clause 1 : Duty to investigate certain deaths
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Lord Kingsland: As your Lordships will see, the amendment seeks clarification from the Government that the jurisdiction of the coroner is determined by the location of the body; in other words, the location of the death is irrelevant. If a body comes to rest in a particular coronial jurisdiction, no matter where the death occurs, that coroner is seized of his responsibilities. I believe I need say no more than that. I beg to move.
Lord Alton of Liverpool: Amendment 2 stands in this group and is in my name and that of my noble friend Lady Finlay of Llandaff. I strongly support the point on clarification that the noble Lord, Lord Kingsland, has just made. I look forward to hearing the Minister’s response. Amendment 2 would add to the Bill,
- “or when the coroner has reason to believe that the circumstances of the death were such that, in the public interest, the death should be investigated”.
At the beginning of 2008, following the delays in implementing many of the recommendations that arose from the murder of patients by Dr Harold Shipman and the subsequent murder in 2002 of patients at Leeds General Infirmary by the nurse Colin Norris, I tabled a series of Questions to the Government. The Shipman murders had led to an inquiry, which published six reports and 228 recommendations at a cost to the public purse of some £21 million. Weaknesses were discovered in the death certification process; the requirement for one doctor alone to certify a death and decide on referral to a coroner; and the failure to cross-reference notified deaths and look for trends and patterns. Among the 228 recommendations were many other proposals to strengthen the system of public protection.
After Shipman’s trial, the inquiry, chaired by Dame Janet Smith, decided that there was enough evidence to suggest that Shipman had probably killed around 250 people, of whom 218 could be identified. About 80 per cent of his victims were women. In the case of Nurse Colin Norris, on 8 March 2008, he was convicted of murdering four elderly patients and attempting to murder another. Mr Justice Griffith told Norris, in sentencing:
“You are, I have absolutely no doubt, a thoroughly evil and dangerous man. You are an arrogant and manipulative man with a real dislike of elderly patients. The most telling evidence was that observation of one of your female patients, Bridget Tarpey, who said, ‘He didn’t like us old women’”.
On 25 March 2008, the noble Lord, Lord Darzi, in responding to my Written Questions about these events, stated:
“I understand that the Yorkshire and Humberside Strategic Health Authority is arranging for an independent investigation of the events at Leeds General Infirmary and it would therefore be inappropriate to comment further at this stage”.—[Official Report, 25/3/08; col. WA81.]
Later, on 21 May 2008, the noble Lord replied to my Written Questions about the Shipman recommendations, stating:
“Clauses implementing these important reforms will be included in the coroners and death certification Bill announced as part of the Government’s draft legislative programmes for 2008-09”.
“The Government believe that these proposals represent a transparent, proportionate, consistent and affordable response to the weaknesses identified by the Shipman inquiry that will provide greater protection for the public and improve the quality and accuracy of death certification”.—[Official Report, 21/5/08; col. WA196.]
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I recognise, as I told the noble Lord, Lord Bach, at Second Reading, that this Bill goes a long way in trying to prevent a repetition of these appalling crimes that took place in the north of England. However, there are still anomalies in the law that could allow cases such as those that I have described to slip through. At Second Reading, I asked the Minister how many of the 228 recommendations of the Shipman inquiry had been incorporated into this legislation, and what further measures would be needed to deal with the failings identified by the Norris inquiry. Last week I called the Minister’s office to indicate that I would pursue the question today. I hope that it will now be possible to answer that inquiry. For the sake of clarity, I inform the Committee that I met Dame Janet Smith with my noble friend Lady Finlay of Llandaff. We discussed the amendments that I have tabled to the first part of the Bill. They have been tabled in consultation with Dame Janet Smith and try to close the gap that still exists in the legislation. Out of courtesy, I copied details of the amendments in advance to the noble Lord, Lord Kingsland, and the noble Lords who represent the Liberal Democrat Front Bench. I believe that the incorporation of the amendments standing in my name would improve this legislation and go a long way to answering Dame Janet’s concerns.
In particular, I take the Committee to page 54 of the Ministry of Justice document published on 21 May 2008 entitled, Statutory Duty for Doctors and Other Public Service Personnel to Report Deaths to the Coroner, (CP(R) 12/07). Paragraph 6 states:
“Coroners have a broad duty to investigate unnatural deaths, as well as all deaths which occur in custody or other state detention or during the course of police operations. There was a general consensus that the right categories of deaths were included in the consultation paper flowing from this general definition. Many helpful suggestions were put forward to help clarify the detail. Following the consultation process, we believe that the following categories of cases that should be referred to the coroner will provide the basis for further work and consultation”.
I shall give the Committee details of what appears in that list. I know that the Government have an inbred dislike of including lists in legislation so I am not inviting them to include the entire list but these were the conclusions that were registered by the Government themselves in answer to the consultation paper. My amendment seeks to take the list and in a generic way provide a trigger mechanism for investigating any deaths that might fall into these categories.
The list in the document refers to:
- “death resulting from self harm and neglect (excluding deaths from alcohol or nicotine abuse where the death would not be investigated but for those reasons); death resulting from neglect or abuse where there is an established duty of care by a public authority, other organisations and individuals; death occurring during or shortly after a period of detention; death caused or contributed to by the conduct of the police or any other state authority or public organisation; death relating to past or present employment; death resulting from lack of care or appropriate treatment, defective treatment and adverse reaction to prescribed medicine; death of a child where it is unexpected; death where a violent crime is suspected; sudden and accidental death, and deaths resulting from traffic incidents; where a death has not been certified as the doctor is unable to identify with any confidence the cause of death; death where there is reason to believe it may have been caused or contributed by a disease or condition that has been specified as being reportable to the coroner because of
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Let us take that last category alone,
or deaths in hospitals through, say, the outbreak of MRSA, or a disease such as sepsis where bereaved families might well believe that a loved one has died through negligence and yet the cause of death might not appear to be unnatural. I refer the Minister to page 18 of the response to the consultation document and the specific request of Dame Janet Smith and Her Honour Mrs Justice Swift, who specifically asked that some of the categories to which I have just referred should be incorporated in the legislation as a way for people who feel that the system has not responded to their concerns to be assured that the matter will be addressed.
This amendment is designed to provide a catch-all for all those categories in the list I mentioned which are not spelt out in the Bill. It would remedy the disconnect between what the doctor has to report and what may warrant an investigation in the public interest. I have with me a copy of the final death certificate issued by Harold Shipman. It was given to me by Dame Janet and details the death of Mrs Kathleen Grundy. She died at the age of 81 on 25 June 1998. The day before her death this elderly but sprightly and healthy lady had provided hospitality for her elderly friends at a club she attended. Her death certificate simply records that “old age” was the,
We owe it to the memory of victims of Shipman such as Mrs Grundy to get this right. We also owe it to Dame Janet and her outstanding colleagues who have provided such a remarkable public service in their meticulous and comprehensive inquiry. I hope that the Minister will feel able to respond positively to the amendment that I have laid before your Lordships’ House.
Lord Dubs: I would like to speak to Amendment 3 in my name. This stems from the work of the Joint Committee on Human Rights of which I am a member. Before I get to the heart of the amendment, I congratulate the Government on requiring coroners to investigate deaths that have occurred in state detention. This is a positive human-rights move. The purpose of the amendment is to make it clear what state detention is. All we have is the phrase,
That is a good move but it would be better if we could have clarity in the Bill about what state detention means.
We have the Explanatory Notes to the Bill, which are very useful and come in a thick tome. They explain the Government’s view that the extension enhances the state’s ability to meet its obligations under Article 2 of the European Convention on Human Rights in relation to a number of cases where the liberty of the subject may have been constrained—for example, where people have died while being detained in a variety of contexts, such as in prisons, by the police, in court cells, in young offender institutions, in secure training centres, in secure accommodation and under mental health or immigration and asylum legislation. Of course,
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I am not saying that the amendment includes all the possible instances of where a coroner’s investigation might be necessary. Indeed, the amendment says that the list would “include” the following. Therefore, the list is not comprehensive but it would certainly add clarity to the Bill and I hope that the Government will agree that, rather than hiding this in the Explanatory Notes, it is better to have it in the Bill so that everyone knows exactly what we mean. Having said that, I repeat my welcome for the inclusion of the provision by the Government but I just think that they should go one step further in making it clearer.
5.15 pm
Baroness Finlay of Llandaff: I have added my name to the amendment that has already been discussed by my noble friend Lord Alton, and I should like to add a little more to the points that he made.
We have been told that the role of the medical examiners will be to feed into the governance processes and to detect failings in care and drive up standards of care within the jurisdiction of a PCT area. However, one problem is how to define a natural death and how to decide whether the death is natural but has been brought forward in time or whether it has occurred because of clinical non-responsiveness—I shall not say “negligence”, as that is too strong a word, but I am referring to whether something could have been done to avoid the death. A classic example is death in childbirth. Medical science now means that very few women, but still too many, die in childbirth in this country, but of course in many other parts of the world a catastrophically large number of women still die in that way. When these deaths are investigated, some of them are, sadly, found to be due to medical negligence. Examples are where, for whatever reason, a woman has not been oxygenated during a caesarean section under anaesthesia, where the response to something such as a catastrophic haemorrhage has been too slow or where the management of labour has led to some complication which, although rare, does occur, such as a ruptured uterus and the catastrophic events that follow that. These are so-called natural deaths but certainly they are totally unexpected and potentially avoidable. I can of course understand why you cannot define “natural” or “unnatural” clearly in the Bill; it is understood in the way that you speak about things.
The other reason for having a public interest test is that deaths which are due to, for example, infection or environmental issues gradually come to light as a clustering of deaths occurs. As these deaths unroll, the investigation focuses not so much on one individual but on a group of individuals. We have recently heard about swine flu in Mexico, where the mortality rate has been particularly high. It seems that that may be due to the high arsenic levels in the groundwater. That has meant that there is a degree of subliminal arsenic poisoning in the population which inhibits people’s immune system and makes them more vulnerable to the severe effects of swine flu. Therefore, they have
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Where there is a clustering of deaths, the coroner has to be able to investigate them, not so much for the individual but because of the public interest. With time, we may well find that something such as environmental toxins causes a clustering of deaths, because we do not know what lies ahead.
I am sure the Minister will say that there is great sense in not putting lists in legislation. If you make a list, there is always the problem of what is to be left out. I would simply commend to him the concept of public interest. It would underline the governance role that has been emphasised in some of the reforms of the coronial system.
Lord Alderdice: I shall speak to Amendments 2 and 3. In beginning his speech, the noble Lord, Lord Alton, referred us back to the Shipman inquiry and the dreadful events leading up to it. As I pointed out on Second Reading, the Government rightly moved very quickly to deal with some of the medical aspects, but it has taken more time to deal with the coroners aspects. It seems to me that the important point in the comments just made by the noble Lord, Lord Alton, and the noble Baroness, Lady Finlay, is that sufficient attention had not been paid to the clustering of deaths. If proper attention had been paid, it would have been clear that there was an emerging problem. Indeed, as I understand it, the first observation of the problem ultimately came not from the coroners but from others. As we go through the Bill we will find a number of circumstances that bring us back to that dreadful experience, because part of the business of the Bill is to address and redress that experience. One of the ways of doing that is to give the coroners the responsibility to look a little more widely than they have traditionally done. That is very important.
As the noble Lord, Lord Dubs, said when speaking to his amendment, which we support, we all welcome the new extended duty to investigate deaths in state detention; we very much welcome the human rights-enhancing components of this measure. As he said, however, it is a little disappointing that we find this only in the Explanatory Notes. There does not seem to be any reason why it should not be spelt out and explained in the Bill. “State detention” has different meanings to different people. It is important to spell it out and to make it clear, as he has done in his amendment. If another, more precise amendment is proposed, so be it, but we think that it is important to spell it out. That is not to say that we take the view that coroners should restrict themselves to investigating whether we are all compliant with the human rights convention. We will come to that a little later.
Perhaps I may point out one specific way in which even the excellent amendment from the noble Lord, Lord Dubs, seems not to go quite far enough. He refers in paragraph (b) to those detained under mental health legislation. What we usually think about is how important it is to ensure that people are not inappropriately detained under any legislation, including mental health legislation. However, one way
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So even if we were to adopt the amendment of the noble Lord, Lord Dubs—as I say, we very much support adopting it—one incredibly important group of people would not be addressed, precisely because they had moved out of state detention at the very point when they came to harm. That is why not only the noble Lord’s amendment but the prior amendment tabled by the noble Lord, Lord Alton, and the noble Baroness, Lady Finlay, are very important. I think that we will also come to other amendments that will help expand this a little further. At this point, however, we find these amendments extremely helpful. We look forward to the Minister’s comments.
The Parliamentary Under-Secretary of State, Ministry of Justice (Lord Bach): I thank all noble Lords who have spoken on this group of amendments. The noble Lord, Lord Kingsland, asked for clarification on Amendment 1. We argue that Clause 1 makes it clear that the coroner’s duty to investigate a death is triggered by virtue of being made aware of the body of the deceased person being located within his or her area. Where the death actually occurred is largely irrelevant to the triggering of that duty, although if the body were moved after death from one area to another, the duty would apply only to the first coroner to whom the report was made. That also applies to deaths that occur overseas—a matter that I know is of concern to many noble Lords—but where the body is repatriated to England and Wales. In such cases, the duty to investigate the death lies with the coroner within whose jurisdiction the body is returned. I hope that in those few words I have satisfactorily clarified the Government’s position on Clause 1.
Turning to Amendment 2, I refer noble Lords to regulations under Clause 18, which will prescribe cases and circumstances in which a death should be reported to a coroner, which will provide more detail as to the types of case which will trigger a coroner's duty to investigate. We shall be consulting further on the content of those regulations as part of the secondary legislation process. The noble Lord, Lord Alton, and other noble Lords mentioned the tragic, awful case of those who were murdered by Dr Shipman. I thank the noble Lord for saying that we have gone a long way in attempting to deal with the issues that that ghastly case threw up. His point is that the deaths that occurred at the hands of Dr Shipman appeared at first glance to be wholly natural and non-suspicious but, with the benefit of hindsight, it would have been in the public interest to investigate them.
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We believe that the new death certification procedures contained later in the Bill will succeed much more readily in detecting such deaths and bringing them to the attention of the coroner, so that the duty to investigate will be triggered where necessary. I stress that the coroner's duty to investigate is a continuing duty. If fresh evidence regarding a death comes to light later—evidence that quite clearly brings the death in question within the scope of Clause 1(2)—an investigation must be held even if a period of some months or even years has passed since the death in question.
The noble Lord wrote to me, and just this morning I signed off the letter back to him, which will be copied to all those who spoke on Second Reading. In advance of his receiving my letter, perhaps I may tell him what I had to say about his request for figures regarding the exact number of recommendations. On the Shipman inquiry, it states:
“The ... Bill incorporates legislation responding to the Shipman Inquiry’s Third Report .... As you know, whilst accepting the findings of the inquiry, the Government has decided to adopt a different approach to reforming the coroner service than that recommended by Dame Janet Smith. For this reason, [it] is not possible to provide a figure regarding the exact number of recommendations responded to by legislation incorporated in the Bill. More generally, you will wish to be aware that the Coroners and Justice Bill is the last piece of primary legislation required to implement the Government’s wide ranging programme of action in response to the recommendations of the Shipman Inquiry”.
I also wrote to the noble Lord about the case of Colin Norris, which he referred to today.
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