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Given that one of the chief benefits of the coronial system must surely be the capacity to learn from mistakes, this is, in our view, a very lax requirement in the Bill. Our Amendment 92 changes the discretion to a duty. If the coroner feels that someone who is in a position to make changes which might prevent another death has the power to do so, it ought to be incumbent on the coroner to act on that opinion.
Amendment 95 is a follow-up provision. It allows the coroner to keep an eye on what action is being taken on his recommendation. While the amendment does not, in fact, confer any substantive power to compel action to be taken, the pressure it creates would presumably keep the matter from being kicked into the long grass.
In support of this argument I can do no better than turn to the speech of my honourable friend Mr Henry Bellingham in Committee in another place.
“If one considers what happens elsewhere—for example, in New South Wales— recommendations are an integral part of the inquest process and are logged in a detailed document at the end of the inquest. The document is then available to the public and is tabled in Parliament. Doing so obviously exerts substantial political pressure on the Government to take action. In Ontario, for example, the inquest jury gives a verdict and makes recommendations, which are published centrally and sent to all the parties involved. Implementation is monitored annually by a department of the chief coroner’s office. Although our amendment does not go as far as the provisions in Victoria, New South Wales or Ontario, it is a sensible move in the right direction. It would put a statutory duty on the coroner to make those reports. It would put the duty
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I shall await the Minister’s reply with keen anticipation.
Baroness Butler-Sloss: I was moved by the powerful plea of the noble Baroness, Lady Finlay of Llandaff, but I want to speak to the two amendments from the noble Lord, Lord Kingsland. I find it extraordinary, in paragraph 6 of Schedule 4, that where a senior coroner finds that an investigation,
- “gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist... and ... action should be taken to prevent the occurrence or continuation of such circumstances ... the coroner may report”.
The wording of the paragraph is strong, but its conclusion is weak. That makes for an odd mix. If it is of sufficient importance under paragraph 6(1)(a), (b) and (c), then one would expect the coroner to have an obligation to report. The other amendment, Amendment 95, is a helpful addendum to what seems to be the absolutely necessary Amendment 92.
Lord Bach: We wholeheartedly endorse the laudable objectives of all noble Lords who have moved or spoken to amendments in this group. The objective is to ensure that coroners are as effective as possible in their role in preventing future deaths. I reassure the Committee that in our view the Bill already provides for the measures that are proposed, although I accept that this may not be readily apparent from the way that Part 1 of the Bill is structured.
The first part of Amendment 91 seeks to extend the powers of coroners under paragraph 6 of Schedule 4 so that they may make recommendations, as well as issue reports to any person, in order to prevent future deaths. We believe that this is implicit in the existing drafting of the Bill, and that any report issued under that paragraph may include recommendations to prevent future deaths.
At present, coroners do not have any express power to make recommendations. Nevertheless, coroners make recommendations in reports made under rule 43 of the Coroners Rules 1984, revised, as we heard earlier, as recently as July 2008. Coroners are in no doubt that they may include recommendations in these reports, and frequently so do. The indications are that the new system is working well. My right honourable friend the Lord Chancellor will publish the first batch of reports and responses before the Summer Recess.
Staying with this issue, Amendment 92 could compel the coroner to make a report to prevent future deaths, rather than merely to permit this. Our concern is that this might fetter a coroner’s judicial discretion in deciding when it is appropriate to issue such a report. I understand the points made so cogently by the noble Lord, Lord Kingsland, and the noble and learned Baroness, Lady Butler-Sloss, but we think that where we can leave it to the discretion of the coroner, then as a matter of principle we should. In this case it would be better to leave such matters to the coroner’s discretion because in our view the coroner will do the right thing.
Amendment 95 would give the coroner the power to request that the report’s recipient provide an update after three months on action that they have taken. Amendment 94, in its turn, states that the report’s
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I move on to the second part of Amendment 91 and to Amendment 96, which seek to ensure that a national record is maintained by the Chief Coroner of all reports and recommendations to prevent future deaths, and that a digest of all such reports and recommendations is published annually. We wholeheartedly endorse such an approach and refer the noble Lord to paragraph 6(3) of Schedule 4 and Clause 29(4)(b), which already make like provision. Together, those provisions already provide for the Chief Coroner to receive all reports to prevent future deaths and the responses of the recipients of such reports, and for the Chief Coroner then to summarise them every year in his or her annual report to the Lord Chancellor.
Amendment 93, tabled by the noble Lord, Lord Alderdice, would require the senior coroner to send a copy of any report to prevent future deaths to the relatives of the deceased and any other interested person and to the Lord Chancellor, who may publish it. This is an unnecessary level of detail for primary legislation. Under Rule 43, bereaved people and other interested persons already receive reports and the responses to them. This too will not be diluted under the Bill.
As I have mentioned, Clause 29(4)(b) already provides for publication of a summary of the reports. I hope the noble Lord may in some way be reassured that the procedure for reports to prevent future deaths set out in his amendments is already catered for in the Bill and what will be the associated secondary legislation.
Staying with the Chief Coroner’s annual report to the Lord Chancellor, Amendment 117, tabled by the noble Baroness, Lady Finlay, would require the report to contain an analysis of jury findings, and an analysis of reports to prevent future deaths and responses to them. Again, I want to do my best to persuade the noble Baroness that the policy behind her amendment is very likely to be followed in practice. We would certainly expect the Chief Coroner’s annual report to contain details of verdicts in different coroner areas. Clause 29(4)(b) already provides for a summary of reports to prevent deaths, and of the responses to them, to be included in the annual report.
In the course of summarising and assessing all of these matters for his or her annual report, it is inevitable that the Chief Coroner will provide some analysis of the data he or she receives from coroners.
Amendment 118 would require the Lord Chancellor to take “any action” he thought “appropriate” in response to the Chief Coroner’s annual report. I will explain what I believe will happen in practice and why this amendment is unnecessary. Clause 29(7) already provides for the Lord Chancellor to request advice from the Chief Coroner on any matter he wishes regarding the operation of the coroner system. The
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I am sure that any Lord Chancellor would wish to take whatever action is possible to support the Chief Coroner’s analysis of particular problems. Certainly the present Lord Chancellor will wish to do so, particularly in the early years as the new system beds in.
Amendment 131 is an important amendment as it sets out in detail some objectives. We share entirely the objectives to ensure that in the reformed system the Chief Coroner, in conjunction with the medical examiner service, is well placed to identify clusters or trends of deaths, so that he or she can determine whether action is needed, at a local or national level, to prevent deaths in the future. Amendment 131 seeks to empower the Chief Coroner to order an investigation into the causes of a cluster of deaths, or a trend, and send the results of the investigation to an appropriate authority which could take action to prevent subsequent deaths. It would also provide for the Chief Coroner to require information from coroners and medical examiners and send the Lord Chancellor an annual report, which may include details of trends identified and actions taken. I want to persuade the noble Lord that this proposed new clause is unnecessary.
I will focus first on the proposed new subsections (1) to (3). Coroners regulations made under Clause 35 already provide for the Chief Coroner to require information from coroners. However, I would like to clarify that this will not extend to medical examiners, as the amendment suggests it should. The Chief Coroner will have no formal authority over the medical examiners, as his or her jurisdiction extends only to those deaths which are subject to investigation by coroners, namely those deaths of violent, unnatural or unknown cause, or those that occurred when someone was in state detention.
One of the Chief Coroner’s key roles, however, as the national head of the reformed coroner service, will be to review national statistics on deaths and coroner verdicts. Working with the head of the medical examiner service and his or her own national medical adviser, the Chief Coroner will identify patterns or trends. In this way the Chief Coroner will be able to identify where there has been a particular cluster of deaths, or where it seems that reporting to a coroner is high, low or otherwise unusual in any area.
I return to paragraph 6 of Schedule 4. Under that paragraph, the Chief Coroner will receive copies of all reports, and responses from organisations to those reports, to prevent future deaths and not just those that appear to be part of a trend or cluster. This will ensure that the Chief Coroner has oversight of the causes of all the deaths that are subject to reports and of the action being proposed to prevent deaths in the future.
9.45 pm
Subsections (4) to (6) of the proposed new clause deal with investigations where trends in deaths are identified. The Chief Coroner’s work in identifying trends may include the commissioning of research or co-ordinating of research requests. These are important functions which the Chief Coroner's new national
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Proposed new subsection (6) states that an authority that receives a report of an investigation carried out under proposed new subsection (4) must say what it intends to do to prevent future deaths. We think that that is overly prescriptive as there may be no further action that the organisation can take. Already under paragraph 6 of Schedule 4, an organisation that receives a coroner's report arising from an individual case to prevent future deaths must respond to the coroner, who will then send a copy of the response to the Chief Coroner. We think that that provides flexibility for a recipient to respond by describing action that it has already taken or setting out why no action can be taken if that is justifiably the case. We think that flexibility is important.
Finally, on subsections (7) and (8) of the proposed new clause in Amendment 131, Clause 29 already places a duty on the Chief Coroner to submit an annual report to the Lord Chancellor. Such reports must include any matters that either the Chief Coroner or the Lord Chancellor deems appropriate. We can be confident, therefore, that the Chief Coroner will use his or her annual report to publicise any trends in deaths and how they are being addressed.
I have attempted to reassure the Committee that our aim is to identify trends or clusters of deaths and to take action to prevent them, and that it is achievable within the framework already set out in the Bill.
Lord Kingsland: Perhaps I may return to paragraph 6(1) of Schedule 4, a matter to which the noble and learned Baroness, Lady Butler-Sloss, also addressed herself. I simply want to understand exactly what the Minister is saying.
Here we have a situation where a senior coroner has been conducting an investigation. That investigation gives rise to a concern that there are circumstances that create a risk of other deaths, or that the risk will continue to exist in the future, and—and here I quote paragraph 6(1)(c)—
- “in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances”.
So he has reached that rather devastating conclusion, yet the legislation goes on to say that his obligation is only that he,
The Minister justified the use of the word “may” by saying that it would be wrong to compel a judge to do anything in these circumstances. I must confess to being rather puzzled by that response. This Bill is littered with obligations imposed on coroners at all levels. So why in this case would it be wrong to say “must” rather than “may”?
Judges have discretion in relation to their judicial tasks; but in the context of coming to their conclusions in court, they are often faced with obligations. For
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Lord Bach: The noble Lord, Lord Kingsland, makes a very powerful point—one that I have now had a chance to consider further. The point was bolstered earlier by the noble and learned Baroness, Lady Butler-Sloss. I will take that point back and consider carefully the argument that has been put. Perhaps I may talk to the noble Lord about this issue before we return on Report.
Lord Kingsland: I am extremely grateful to the Minister for that response.
Lord Alderdice: We must all be grateful to the Minister, and to other noble Lords who have contributed to the debate. When I introduced it, I said that a number of amendments in the group laid out various ways in which we could try to ensure that what came out of a coroner’s inquiry and inquest was not forgotten or lost. That is the key thing. There are various ways in which it can be done. It can be done by putting an obligation on the coroner. It can be done by putting an obligation on the Chief Coroner. It can be done by putting an obligation on all of us to try to ensure that, when reports come annually from the Chief Coroner, they are properly scrutinised.
What the Minister has done in his final response is to indicate something of the route and direction that may be most efficacious. I will take that away and think about it, so that when we come back and see what the Minister’s thoughts are, we might strengthen it, so that what is learnt is not forgotten but acted upon and implemented for the good of the community. As I said, there is often little more that one can do for the family and friends who have lost loved ones by whatever means. However, if they know that it is not forgotten and someone else will not suffer, that can often be a worthwhile and important thing, and something of great value to the community as a whole. With the positive encouragement that the Minister is going to think about this and come back—and all of us can think and come back—I beg leave to withdraw the amendment.
Amendments 92 to 96 not moved.
Schedule 4, as amended, agreed.
97: Schedule 5, page 128, line 25, after “coroner” insert “, or (as the case may be) the Coroner for Treasure,”
98: Schedule 5, page 128, line 36, after “coroner” insert “, or (as the case may be) the Coroner for Treasure,”
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100: Schedule 5, page 129, line 35, after “coroner” insert “or the Coroner for Treasure”
Schedule 5, as amended, agreed.
Schedule 6 : Allowances, fees and expenses
Amendments 106 and 107 not moved.
108: Schedule 6, page 131, line 33, leave out or “by a judge” and insert “the Coroner for Treasure or by a judge, former judge or former coroner”
Schedule 6, as amended, agreed.
Schedule 7: Chief Coroner and Deputy Chief Coroners
Amendments 114 and 114A not moved.
Schedule 7, as amended, agreed.
Clause 29: Reports and advice to the Lord Chancellor from the Chief Coroner
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Amendments 117 and 118 not moved.
Clause 29, as amended, agreed.
Clause 30: Regulations about training
120: Clause 30, page 16, line 36, at end insert—
“(aa) the Coroner for Treasure and Assistant Coroners for Treasure;”
Amendments 120 and 121 agreed.
Clause 30, as amended, agreed.
Clause 31: Inspection of coroner system
Clause 31, as amended, agreed.
Clause 32: Appeals to the Chief Coroner
127: Clause 32, page 18, line 19, at end insert—
“(2A) An interested person may appeal to the Chief Coroner against a decision made by the Coroner for Treasure (or an Assistant Coroner for Treasure) in connection with—
(a) an object that is or may be treasure or treasure trove, or
(b) an investigation or inquest under Chapter (Investigations concerning treasure) concerning such an object,
including a decision embodied in the determination of a question mentioned in section (Investigations concerning treasure)(5)(a) or (b).”
128: Clause 32, page 18, leave out line 21 and insert—
“(a) a decision that falls within subsection (2), or
(b) a decision of a kind mentioned in subsection (2A).”
128A: Clause 32, page 18, line 24, at end insert—
“( ) When making an order under subsection (5), the Lord Chancellor shall consult those persons whom he thinks appropriate.”
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