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Coroners’ System and Death Certification

That is my view. I do not recall the Committee discussing the matter in such detail, although I remember the circumstances to which my hon. Friend refers. He dealt closely with the families involved. Most families have sensitivities about this; some have very strong views and some religious groups have deep objections of principle. On occasion, those may have to be overridden, but that should not be done without consultation. The process must have consultation built into it. This comes back to the resources at the disposal of the coroner and the coroner’s officers, as well as the training that they receive. I turn now to death certification, which was central to the Shipman cases. We felt strongly that the two areas of reform that I have mentioned must go together, and we referred to the evasive and vague answers from departmental witnesses on the matter. We criticised the tinkering at the edges of a system that has already been deemed unsafe and unsatisfactory by two Government-commissioned reviews. At last, we now have proposals. They appear to be a very significant improvement; but, as far as I know, no coroners were consulted on them. That does not bode well for the achievement of an integrated solution. What is now proposed is that each national health service trust—whether a hospital trust or a primary care trust—would have its own medical examiner in the clinical governance team. In addition, all medical certificates of cause of death—MCCDs, which I referred to loosely, but incorrectly, as death certificates—would be subject to scrutiny by the examiner, who would also decide whether to refer the case to the coroner and would set out the reasons for doing so. Medical examiners would have full access to medical records. The new proposal goes a long way to meeting the Shipman inquiry concerns except, perhaps, in one respect: it is not clear that the medical examiner would be seen as fully independent of the treating doctor. The trust employing the medical examiner would usually have been the trust that supplied the medical treatment. The same trust could have liability if negligence were proved. Families who think that treatment contributed to, or failed to prevent, avoidable death are likely to think that the trust’s doctors will close ranks. Why not site the medical examiner in the coroner’s office, rather than have a perceived lack of independence, and a potential third stage in which the coroner’s medical adviser considers the medical examiner’s report into the certifying doctor’s certification of the cause of death? Nobody asked for a three-stage medical checking process, but that could be the cumbersome result of siting the medical examiner in the employing trust and not in the coroner’s office. I hope that both the Departments involved will look again at why the medical examiner is being located within the NHS structure. Tom Luce, whom I have consulted, shares my concern. That aside, the proposal seems to be a significant improvement. It needs to proceed alongside, and in step with, reform of the structure of the coroner’s system. There is clearly a case for much closer co-ordination of coroners’ and registrars’ offices. We would not want a reduction in the local registrar’s office networks, which need to be located as close as possible to where bereaved people live. In centres where co-location is possible, that has significant advantages for families and for the efficiency of the service. There are many other aspects of our report and of the Government’s proposals that time does not allow me to address. I merely mention in passing that the Government appear to accept our view that public inquests should remain the standard forum for those cases where an inquest is necessary. The charter for the bereaved is a good idea, but it will be of no use if gaps in the reform proposals mean that the expectations that it creates are not met. Many coroners have great difficulty in getting the use of suitable courts for inquests. Apart from in those cities where a dedicated court in coroners’ offices is the best solution, the Court Service must recognise a responsibility to assist coroners in providing court space, and coroners’ needs should be considered whenever court closures are under consideration, because coroners are users of court premises. Some of those premises are being closed. We also had concerns that the proposed appeals might overburden the system unless scope is provided and those who could undertake an appeal were more clearly defined. The Government are still considering their view on several issues, including the role of juries, deaths abroad and the legal status of coroner’s officers. I should like coroner’s officers to have a status conferred by statute—in the Bill. I conclude by asking the Government some questions. When will the revised Bill be published? Will it resolve the wide range of issues that the Committee and others have identified? What is the timetable for the remaining decisions? The coroners and death certification systems affect families at their most vulnerable moments—when they have lost a loved one. I have experienced such situations extensively. We need to get these hugely important matters right. My Committee and I, along with most coroners, still have serious concerns about gaps in the scheme, but we all want to see progress—surely it can be achieved. If the Minister brings forward a revised Bill to which all the key stakeholders can give their support, I think her chances of getting the Government’s business managers to give it the necessary parliamentary time will be much greater than they were the last time she tried.