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Coroners’ System and Death Certification

I assure the House that I am not waiting for anything. I am getting on with addressing the issues, not only so that I can be better informed on what is the right policy solution for the Bill, but so that we can make a difference now by working with coroners and local authorities. I want an open and transparent understanding of how the system varies from area to area, and realistic dialogue and discussion with local authorities about why that is so and how things can be improved. I move on to another point that concerned all Members—the question of disclosure, which was raised by my hon. Friend the Member for Llanelli. The problem is two-fold. The bereaved families who we met, who suggested how to run inquests into those in the armed forces who lost their lives in Iraq, and those bereaved families who helped us with our pre-legislative scrutiny told us that, at the inquests, they would sometimes see that the coroner had a thick pile papers on his desk and that the counsel for the military had an equally thick pile, while they had only two or three sheets of paper. I also heard a complaint from someone whose daughter was killed by a speeding police car. The police authority, the chief constable and the Police Federation representative each had great wodges of documents, reports and legal representation—I shall deal with that point in a moment—and the bereaved family, who cared most about that death, had only a small amount of information. The problem is that information is not being given to relatives in advance. We are analysing the reasons for that, and we intend to issue guidance to coroners on ensuring that information is given to them in advance. We do not want bereaved families to find themselves unable to follow proceedings because they do not have the same documents as everyone else. On the one hand we have inadequate advance disclosure, and on the other we have disclosure to people who are not entitled to it. That points up the problem of not having a national standard. In my daily work as Minister with responsibility for coroners policy, I am trying to assist the process; I want people to recognise what the minimum standards should be in the absence of a national system. I want to move the situation forward. That is something that the chief coroner will be able to help with. We have an independent judicial system, and I am responsible for policy. However, when I receive complaints or when I hear of problems—for example, in relation to the armed forces deaths in Iraq—it is impossible for me to sit back and say, ““Let’s wait until the next Queen’s Speech and see whether we have a Bill.”” In the absence of anyone else, I and my officials—I pay tribute to them; they are from the Home Office—are doing what we can without encroaching on the independence of the system. I want to move forward, but I am explaining the situation as it is now. I think that everyone agrees that, if there is a problem and people have a complaint about how they were dealt with by a coroner’s officer or a coroner, there is nowhere for such complaints to be considered and acted upon or for lessons to be learned. Sometimes, people simply want to complain so that the situation can be recognised and changed. At other times, they want to appeal a finding, or have it reviewed. However, as the Select Committee made clear, the ability to appeal is very restricted. Hon. Members also spoke about the appointment system. Some parts of the coroners’ system can be seen as our only hereditary system—except, of course, for the monarchy. Sometimes, the job belongs within a solicitor’s firm, so one practice can hold the coronership. If that practice is a family firm, the job will go from father to son, and from son to daughter. None of us think that that is the right way to run the system. I agree with the hon. Member for North-West Norfolk (Mr. Bellingham), however: not only is ours a non-appointment system, but some people regard it as a part of their local public service. I do not take anything away from those who do so. The hon. Gentleman is right also that many who are called part-time coroners have given up their other jobs and are acting as full-time coroners, but they are paid only as part-timers. It is no disservice to those who do so to say that it is not acceptable to have a system with no proper appointments—one that can be run by the partners of a coroners’ firm in which the job can go from father to son. If someone can appoint their own deputy coroner, when the local authority comes to make an appointment, the only person qualified for the job has already been appointed; indeed, he will have been working alongside the coroner, perhaps for six years. That is how things work, and we do not think that it is acceptable for appointments to be made in that way. We are also concerned about the lack of national training standards for coroners’ officers and that there is a postcode lottery. Those are the problems in the system. As previous mentioned, we recently carried out a poll of bereaved relatives to measure their satisfaction rating, because we only tend to see the complaints about those 30,000 inquests. There were some grave and serious complaints, however, in our survey, we also found that bereaved relatives judged their experience of the coroner service to have resulted in a higher level of satisfaction than their experience of the NHS. Although nothing can overtake the misery of somebody who is badly treated in an inquest, people have an ocean of gratitude for those who go the extra mile and do not just treat the situation as being all in a day’s work but understand that it is an incredibly stressful and difficult time in people’s lives. For example, a woman who had worked in the coroner’s court and pathology system in Sheffield for many years told me that, when dealing with the death of a child, she prepared the child in the mortuary and asked the mother to give her the washing powder and fabric softener that she usually used on the child’s clothes. When the mother came to see her child and be with the body, the child’s clothes smelt not of formaldehyde or horrible chemicals, but like her child. There are stories from all over the country of people who have strained themselves to ensure that the system helps those who are dealing with a sudden, unexplained or violent death. I will explain what I am currently doing to deal with some of the problems. As I have mentioned, I am trying to get to the bottom of the variation in the amount that is spent in different local authority areas. So far, that does not seem to be related to the number of deaths. I am also examining the variation in time that an inquest takes, as it does not seem to correlate to the amount of money spent. We will shortly introduce the cremation regulations, which will automatically allow relatives to have copies of the cremation certificate so that they can see if there are any problems. That was something that Ann Alexander, who represented the bereaved relatives of the Shipman murders, asked to be done. We will introduce those regulations for consultation in April. We are also dealing with the situation in Oxfordshire. Hon. Members will understand that, when military fatalities are flown into Brize Norton, that is where the body lies, and once the coroner has opened an inquest, there is no possibility to transfer the body to another coroner’s area because each coroner’s jurisdiction is a law unto itself. Therefore, delays build up because a body cannot subsequently be transferred to the coroner in the jurisdiction where the person was stationed in the UK or where their relatives live. That has caused incredible difficulties for many relatives who have had to travel hundreds of miles at great expense to themselves and been unable to be supported by as many family members and friends as they would have liked because of travelling expenses. Those military fatalities have led to many deaths from abroad coming into the Oxfordshire coroner’s jurisdiction. Often such deaths have occurred in complex circumstances and it is difficult to obtain the necessary evidence, much of which is very technical. Unacceptable delays have occurred and, because of an absence of transparency in the system, it took a while for us to recognise that there was a delay building-up. No reporting system is in place to bring such a build up of cases to the relevant person’s attention, and I pay tribute to my ministerial colleagues in the Ministry of Defence, who raised this matter with me. They were particularly concerned about the service families involved. We were able to work with the Oxfordshire coroner and provide the resources for him to appoint extra coroners, so that we could have many inquests running at the same time to ensure that such a terrible delay was brought to an end. In many cases, people had been waiting four, five or six years for inquests. I pay tribute to Sir Richard Curtis—a retired High Court judge, who as assistant deputy coroner, dealt with one of the most complex technical cases involving a helicopter—and to Selena Lynch, a barrister, who was an assistant deputy coroner, and to Andrew Walker for the work that they are doing to ensure that the relatives of those who have died in Iraq get the answers to their questions. One of the responsibilities of a chief coroner will be to back up an individual coroner in a particular jurisdiction when they need evidence from abroad or some other agency. If a coroner felt that they were not getting the information that they needed, a chief coroner at a level similar to that of the Lord Chief Justice will be able to contact the authority involved and say, ““My coroner is not getting the information that they need from you””. In the absence of a chief coroner, that role is, to some extent, falling to me. I have taken it upon myself to see the American ambassador and ask him to give the relevant information to the Oxfordshire coroner, so that he can conduct a proper inquest into the deaths of those military personnel in Iraq.