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Coroners Bill

asked Her Majesty’s Government what action they propose to take in view of the absence of a coroners Bill in the legislative programme. The noble Baroness said: I was sorry to see no coroners Bill in the gracious Speech, hence I have instigated this debate. A complete overhaul of coroners’ services in terms of both infrastructure and legislation is long overdue. I start with the subject of death certification. Reform of death certification has been recommended by a succession of reports, including the Brodrick report in 1971, the Luce report in 2003 and, most recently, Dame Janet Smith’s report on Harold Shipman. The cremation certificate system, which requires families to pay a fee, has proven inadequate in detecting patterns of criminal practice and I believe does not detect poor clinical performance or systematic errors in death certification. A better system of scrutiny of all deaths—not just those involving cremation—with built-in statistical analysis is required and is now easily within the competency of an IT programme. It should analyse deaths and certification by doctor, by location of healthcare delivery and by cause—similar to the data from the Prescription Pricing Authority. For example, hospice doctors will of course certify more deaths than GPs but high numbers from one service, wherever that service is in healthcare, that lie outside the normative curve could at least be spotted. As for determining the cause of death, it seems that the coroner should be able to pursue a diagnosis beyond an immediate ““mode”” of death and to obtain a precise diagnosis by further pathological investigation for the benefit of a family and also for the benefit of the healthcare system. There is a need for authoritative guidance to coroners and pathologists on exactly what a coroner’s post-mortem should achieve. To exclude unnatural causes of death is far too simplistic. Fewer and fewer non-coroners’ post-mortems are being done, so verification of the precise medical cause of death is happening less and less, yet it is essential for an audit of clinical services to improve patient safety. Furthermore, it is unclear what level of investigation is justified—and lawful—once unnatural causes have been excluded. Perhaps I may give an example. A patient with mesothelioma dies at home. Because the illness is related to asbestos, this results in a police interrogation of the bereaved family, even though the diagnosis has been clearly established. That is an unnecessary and hurtful consequence of current regulations. If we had a chief coroner, that could be completely avoided. Another example is that, currently, if a patient dies with a dementia syndrome, a coroner is not motivated to establish the cause of the dementia—an expensive procedure costing around £600—even though the family may wish it. Therefore, if it happens at all, a research programme might pick it up as a by-product of the family agreeing to donate the brain for further research. However, dementia represents an increasing cost to the public purse, so the underlying causes need to be known if we are even to plan spending in the future. Sometimes information might prevent a premature death. I was recently told of a case of sudden adult cardiac death where the strong suspicion was of an inherited cardiomyopathy. A coroner’s post-mortem was done but, despite having the consent of the relatives, the coroner refused to pay for appropriate specialist investigation of the heart, with genetic testing, because it was clear that the death was due to natural causes. The coroner had neither remit nor resources to undertake investigations for the benefit of the relatives. The NHS then also refused to pay because the test would be for the benefit of the relatives, not the deceased, and the deceased came from a different primary care trust from the relatives. Yet such investigations would have clarified future management of the close relatives and could have lowered their risk of sudden death. Why is complex, controversial and expensive legislative change to medical revalidation being pushed with greater vigour than legislation to permit improvements in the investigation of death? A draft Coroners Bill was announced for this Session, published, then dropped. That is unjustifiable. I shall move on to the provision of medical advice. The draft Bill, as previously published, emphasised legal aspects, but the medical aspects of ascertaining a cause of death are key to accuracy and require expertise. Surely it is the medically qualified specialist pathologist who should have the ability to pursue the appropriate investigations and dictate how to examine the body, rather than the coroner, who often is not medically qualified at all. Nowhere is that more important than in the vexed issue of sudden and unexpected death in infants. The report by the noble Baroness, Lady Kennedy, into that subject recommended that tissue blocks and slides should be retained in perpetuity after a post-mortem examination in a case of sudden infant death syndrome, in case future developments justified re-examination of those samples. When we debated the Human Tissue Bill, I stressed the need to be able to revisit the specimens but the Government did not accept that. Now retention is illegal without ““appropriate consent”” once the work of the coroner has been completed. If the parent had been culpable, of course they would want to ensure that all tissue was cremated and all evidence destroyed. If not, then in the horrible and unthinkable event of a second cot death, the tissues could be re-examined. The situation in Scotland is exactly the opposite to that in England and Wales because, under the Human Tissue (Scotland) Act, the blocks and slides become part of the deceased’s medical record and the pathologist is specifically prohibited from disposing of them or returning them to the parents. That polar difference between Scottish and English law is contrary to the stated intention that the tissue legislation between the two jurisdictions should have broadly the same effect. The noble Baroness, Lady Kennedy, also recommended that certain time-sensitive samples, such as blood, cerebrospinal fluid and nasal swabs for microbiological investigation, should be taken as soon as possible after the death of the child has been confirmed to maximise the chances of ascertaining fully and reliably the cause of death. She clearly anticipated that this testing would take place in accident and emergency departments before transfer to a mortuary. However, the Human Tissue Act 2004 has made such sampling illegal, except where the A&E department has a Human Tissue Authority licence to undertake such sampling—but there is cost and complexity to obtaining such a licence. The Royal College of Pathologists believes that this was an oversight and that this consequence of the Human Tissue Act was not recognised prior to Royal Assent. A coroners Bill could easily correct that anomaly. Why do we need a chief coroner? We need a national structure to ensure consistency of standards and to ensure that the investigation of deaths is carried out to a gold standard nationally. I have already mentioned the problem of mesothelioma, which could be easily solved if we had a chief coroner. The current law has to be ignored when it comes to setting a gold standard. We have a shortage of highly specialised paediatric pathologists, so the bodies of dead children are being transported great distances for post-mortem examination. This is a serious issue because the law as it stands states that a body can be transported only to the adjoining coronial area of jurisdiction. When a family has to deal with the sudden death of a child, they must know that a satisfactory post-mortem has been carried out—and carried out within the law. The Ministry of Justice is aware of the problem, but everyone turns a blind eye to the benefit of the bereaved. It is time that the needs of the bereaved, particularly their need for information, were properly addressed. Pathologists undertaking coroners’ post-mortems must know the wishes of the relatives before the post-mortem starts in order to be able to respect them, not simply consult them later. Relatives need information. I should like to see them have a copy of the pathologist’s report interpreted for them as a routine, with a copy to the GP so that they can ask questions later. After Alder Hey, the University Hospital of Wales established a group, similar to the groups established in hospitals up and down the country, to take inquiries about tissue samples and retained tissues. When the family were not satisfied with the first-line response team, a few of us gave one-hour appointments for relatives to ask questions and tried to allay their concerns. The overriding factor was that they wanted answers. One woman said to me that she had waited 15 years to understand why her daughter had died. In that hour, I finally gave her the answers. That situation cannot be allowed to continue. The charter for the bereaved lays out important guidance. I hope that it will not be abandoned now that the responsible ministry has changed. The legislative changes must be underpinned by organisational changes and clarification of funding. The ““who pays”” issues are now working increasingly against good practice. The Department of Health consultation on death certification in pandemic flu mentions reforms, but when are they coming? Until we modernise the coronial system we risk denying justice to our dead and their bereaved families.