Redfern Inquiry
The Parliamentary Under-Secretary of State, Department of Energy and Climate Change (Lord Marland)
My Lords, with the leave of the House, I shall now repeat a Statement made in the other place by my right honourable friend the Secretary of State for Energy and Climate Change. The Statement is as follows:
“Mr Speaker, today I am publishing the report of the Redfern inquiry, which was established in 2007 to investigate the processes and practices surrounding the analysis of human tissue that was carried out in UK nuclear facilities from 1955 to 1992.
The inquiry examined the circumstances in which organs or tissue were removed from individuals at NHS or other facilities, and sent to be analysed at nuclear laboratory establishments.
To lose a family member is tragic. To find out, sometimes decades later, that tissue had been taken without consent, is an unimaginable distress. That knowledge is a burden no-one should have to bear.
There is no time limit on grief, or on apologies. I would like to take this opportunity to express my heartfelt regret and to apologise to the families and relatives of those involved. I hope that the publication of today’s report goes some way toward providing the closure that they deserve.
The events described in the inquiry should never have happened in the first place. We have learnt the lessons of the past. The law on human tissue has been reviewed and there is now a rigorous regulatory system in place, in which both the public and professionals have confidence.
I would like to thank the chairman of the inquiry, Mr Michael Redfern QC, for conducting the investigation. The inquiry has also benefited from the support of the nuclear industry and other key stakeholders, who have co-operated fully.
The inquiry was established to investigate the circumstances in which organs were removed from individuals and were sent to and analysed at Sellafield. However, as evidence came to light of similar work carried out at other sites and of studies involving non-nuclear workers, Mr Redfern was asked to make these additional cases part of his inquiry.
It was initially sponsored by the Department of Trade and Industry, which at the time had responsibility for energy policy. The Department of Health became co-sponsors when the terms of reference were expanded to allow the inquiry to access relevant NHS information and to investigate the part played by hospitals in which the post mortem examinations had been conducted. Although not a sponsor of the inquiry, the Ministry of Justice also has an interest in the inquiry’s findings and recommendations in respect of the coroner’s role.
The report highlights unacceptable working practices within the nuclear industry, National Health Service pathology services and the coronial service, and concludes that families’ views were not always obtained as required under the Human Tissue Act 1961. It acknowledges that these events occurred a number of decades ago, and puts them within the context of the times and current practice. Many of the issues raised by the inquiry have since been addressed by changes to the law, including the Human Tissue Act 2004.
The inquiry found that organs from 64 former Sellafield workers were removed by pathologists and taken for analysis at Sellafield between 1960 and 1991. In addition, organs taken from 12 workers at other nuclear sites were analysed at, or at the request of, Sellafield, giving a total cohort of 76. The inquiry also found evidence of other individuals whose organs were analysed at Sellafield.
The report finds that there was a lack of ethical consideration of the implications of the work the industry was doing; that there was limited supervision undertaken; and that relationships between pathologists, coroners and the Sellafield medical officers became too close.
The inquiry has found that organs from a small number of former Ministry of Defence employees were also removed for analysis. It has been difficult to establish the legality of a minority of these removals. Also, during the 1950s and 1960s, the Medical Research Council oversaw research measuring levels of Strontium-90 in human bone obtained at post mortem. It was a national survey involving more than 6,000 people, mostly children, and was not linked to former nuclear workers.
The inquiry also considered work undertaken by the National Radiological Protection Board across its entire remit. The inquiry found that families’ views about organ retention were not always sought, and that very few families knew that organs were taken for analysis. Research using human tissue at that time was carried out under different legislation, and within a culture that took an approach to these matters very different from our approach today. That is not to diminish the distress and suffering caused to families by the events of the past. However, we have learnt from the mistakes of the past, and we now have in place the legislative and regulatory framework that makes consent the fundamental principle underpinning the lawful retention and use of body parts, organs and tissue from the living or the deceased for such purposes.
My right honourable friend the Secretary of State for Health and I welcome the recognition given by the inquiry to the changes in the law, and the associated regulatory framework relating to the taking, use and storage of human tissue, that has been put in place since the events leading up to this inquiry.
Since the Human Tissue Act 2004 came into force, we have seen the development of robust regulation which focuses on compliance through the provision of expert advice and guidance—and where regulatory action is taken if standards are not met.
My right honourable friend the Secretary of State for Justice has the principal interest in the findings of the inquiry relating to the role of coroners. His department is responsible for coronial law and policy, but as coroners are independent judicial office holders, it does not monitor how they carry out their functions in individual cases unless specific complaints are made.
Communication between families, coroners and pathologists was, and still is, vitally important. Changes to the Coroners Rules 1984, introduced alongside the human tissue legislation, are aimed at ensuring that families’ wishes about what happens to organs and tissues retained after a post mortem examination can be properly established and acted upon. My right honourable friend the Secretary of State for Justice also intends to take forward several provisions in the Coroners and Justice Act 2009 which address other problems Mr Redfern identifies, and which also aim to prevent any recurrence of the events that led to the establishment of his inquiry.
Although the Government are not proceeding with the role of chief coroner, we intend to transfer many of the intended leadership functions of the post to the Lord Chancellor, or possibly the senior judiciary. There will be higher standards when commissioning post-mortem examinations, and in the way coroners communicate with bereaved families. There will be more effective operational delivery and an end to rigid geographical boundary restrictions. Training of coroners and their staff will be maintained and improved, and coroners’ work will be more transparent, so that unacceptable practices can be avoided or challenged and deficiencies tackled. We are also considering introducing the new, more accountable system for appointing coroners and their deputies enabled by the 2009 Act.
The inquiry has sought and received assurances from all of the key nuclear industry stakeholders that the practice of retaining organs or tissue at autopsy has ceased. I hope that the families of those involved can take some comfort from the knowledge that the practices that this inquiry examined simply would not be permissible today.
I commend this Statement to the House”.
My Lords, that concludes the Statement.
Baroness Smith of Basildon
My Lords, I am grateful to the Minister for repeating the Statement today. On behalf of these Benches, I concur with his expressions of regret and apology to the families. The grief and shock that they experienced, in so many cases years after the death of their loved one, was compounded by not knowing the full facts or reasons why. I hope that they will now be confident that this report has done all that is possible to address the issues.
I also join the Minister in his appreciation and thanks for the work that Michael Redfern QC and his team undertook. The issue has been both complex and sensitive, and it is right that there has been an inquiry of this depth, level and seriousness. I have had only a short time to go through this very thorough piece of work, but it is clear that it is of the highest standard. The nuclear industry will want to make its own comments, but I note and welcome that it fully co-operated with the inquiry.
As the Minister said, the report was initially into the fact that tissue was taken from 65 individuals who died between November 1962 and August 1991 and had worked in the nuclear industry, but it was later extended. When this came to light, it was not clear that permission had ever been granted by the next of kin, and in most cases it appeared to have been authorised at the request of the coroner. Because of the length of time it had taken for this to come to light, and the lack of information, Alistair Darling, who was then Secretary of State for Trade and Industry, asked Michael Redfern to undertake an independent investigation, which was expanded to take into account other relevant incidents.
It is clear, as was said in the Statement, that this was a different era with different standards, and that lessons have been learnt from the past. However, that cannot excuse the fact that the report makes it clear that it was “profound ignorance” of the law that led to organs and tissues being removed, in breach of the Human Tissue Act 1961—although it must be relevant that at that time there was no independent regulatory authority. There was a clear failure of leadership, as the report identifies.
I have five questions for the Minister and his colleagues. Given the seriousness of the report, I am pleased to see so many Ministers in the Chamber today, because this cuts across different departments. First, is the Minister satisfied that the inquiry was able to look at the full extent of the issue, and that such practices do not exist at all today? Secondly, what discussions have the Government had, and what discussions do they plan to have, with the professions concerned to ensure not only that there are robust procedures in place, but that these are effectively monitored?
Thirdly, Michael Redfern comments that changes in the law—the Human Tissue Act 2004 and the Coroners (Amendment) Rules 2005—have addressed many of the concerns. That is welcome. The Minister will recall that the Human Tissue Act 2004 was brought in following the Alder Hey inquiry, which was also chaired by Michael Redfern QC. The fundamental principle of the Human Tissue Act 2004 was that of consent. It established the Human Tissue Authority as the independent public watchdog in this area. Only last month it was able to report an increase in public and professional confidence in human tissue regulation, which is welcome. One of its great strengths is its independence from government. It would help the House if the Minister would explain why the Government now propose to abolish the Human Tissue Authority, and whether in the light of this report they will reconsider their plans.
Fourthly, I know that the Minister is confident that the Coroners (Amendment) Rules 2005 addressed the concerns raised, and that he understands the issues that led to the Coroners and Justice Act 2009. This Act addressed the issue of leadership through changes in the system, including the appointment of a chief coroner with responsibility for ensuring good leadership, training the network of coroners and running the Appeals Service. Although the appointment of a highly respected and very distinguished judge was initially made, the Government now propose to abolish this post as well, as was acknowledged in the Statement. Have the Government discussed these proposals with Michael Redfern following his report?
I hear what the Government say about the 2009 Act. However, if the intention is to bring the responsibilities of the chief coroner in-house, as it were, into the Ministry of Justice, do the Minister and his ministerial colleagues really feel that this will provide the reassurance that the public and the families concerned deserve? If the Government are to seek someone from the senior judiciary, why not just confirm the appointment of the senior judge who was previously appointed to the post of chief coroner? I appreciate that the noble Lord may not be able to respond to that point today but I hope that he will take it back and discuss it with his ministerial colleagues across government. It is an extremely important issue. We want to ensure that there is public and professional confidence in the system, so I hope that he will ask his colleagues to reconsider the point.
Finally, the Government have shown appropriate sensitivity in contacting and briefing the families concerned and in making the report available to them. I also understand and welcome the fact that Michael Redfern will be meeting them today.
I understand, too, that a freephone helpline has been established. Perhaps I may make what may seem, but is not, a trivial point. Many mobile phone users cannot access freephone numbers, so I ask the Minister to ensure that the helpline is also available free to mobile phone users.
Once again, we are all very grateful for and appreciate the work and commitment of Michael Redfern QC and his team. I hope that the Minister and his colleagues will take on board our concerns and ensure that other actions that we take through the Public Bodies Bill do not diminish the important and welcome progress that has been made in this area.
Lord Marland
My Lords, I thank the noble Baroness for her questions, which get to the heart of this tragic and very unsatisfactory matter. Clearly, we have met Michael Redfern QC. We have been briefed by him about the outcome of this report and have looked very closely at the potential shortcomings. As the noble Baroness said, he is comfortable and satisfied that the Human Tissue Act 2004 addresses most of the problems. He has made various comments about the role of coroners, and I shall come to those in a minute.
For the sake of confirmation, as I said in the Statement, we have had absolute assurances from stakeholders that events such as this should not happen again. This inquiry has obviously highlighted and profiled the importance of the situation. I am told that the Human Tissue Authority is a matter for the Department of Health but I can say that we recognise the importance of the authority’s functions. We propose to reallocate those functions to the Care Quality Commission and, if we so decide, to have a new research regulator. That is the department’s response to this situation.
I turn to the appointment of the chief coroner and the need to change the coronial system and make the fundamental changes that are required in accountability. As I said earlier, these are independent judicial officeholders and, when they retire, they are no longer accountable. We have to make them accountable and make changes that bring about greater accountability and stronger lines of direction. Therefore, the Ministry of Justice has decided that, for the moment, the coronial service will report directly to the Lord Chancellor or a Judiciary Minister—a situation that can be reviewed. In addition, there will be a new charter for the bereaved. There is about to be consultation on that and it should be published in the new year.
I am very grateful for the noble Baroness’s comments about the helpline. I am afraid that I cannot comment on whether it can be reached on a mobile phone but I will look into the matter and take on board her excellent point.
Baroness Parminter
My Lords, my thoughts and prayers are with the families and surviving relatives of those involved as they hear the results of the inquiry today. It will clearly come as some consolation that these appalling practices, including the disposal of body parts, are no longer legal. We have indeed moved on in practices and procedures and the ethical framework that governs such decisions. However, my question is: has the nuclear industry moved on? One of the key points of the inquiry’s remit was to identify the purpose for which these body parts and tissues were removed, as well as the conclusions of the research. Can the Minister inform the House whether the nuclear industry will communicate to the families involved the value of and conclusions from that research, giving them the respect that they deserve and helping to end the culture of secrecy which pervades the nuclear industry?
Lord Marland
I think I can assure the noble Baroness that the nuclear industry has moved on. There is deep sympathy within the community surrounding these awful events, and that has been manifested through the full co-operation shown by Sellafield and the boards represented there, together with their support for the inquiry, as I referenced earlier. It is important that the families involved are given all the support that they need at what is a very grim time for them, and it is incumbent on the authorities at Sellafield to show them due respect in that regard.
Lord Campbell-Savours
My Lords, I recognise that mistakes were made and that many families were distressed, but is it not true that the removal of organs was hugely beneficial to science, particularly in the assessment and examination of medical conditions? One hopes that, in their distress, the families will at least recognise that many developments have arisen from the research into those organs. Finally, on what is perhaps a more delicate matter, can we be assured that the announcement today will not lead to a spate of applications for compensation by any of those who may feel that they are owed some kind of recompense?
Lord Marland
I thank the noble Lord, Lord Campbell-Savours, for his question. Of course, no one knows that community better than he does, having served it for many years as a Member of Parliament. This episode took place many years ago and attitudes have changed. We have to respect that fact and respond accordingly. We understand that at the moment there is no attempt by any of the families to seek compensation, and our legal information is that that would be difficult to provide.
Baroness Thornton
My Lords, I invite the Minister to congratulate the GMB trade union on its role in this matter, because it was that union’s campaigning work right at the beginning that championed the rights of bereaved families within the nuclear industry. Related to that matter, perhaps I may raise with the Minister the fact that the Health Protection Agency, which provides the scientific base for safety within the nuclear industry, is another body threatened with abolition by his Government. Again, the trade unions have expressed grave concerns about that, as it is an industry in which safety is very important. Therefore, I seek the Minister’s reassurance that workers within this industry will continue to benefit from the highest standards of safety.
Lord Marland
The noble Baroness is right that any organisation that seeks justice and honour for this awful thing deserves our support, congratulations and thanks. As to her comment on the Health Protection Agency, she is right that it is being abolished. Much more importantly, we will now have a direct relationship to the Department of Health and the ministerial running of it. That highlights its importance but it takes away a layer of management so that we can be directly involved in this particular case.