Public Bodies Bill [HL]

Baroness Finlay of Llandaff Excerpts

Tuesday 14th December 2010 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

26: Schedule 1, page 16, line 17, leave out “Chief Coroner, Deputy Chief Coroners, Medical Advisers to the Chief Coroner and Deputy Medical Advisers to the Chief Coroner.”

[Baroness Finlay of Llandaff]

My Lords, this amendment seeks to ensure that the long-awaited chief coroner, as set up in the Coroners and Justice Act, is not abandoned. I shall explain, first, why an independent chief coroner is essential for national functions to be adequately discharged and, secondly, why the cost basis of the decision to list the chief coroner, medical advisers and deputies is flawed, as dispensing with leadership to reform the coronial system will stack up costs, not save money. This amendment is strongly supported by all the experts in the field with whom I have had contact and by many from the voluntary sector, including INQUEST and the Royal British Legion.

The current system is not fit for purpose, being based on the 1887 Act. Even the 1988 Act was only consolidating, ignoring the Brodrick committee report. Repeatedly, fundamental reviews have been commissioned and, repeatedly, their key recommendation has been for a chief coroner with appropriate medical advice. In 2003, the fundamental review of death certification and investigation, the Luce review, was quickly followed by the third report of the Shipman inquiry. Both called for radical reform and leadership. As the Ministry of Justice’s own impact assessment on the Coroners and Justice Bill said:

“The Shipman Inquiry … and the Fundamental Review of Death Certification and Investigation”—

the Luce report—

“found the level of service provided to bereaved people was inconsistent; family and friends were not always involved in coroners’ investigations; there was a lack of leadership and training for coroners; and insufficient medical knowledge in the system as a whole”.

Luce’s headline recommendation was for a chief coroner from the higher judiciary to oversee standards and handle appeals.

Dame Janet found that to a large extent coroners are left to their own devices, with no guidance to coroners, no appeals system by which unsatisfactory decisions can be set aside, no job description and no appraisals. She proposed that leadership for coroners should come from a chief judicial coroner, with senior medical advice as appropriate, independent of the Government. Indeed, she said:

“In my view, it would no longer be satisfactory for the coroner service to be administered from within a Government Department”.

Four weeks ago we had the Redfern report, again calling for co-ordination and leadership.

The Coroners and Justice Act took three years of review and consultation and was supported across all parties. It made provision for such leadership. Dame Janet has noted that, with no appeal mechanism, the only route to challenge decisions is judicial review, but that a quicker and cheaper means of appeal could and should be provided whereby decisions, whether in a report or at inquest, that are wrong can be set aside, and that such an appeals system should be run by the chief coroner.

Coroners themselves have estimated that there might be up to 1,000 appeals per annum but a better local complaints procedure would decrease these. Currently, however, with the only recourse being to judicial review, there are about 25 judicial reviews a year. Each costs somewhere around £40,000 to £60,000, although no one can provide me with a good costing on it. So our current inadequate system is costing at least £500,000 to £750,000, and with such an unmet need the numbers will only rise.

The coroners need leadership that they can respect to bring about change. Where a coroner has written a rule 43 recommendation to try to avoid further deaths, without a chief coroner, where are the levers to look at the public safety issues across the UK? Military deaths deserve an inquest by a coroner with military knowledge. Inquests into child deaths require specific skills. Inadequate post-mortems, as evidenced by the 2006 NCEPOD report, need an on-going audit to drive up standards. To do that, leadership is needed.

Freddy Patel did many post-mortems—many coroners used him, not just one—but, with no leadership from a medical adviser to the chief coroner, substandard practice goes largely undetected. A poor post-mortem can result in a wrongful conclusion, a lack of justice, miscarriages of justice and a failure to prevent avoidable deaths. Coroners have such a duty to prevent further deaths. The rule 43 recommendation can be issued but, without a national overview to map trends, outliers go unnoticed. We know that they have gone unnoticed for years.

Accurate data on deaths are essential. Deaths classified as drowning are sometimes due to an inherited heart problem that results in the heart stopping on hitting cold water. With that undetected, the wrong conclusions are drawn and the relatives of the deceased are left at risk of sudden death themselves.

The training of coroners is a major problem. Participation is purely voluntary. Training instigated by the Coroners’ Society, and now supported by the Ministry of Justice, remains patchy, with some coroners, as Dame Janet said, never undertaking the voluntary training that is available because they believe that they know all there is to know. Leadership is needed for accountability and oversight to make the delays in inquests a thing of the past and ensure that inquests into complex cases such as military deaths, child deaths and incidents with multiple victims are conducted by coroners with appropriate expertise.

At a time of financial stringencies it seems sensible to disband as many costly organisations as possible, so I turn briefly to the cost basis for the decision. Set-up costs were estimated to be almost £11 million, of which almost £4 million was for IT and £2.5 million for recruitment, publications, additional coroners and transition costs. Transition from what? There is a yawning gap at present. The Ministry of Justice team has four people working on coroners’ issues; by transferring them to the chief coroner, their costs would be offset, as would the training spend by the Ministry of Justice at the moment. Indeed, training could be more cost-effective by using simpler venues and local resources. Having consulted widely, I estimate that the whole set-up cost and per-annum cost could come within a £500,000 envelope. The deputy chief coroner and medical advisers can be drawn from respected senior coroners and local medical advisers already in post, therefore not incurring the costs of new appointments. Further developments can come later; it does not all have to happen at once.

--- Later in debate ---

[Lord Taylor of Holbeach]

I thank my noble and learned friend for that question. It gives me the opportunity to make it clear that to the extent that the chief coroner’s functions are judicial, they will be carried out through direction from the Lord Chief Justice, not the Ministry of Justice. Therefore, the independence of the judiciary in respect of the coronial service is preserved.

[Baroness Finlay of Llandaff]

My Lords, I am most grateful to all noble Lords who have spoken in support of this amendment. However, I fear that we cannot throw away in 109 minutes—we have two to go—what we have waited 109 years for, as the noble Lord, Lord Ramsbotham, said.

The Coroners and Justice Act was duly taken through Parliament; we all miss Lord Kingsland, who led on the Bill from the then Conservative opposition Benches—now they are the coalition Government. I appreciate the Minister’s response, but I am not convinced. I remain convinced that we need leadership; we cannot betray the bereaved, particularly where people have died on active service for this country. There must be complete independence and there must be consistency among coroners. As for judicial review, I just do not know how people can afford it. That is why there are not more of them taking place—people would have to sell their house to go for it.

As we come up to 109 minutes of debate, after 109 years, I beg to test the opinion of the Committee.