West London Coroner’s Court

James Berry Excerpts

Wednesday 16th December 2015 Westminster Hall

[James Berry (Kingston and Surbiton) (Con)]

I beg to move,

That this House has considered standards of service at West London Coroner’s Court.

It is a pleasure to serve under your chairmanship, Sir Roger, and to see so many colleagues here who have been so vocal on this important issue for their constituents and mine. Two years ago tomorrow, my father died unexpectedly. It was a devastating experience for my family, as death is for every family, but the seamless service from the local council and the coroner made the whole experience just that bit more bearable. Although the registration process itself was clinical, because it was efficient it did not compound our distress as a family. Sadly, the same cannot be said for the experiences of many bereaved relatives of those living in Kingston, Richmond, Hounslow, Ealing, Hillingdon, and Hammersmith and Fulham, which are the boroughs that comprise the jurisdiction of West London coroner’s court.

Since I was elected in May, I have received numerous complaints about the standards of service at West London coroner’s court and about the senior coroner there. Those complaints come not only from bereaved constituents, but from the council itself and, indeed, from our local newspaper, the Surrey Comet. The complaints include: long delays in issuing death certificates; inordinate delays in bringing on inquests; a telephone service that is never answered when relatives call for advice; crass errors on death certificates, such as getting the age or sex of the deceased wrong; and general rudeness to boot.

It is important to note at the outset—I note your guidance, Sir Roger—that I do not intend to criticise the senior coroner personally, because I know that there is a complaint against him by a number of councils, and that that is under investigation. I would not want to impede that investigation, but there are three issues that I would like to consider in some detail: delays, burials for certain faiths, and deprivation of liberty safeguards.

West London coroner’s court has one of the worst records for delays in the country. It takes almost double the national average time to process inquests. The delays are a shocking abrogation of the state’s responsibility to bereaved families, including those in my constituency. The estimated average time taken to process an inquest in England in 2014 was 28 weeks—a figure that has been effectively stable over the past five years. However, in west London and in inner south London, the average time taken to process an inquest is 50 to 53 weeks. The figure of 53 weeks is the worst in the country. In West London coroner’s court, the figure is 50 weeks—the second worst in the country.

In my borough, Kingston upon Thames, the target for registering a death is five days from the date of death, or seven days in a case where a post mortem is required. In 2013-14—the period during which the coroner was appointed, as he was appointed in November 2013—Kingston was meeting that target in 70% of cases. In this year, 2015-16, if we continue on the current trajectory, Kingston Council will meet its target in only 11% of cases, and that is because of delays at West London coroner’s court.

In terms of post mortems, prior to the appointment of the current senior coroner in November 2013, the waiting time in Kingston from a death to a post mortem was two to five days, yet between June and September 2015, the average waiting time was four to six weeks. I understand that the situation has since improved somewhat. Those statistics speak for themselves and do not need labouring, so I will return to the bereaved families who are at the heart of the debate.

For most people, an inquest is a new and somewhat unsettling experience at a very vulnerable time in their life. In most cases, bereaved relatives simply want to bury their dead as soon as possible. In a small number of cases, they want answers or an inquest is required by law, but in all cases, they want to have the system explained to them, and to be kept informed of the reason for and the length of any delays.

Ronke Phillips from “ITV News London” has done a lot of work exposing the problems at West London coroner’s court. In October, ITV London brought a number of families affected by services at West London coroner’s court to Parliament to speak to their MPs, a number of whom are here today. The accounts those families gave of the distress they had been caused were quite moving. There were unexplained delays, no updates, and a telephone service that was never answered and turned out not to be manned at all.

[Mr Dominic Grieve (Beaconsfield) (Con)]

I am sorry to interrupt my hon. Friend’s flow, but I do not want to take up the House’s time by making a speech. He highlights some of the issues very well. My constituent, Mrs Doreen Garcia, had what was essentially a completely straightforward issue in relation to her husband’s death. She needed to get a death certificate because it was essential for the administration of the estate, yet she had to wait more than a year for an inquest that, in the end, was a hearing on the papers because of the complete inefficiency of West London coroner’s court.

[James Berry]

That experience is by no means unique. In terms of the telephone service, when I called up on behalf of a constituent very early on in my role as a new MP, I had to wait on the telephone for more than 45 minutes, and then it became clear that the call was never going to be answered. Frankly, that plumbs the depth of poor service for bereaved families. As I understand it, the senior coroner’s position is that he inherited a backlog from his predecessor in 2013. Be that as it may, he has not cleared that backlog since November 2013, and has compounded the situation with an ill-conceived staff reorganisation and shocking failures to communicate with bereaved families.

[Dr Tania Mathias (Twickenham) (Con)]

On the point about the attitude towards bereaved families, I would like to put on the record that twice I have had people in tears in my constituency surgery over inaccuracies on post mortem certificates, as my hon. Friend the Member for Kingston and Surbiton (James Berry) described. It is extremely distressing for MPs not to be able to improve the situation. I absolutely agree with everything he said.

[James Berry]

Finally on the delays at West London coroner’s court, it would be easy to blame the situation on cuts, but they are not to blame. I wrote to the chief executive of Hammersmith and Fulham Council, which is responsible for funding the coroner service in west London. He made it clear that although the council has had to make cuts to various areas, the coroner service has been protected from those cuts. The responsibility for sorting out this shambles lays squarely with the senior coroner for west London. He needs to get his house in order for the sake of bereaved families living across the boroughs represented here.

[Andy Slaughter (Hammersmith) (Lab)]

I am grateful for the comment that the hon. Gentleman just made. I have been copied into the letter that he received from the chief executive of Hammersmith and Fulham Council, dated yesterday, which points that out. I am sure it was done in good faith, but on the hon. Gentleman’s website, he has said that the situation could be the council’s fault. I hope that he will correct that. One of the issues that we will deal with is putting blame for this matter where it lies.

[James Berry]

I do not intend to go into the technicalities of the Coroners and Justice Act 2009, but it is a matter of interpretation as to whether the local council or the police are responsible for providing administrative staff. However, the council is quite clear that there have been no cuts to the funding that it believes it ought to be providing.

Moving on to the subject of religious burials, Jewish and Muslim families have to bury their dead in a matter of days, and the pressure on those doing so is compounded by the situation at West London coroner’s court. I need not say any more about that, because I can simply welcome the Minister’s recent announcement of a review into the interaction that some faiths have with the coroner service across the whole country. I simply observe that in diverse communities, such as those served by the West London coroner’s court and by MPs here, a reliable out-of-hours process for death certificates that are required over the weekend would seem to be the most sensible way forward.

The third point I would like to make is on the matter of national application—the requirement to hold an inquest when someone dies while subject to deprivation of liberty safeguards. Section 1 of the Coroners and Justice Act 2009 requires that a coroner holds an inquest in certain defined circumstances such as a death in state detention, or a violent or unnatural death. In other cases, the coroner has discretion as to whether to open an inquest, depending on the facts.

Since the Mental Capacity Act 2005 came into force, the definition of whether someone is detained or deprived of their liberty has been tested in the courts on numerous times. In March 2014, the Court of Appeal considered the cases of P v. Cheshire West and Cheshire Council, and P and Q v. Surrey County Council. In those cases, the Court of Appeal gave a very broad definition of deprivation of liberty. The result of that decision has been that authorisations now have to be sought for deprivation of liberty in many more cases than they used to. That includes most cases where a person suffering from dementia lives in a care home and would be prevented from leaving if they attempted to. An inquest must be held in each of those cases because the individual is deemed to be in state detention. In my constituency, we have a nursing home in which 90% of the residents are subject to the deprivation of liberty safeguards. On the current interpretation of the law, there would have to be an inquest into each and every one of those individuals’ death, even if they died entirely predictably in their sleep.

I am not saying that there should be no inquests at all into deaths where the deceased is subject to the deprivation of liberty safeguards—far from it. I am arguing that inquests should be opened at the coroner’s discretion; they should not be mandatory. It was certainly not the intention of this House in passing the Coroners and Justice Act or the Mental Capacity Act to mandate an inquest in every case in which the deprivation of liberty safeguards apply, nor was it the Court of Appeal’s intention in the P and Q cases, so far as I can work out; the issue was not canvassed before the Court at all because the case did not concern inquests.

In support of my point, the Chief Coroner of England and Wales highlighted the problem in his 2014 annual report to the Government, and highlighted the massive increase in the number of deprivation of liberty safeguards from 11,300 in 2013-14 to some 83,000 in the first three quarters of 2014-15, which will inevitably lead to a huge number of additional inquests. I ask the Minister to find legislative time, as a matter of real priority, to exempt people who die while they are subject to deprivation of liberty safeguards from the mandatory requirement to hold an inquest. That change would reduce the pressure that is building on coroners across the country. It would help, but by no means resolve, the problems at the West London coroner’s court, to which I return in closing. It is clear that something must be done to improve the terrible standards of service in that coroner’s court.

[Boris Johnson (Uxbridge and South Ruislip) (Con)]

I congratulate my hon. Friend on securing this debate and on what he is saying. In the few months that I have been back in this House, I have received an amazing volume of complaints about the West London coroner’s court. Can the issues regarding the role of the West London coroner be properly remedied by the Chief Coroner, or should there be a formal investigation by the Ministry of Justice? We need to get to the bottom of what is going on.

[James Berry]

That encapsulates the sentiment of many MPs on this subject. I am pleased to have received reports that the telephone service at West London coroner’s court has improved—that has been confirmed by the leader of Hammersmith and Fulham Council—but the inordinate delays in issuing interim and final death certificates and in bringing on inquests must be addressed now. If that means sitting at the weekend, as judges did after the riots, or if it means appointing additional assistant coroners to help clear the backlog, so be it. By whatever means, the senior coroner, for the sake of bereaved families in our constituencies, must get a grip of the situation now.