West London Coroner’s Court

Ruth Cadbury Excerpts

Wednesday 16th December 2015 Westminster Hall

[Ruth Cadbury (Brentford and Isleworth) (Lab)]

It is a pleasure to serve under your chairmanship, Sir Roger. I thank the hon. Member for Kingston and Surbiton (James Berry) for securing the debate and speaking at a time that may not have been easy for him. I concur with what other Members have said about the memory of his father and about seeing whether there is anything we can do to help the many people—our constituents and their families—who are going through such pain. I also thank him for doing the research on comparative examples to let us know that what we are experiencing is not normal.

Delays in death certificates cause huge disruption and pain to those coping with the death of a loved one. We must not underestimate the problems that the delays at the West London coroner’s court have caused, especially for those planning religious burials, as has been mentioned. I want to share two examples from casework in my constituency, which illustrate two different aspects of the administrative problems being experienced.

First, a constituent of mine sadly passed away at his home in Chiswick in April this year at the age of 85. He had not seen two doctors in the preceding months, so his body was taken to the mortuary and referred for an autopsy. In order to make arrangements for the funeral, the family rang the coroner’s office to establish timings for the release of his body. They were held in a queue for more than 50 minutes without reply and directed to send an email. Two weeks later, the family were still waiting. They had not received an acknowledgement of the email and no phone calls were answered or returned. They did eventually get an answer, but for 16 days, the family had no idea whether the remains would be subject to autopsy or when the body would be released back to the family. That is a common situation.

Secondly, Cheryl Hounslow is the ex-wife of Raymond, who died and an inquest was needed. Although estranged, she was the next of kin. He died in April 2014, and she waited 15 months for an inquest that only went ahead, so far as I understand, after my intervention. It turned out that the person handling the case had all the files ready to present to the coroner within two months, but for some reason they were not passed on. I understand that the staff member may have left, but the case could have been passed on for inquest in June 2014. Every organisation should have a procedure for what happens when staff leave, and files should not disappear when someone leaves an organisation. Cheryl could not get through on the phone and got no response to five emails. It was only when my staff got involved that the case was looked at again. In fairness, when the coroner found out that the paperwork had not been passed on, he expedited the hearing and allowed Cheryl to choose the date of the inquest. He blamed the local authority and the Met police for the poor customer service. With that inquest being brought forward quickly, it will have meant someone else waiting longer.

In any organisation, someone somewhere must be responsible for performance standards. I spent 25 years in local government, and we had systems, processes and accountability. That seems not to be the case in this example. The coroner is a public service that people need when they are at their most vulnerable. I hope that the Minister can respond with a plan of action for us and our constituents.

--- Later in debate ---

[Caroline Dinenage]

I am grateful to the hon. Gentleman for bringing that to my attention. I am absolutely clear that the needs of bereaved people should be at the very centre of all coroners’ services. That was supposed to be the main aim of the coroner reforms that we implemented in July 2013.

The West London coroner’s office in Fulham is very busy. It covers a large geographical area, as we know. In 2014 the office received 3,437 reports of deaths and 383 inquests were held. However, that is no excuse for poor, inefficient, rude and insensitive services, or, in some cases, a lack of communication, particularly at such a difficult time when people are grieving. My hon. Friend the Member for Kingston and Surbiton is not the only Member whose constituents have been unhappy with the level of service they have received from the West London coroner’s office, particularly with regard to the responsiveness of the office. Several Members have written to me detailing individual cases of constituents who have encountered delays, lack of engagement and rudeness from the coroner’s office, and other Members have raised that today.

My officials and the Chief Coroner’s office have also been alerted to problems. These include bereaved families not being able to access death certificates in a timely manner; delays in holding inquests, which is particularly stressful for bereaved families when they are already going through a very upsetting time; and not having staff at the end of the phone to deal with queries and concerns when they are needed. I understand that a number of complaints have also been lodged with the London Borough of Hammersmith and Fulham and that my hon. Friend the Member for Kingston and Surbiton has written to the council’s chief executive on this matter as well.

Earlier this year, the Chief Coroner went to Fulham to visit the senior coroner and his staff. Along with him were representatives from the local authority, which provides the funding and infrastructure for the local coroner service, and also representatives from the Metropolitan police, which provide the coroner’s officers, who are the front-line staff who deal with bereaved people. The senior coroner, the local authority and the police all have a role to play in improving the service. They discussed the issues together and looked at ways to resolve them, and an action plan was agreed. I am pleased to note that, as a result, we are beginning to see signs of a more positive picture emerging from west London. The office has reached its full complement of administrative and investigative staff, including a coroner’s officer manager and six new coroner’s officers. There is now a new way of managing the telephone system so that administrative officers deal with all phone calls in the first instance to relieve the burden on the coroner’s officers, thereby allowing them to focus on progressing cases. However, I take on board the recent instances that the hon. Member for Ealing North has raised about his own experiences with the telephone service. I have made a note of them and my officials will certainly deal with that, because that is not acceptable.

Members will be pleased to hear that west London has now reduced the backlog that it inherited. The senior coroner inherited 400 outstanding inquests when he took up post. That has now been reduced to 70 cases and it is anticipated that these final historic cases will be cleared by the end of February, which will allow staff to focus fully on new cases. The senior coroner has attempted to clear the backlog by making sure there are two courts running in parallel with his assistant coroners hearing cases alongside him.

As the Minister with the coroners portfolio, I share the wish of all Members in the Chamber to resolve matters as quickly as possible. As they have already articulated, the process is not straightforward. The Ministry of Justice has overall responsibility for coroner policy and law, but the responsibility for the delivery and funding of coroner services is a local matter for the appropriate local authority, in this case the London Borough of Hammersmith and Fulham. It is for it to decide how to run and fund the coroner services.

[Ruth Cadbury]

The Minister has outlined where the funding lies and where responsibility for the overall policy and strategy lie. Where does overall responsibility for the monitoring and reporting of performance of coroners’ courts lie?

[Caroline Dinenage]

That would lie with the coroners themselves and with the Chief Coroner, whose post was created in 2012. We now have a Chief Coroner who is responsible for overseeing all such matters, but where there are cases that need to be investigated, it is up to the Judicial Conduct Investigations Office. It is currently investigating the conduct of the West London senior coroner, including the case that the hon. Member for Ealing North referred to earlier. That case has been transferred to the inner west London coroner, Dr Fiona Wilcox, who will now be dealing with it. In cases where performance has not been as expected, it is up to the JCIO to carry out investigations.

[Ruth Cadbury]

The Minister referred to standards. Is there a set of standards for how coroners have to deal with cases? What are the measures against which we know that delivery is getting better or worse, or is adequate, satisfactory or inadequate?

[Caroline Dinenage]

That was all included in the coroner reforms. If the hon. Lady gives me just a little time, I am about to talk about them.

As I said earlier, bereaved people must be at the heart of the coroner service, and that was the key aim of the reforms in the Coroners and Justice Act 2009. The coalition Government implemented those reforms, including the rules and regulations that underpin the Act. The provisions came into force in July 2013 and introduced the role of the Chief Coroner. In September 2012, his honour Judge Peter Thornton QC was appointed as the first Chief Coroner. He has already played a central role in providing guidance for coroners on the new national standards for coroners set out in the legislation. Coroners are now required, for example, to conclude an inquest within six months of a death being reported to them, or as soon as practicable afterwards. They are also required to report coroner investigations that last more than 12 months to the Chief Coroner, who is in turn required to report on that to the Lord Chancellor and to Parliament in his annual report.

For bereaved people and families, the most significant development under the 2009 Act was perhaps the “Guide to Coroner Services” booklet, a document published by the Ministry of Justice that sets out the standards of service that people can expect from coroners’ offices and what they can do if they feel that those standards are not being met. It is vital not only that coroners know what the standards are, but that bereaved people understand how a coroner’s investigation is likely to proceed. The guide is accompanied by a shorter leaflet that sets out the key aspects of an investigation. We have sent hard copies of the guide and the leaflet to every coroner’s office in England and Wales so that they can be given to every bereaved person or family. The guide is also available on the gov.uk website.