The Coroner Service

Tim Loughton Excerpts

Thursday 28th October 2021 Westminster Hall

[Tim Loughton (East Worthing and Shoreham) (Con)]

I am grateful for your intervention, Sir George. I do not have a lot to say, but I want to raise two specific issues, which have both been alluded to by the previous contributors. I congratulate my hon. Friend the Member for Bromley and Chislehurst (Sir Robert Neill) and the Justice Committee on a comprehensive, timely and necessary report.

The two issues that I want to raise are coroners’ investigations into stillbirths—the subject of my private Member’s Bill—and the Shoreham air show crash. To start with the latter, I am sure that colleagues will remember that fateful day in August 2015 when at the Shoreham air show, which had been running for some 28 years, raising large amounts of money and providing a great spectacle in aid of the Royal Air Force charities, a Hawker Hunter jet crashed and 11 innocent bystanders on the ground tragically lost their lives. It was the deadliest air show accident since the Farnborough air show crash in 1952, so that activity has an extraordinary safety record over those many years.

An interim report on the crash was first produced in September 2015 by the air accidents investigation branch. A second report was produced in December 2015, and a third in March 2016. In January 2017, the Civil Aviation Authority accepted all the recommendations. In March 2017, a final report identified pilot error, and in December 2019 there was a supplementary report to the final reports from the AAIB. There was also a prosecution, and the court acquitted the pilot in March 2019. A lot has been written about the tragedy.

The only thing that has not happened is the coroner’s inquest. Six years, two months and six days on from that fateful tragedy on 22 August 2015, the families of the 11 men who lost their lives have still not have the closure that a coroner’s inquest could help to bring. That is made worse by the fact that, in the end, nobody was convicted of any fault. I make no comment about the trial that took place, but it certainly did not answer the questions those families still have. They have had to go through the trauma of not really getting to the bottom of what really happened on that day and not getting the answers that a coroner’s inquest could bring.

I share some of the misgivings about the way the coroners system is working. It is not very effective in certain cases, and it has not been remotely effective in the case of the Shoreham air show victims. There are all sorts of reasons for that. The relationship between the AAIB, the police and the CAA really needs to be looked at in detail. Giving some form of closure, information and comfort to the families of those who lost their lives must be a priority, yet they seem to come at the back of the queue in such considerations.

Something I was involved in to start with was the question of who was going to represent the families at the inquest. The original inquest opened on 2 September 2015, and was adjourned until March 2016. There were pre-inquest review dates, further pre-inquest review dates were set, and a full hearing was originally due in March 2017. That was delayed and postponed, delayed and postponed, and finally in May 2020, it was announced that the hearing would be postponed again until 2021. We are still waiting, and I hope that it will happen before too long. Throughout all that time, the coroner for West Sussex, Penny Schofield, has played a remarkable role and sought at every juncture to keep engaged with the families and keep them in touch as much as possible.

However, it was not clear whether those families would get legal representation paid for by legal aid at the outset. I hope that is now going to happen. It was estimated that 18 public bodies would be represented at the inquest, all of which would get public funds for legal representation. The only people who would not automatically receive funding for legal representation would be the families of the victims—the most important part of that inquiry, one could say. I share the concerns of the Select Committee and of Members who have spoken today: we must ensure that in tragedies such as this, legal representation is automatically available for the families, and the coroner system has to work more efficiently and effectively, not drag on for many years, as it has in this case.

The second case of “dragging on” I want to raise is that of my private Member’s Bill, the Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019, which was passed by Parliament in February and became law in May of that year. Two of the measures in that Act have now come into practice, the first of which is civil partnerships between opposite-sex couples. The first of those civil partnerships happened on new year’s eve 2019, and they have been taken up by many couples and have been a great success. The second measure, which came into effect earlier this year, is the inclusion of mothers’ details on marriage certificates, a historical anomaly going back to 1837 that I am glad to say this Act corrected.

However, two parts of the Act have not come into effect, the first of which is coroners’ investigations into stillbirths, dealt with in section 4. That clause requires the Secretary of State to

“make arrangements for the preparation of a report on whether, and if so how, the law ought to be changed to enable or require coroners to investigate still-births”,

and states that

“The Secretary of State must publish the report prepared under this section”

and that

“After the report has been published, the Lord Chancellor may by regulations amend Part 1 of the Coroners and Justice Act 2009 (coroners etc) to—

(a) enable or require coroners to conduct investigations into still-births”.

Effectively, due to interpretation of the law, coroners cannot investigate deaths until somebody is deemed to have lived, and a baby who is stillborn is not deemed to have lived and therefore does not fall within the remit of the coroner. However, in some cases in which children have been stillborn, serious questions need to be asked. That is why, after representations from many coroners—including my own—and various baby charities, I included that clause in the Act. It is referenced on page 31 of the Justice Committee’s report, urging the Government to get on with publishing that report.

It is slightly odd that I am once again having to go over the reasons why this provision is so important, because we made the case for the Act in the long time it took to get it through Parliament. It was described as the most complicated and comprehensive private Member’s Bill ever to make the statute book, but it was widely supported in this House by Members from all sides, in the Lords, and by many baby charities. The Select Committee on Health and Social Care also included a reference to the Act in a recent report, and it has been supported by my right hon. Friend the Member for South West Surrey (Jeremy Hunt), the former Health Secretary who is now Chair of that Committee. The reason is that, according to the charity Sands, an estimated 500 babies die or are left severely disabled because of an event during their birth that was either not anticipated or not well managed, and there is currently no independent investigation of those intrapartum deaths. That, again, leaves many questions unanswered for many parents.

There have been many improvements to the way the NHS has been dealing with stillbirths, and the Government are to be congratulated on that. Various investigation measures have been brought in, but none of them are independent. They are all within the NHS. That is why it is still deemed necessary that the coroner, in exceptional circumstances where there are unanswered questions, should have the power to investigate. The Minister was involved in my private Member’s Bill and he was very helpful with and supportive of it, but I ask him, when is the report going to be published?

I had a meeting with the Secretary of State for Digital, Culture, Media and Sport, the right hon. Member for Mid Bedfordshire (Ms Dorries) when she was Health Minister as well as this Minister’s predecessor in the Ministry of Justice, in which it was suggested that various details of the consultation would be published before the summer. However, the Department was loth to go ahead with measures because they were worried about the compulsory inquest by coroners causing trauma to parents. I am afraid I do not accept that; it was parents who were asking for these powers.

I am particularly concerned about the sunset provisions in the 2019 Act. Section 4(6) reads:

“No regulations may be made under this section after the period of five years beginning with the day on which the report is published”.

Time is ticking away. I urge the Minister to investigate where the report is. It was never sent to me, so was it published on the quiet? Can we see the full result of the consultation responses? Will he go away and look at when we can have regulations brought forward, which the vast majority of people have agreed is necessary, so that the third important part of my 2019 Act can come into force? It will give great comfort to many parents who are concerned that they had a stillborn child in circumstances where many questions have not been answered.

In some cases that results in legal action taking place. The provisions in the 2019 Act will cut down on that sort of legal action and hopefully give quicker and more effective answers to those parents who have gone through the traumatic experience of suffering a stillbirth. There are good reasons why the law was passed by the House. I see no good reason why it has not become effective. Can the Minister respond as to when we can expect the good news?