Henry Bellingham (Shadow Minister, Justice; North West Norfolk, Conservative)

I beg to move amendment 360, in clause 18, page 9, line 23, at beginning insert ‘The Chief Coroner in consultation with’.

Roger Gale (North Thanet, Conservative)

With this it will be convenient to discuss the following: amendment 116, in clause 18, page 9, line 23, after ‘Wales)’, insert

‘, after consulting the local senior coroner,’.

Amendment 361, in clause 18, page 9, line 26, leave out ‘Each Trust or Board’ and insert ‘The Chief Coroner’.

Henry Bellingham (Shadow Minister, Justice; North West Norfolk, Conservative)

This very important clause introduces the new post of medical examiner. That post is very important indeed to the future of the coronial service. It is a crucial part of the new set of checks and balances, especially in this post-Shipman era. Dame Janet Smith’s 600-page report on the Shipman tragedy strongly recommended that a new post of medical examiner be introduced.

Resources are an issue. Touching briefly on subsection (2)(a), the explanatory notes state that primary care trusts and local health boards must

“appoint enough medical examiners, and make available enough funds and other resources (including medical examiner’s officers) to enable the medical examiners to discharge their functions”

correctly, properly and efficiently. What sanctions there will be on the Department of Health in the event of  failure to meet those commitments, and what discussions has the Minister had with her counterparts in the Department of Health?

That is an important preliminary point, but the key issue is the independence of medical examiners. It is wrong that medical examiners will be appointed by the PCTs and LHBs. Amendments 360 and 361 would make a small but significant change so that the chief coroner would appoint a medical examiner in consultation with the PCTs and LHBs. It is an important change that should be made because it is vital that such an important post remains independent of the local health service.

Let me quote the Law Society briefing that was sent to members of the Committee. The Law Society wanted to delete the whole of subsection (5) and to put in extra safeguards, but I think that our alternative offers a neater way forward. The Law Society says:

“The new position of medical examiner is intended as the bridge between the health services and the coroner service. However as the employee of the Primary Care Trust or Local Health Board, the medical examiner would be acting as the filter for the death certificates provided by colleagues in the health service. In that case he is likely to trust the judgement of fellow medical professionals. There could also be pressure from his employer, and the Law Society believes there needs to be stronger checks.”

I would not say that there is a danger that the professional integrity of medical could be compromised if they were appointed by the PCTs, who would also be their employers—I do not accept that. However, I do believe that the very simple extra safeguard makes a great deal of sense.

The Minister may be a bit battered and bruised from her recent encounter on the “Today” programme, when she was interviewed alongside Dame Janet Smith. I thought that the Minister was her usual courageous self.

Bridget Prentice (Parliamentary Under-Secretary, Ministry of Justice; Lewisham East, Labour)

It wasn’t me.

Henry Bellingham (Shadow Minister, Justice; North West Norfolk, Conservative)

Well, a Minister was interviewed alongside Dame Janet Smith, the editor of the Shipman report. Dame Janet made it clear that she was very concerned and unhappy about the post of medical examiner not being independent enough. Although she welcomes the appointment of medical examiners and feels that it is an important part of moving on from the post-Shipman era and using the Bill to update the service, her criticism of the clause was founded on her view that that medical examiners must be independent. Our clause, and its consequential amendment, achieve that aim.

Jennifer Willott (Cardiff Central, Liberal Democrat)

Amendment 116, which is in my name and that of my hon. Friend the Member for Cambridge, is trying to achieve a similar aim to that just highlighted by the hon. Member for North-West Norfolk. We share his concerns about the independence of the NHS medical examiner, but we are also looking at the link between senior coroners and medical examiners in their local area.

One of the most important things, which was flagged up by the Coroners Society in its evidence to the Committee, is that by taking away the right for the coroner to be medically trained, so that now they will be only legally  trained, a number of coroners feel that it is important that they have that easy access to medical advice. We all welcome the creation of the post of medical examiner—it is clearly important. However, because of the importance of the link between the coroners and the medical examiner, it is important that they work closely together—preferably co-located—and have a strong local link.

Our amendment reinforces that local link by ensuring that, before someone is recruited as a medical examiner for a particular area, the local senior coroner has to be consulted so that they have some sort of say in the recruitment. We can then ensure that that working relationship is built into the system. My concern about the amendment tabled by the hon. Member for North-West Norfolk is that it removes the local ink entirely by giving the recruitment of the medical examiners to the chief coroner.

Henry Bellingham (Shadow Minister, Justice; North West Norfolk, Conservative)

“In consultation with”.

Jennifer Willott (Cardiff Central, Liberal Democrat)

Yes. “In consultation with” the local health board and the PCT. It does the opposite of what our amendment does, which is getting the local senior coroner involved in the recruitment rather than taking it to the level above. It is the local link that will be crucial.

As the hon. Gentleman said, there will be an important role for the medical examiners in improving the death certification process and ensuring that we do not have any recurrence of the Shipman scenario. However, the link between the coroners and the medical examiners is a key omission from the Bill. That issue was also raised by the Justice Committee, which was concerned that that aspect was not sufficiently highlighted. Will the Minister ensure that the local link between the two services is in the Bill?

The hon. Gentleman also raised the independence of medical examiners, which, as he said, has been flagged up by the Law Society. However, it is quite telling that the Medical Protection Society, which represents the interests of doctors, is also deeply concerned about the matter. People from both sides are concerned about whether this ensures enough independence for medical examiners. There have been some instances where coroners have found that their link to the local authority has been problematic when a local authority has been implicated in some way in a death that the coroner is looking into. However, that is rare—much more rare than it would be with the medical examiner and the local NHS, as the NHS is much more often involved in cases that come before the coroner’s court. This issue needs to be looked into as concerns have been raised by a wide range of people.

There is potential in the Bill’s drafting for medical examiners to feel isolated within the system. If their funding depends entirely on the local primary care trust or health board and they are not properly tied in with the local coroners system, they could be isolated in difficult cases and struggle with funding. Will the Minister respond to that?

As a Welsh Member of Parliament, like the right hon. Member for Cardiff, South and Penarth, I understand that local health boards will no longer exist—[Interruption.] Sorry; and the hon. Member for Wrexham. I understand  that local health boards will no longer exist by the time the Bill becomes law. I am not sure whether that needs to be flagged up.

Bridget Prentice (Parliamentary Under-Secretary, Ministry of Justice; Lewisham East, Labour)

Now that we know how many Welsh Members we have in the Committee, we will proceed. This is an important debate about the independence of medical examiners. They will be appointed by the primary care trusts and local health boards for the very reason—I hope that this answers the hon. Lady’s final concern—that they will then be closely involved with clinical governance teams and establish whether patterns or clusters of deaths, for example, give any cause for concern. They will therefore be able to improve medical provision locally. However, clearly, they will also have to work closely with coroners, not least because of the important role they will play in providing coroners with general medical advice.

The Department of Health has made it clear in its response to the public consultation on improving the process of death certification that primary care trusts and local health boards will involve the local coroner in their arrangements for the appointment of the medical examiner. Therefore, I do not think that we need to put that provision into the Bill, as amendment 116 would do.

On amendments 360 and 361, I agree absolutely that medical examiners need clear lines of accountability, but I am not persuaded that the amendments’ approach is necessarily the correct one. I do not think that it is appropriate for the chief coroner to be directly involved in the appointment, resourcing or monitoring of medical examiners, but I see the role of the new national medical adviser to the chief coroner as the important bridge between the two. He or she will agree the national job description for medical examiners as well as the protocol setting out the minimum level of scrutiny that medical examiners must complete. The national medical adviser will also contribute to the development of training for medical examiners and have a role in the resolution of any disputes that arise between medical examiners and coroners.

The provision of the medical examiner service against clear standards of service provision will be part of the process of auditing primary care trusts and will be carried out by the Healthcare Commission. I was a little concerned by the comments of the hon. Member for North-West Norfolk about the way that the medical adviser should be appointed. His hon. Friend the Member for South Cambridgeshire (Mr. Lansley) said in a Westminster Hall debate:

“I have seen that Ministers wish to embed medical examiners in primary care trusts. I think that that is the right thing to do, as it will put medical examiners in a position where they can link their role into performance management of primary care providers and commissioners.”—[Official Report, Westminster Hall, 21 June 2007; Vol. 461, c. 534WH.]

That is exactly the right way forward. We believe that it is vital that the public are confident that the examiners will be able to carry out independent scrutiny. The Bill provides for that in two ways. First, we specify that primary care trusts in England and local health boards in Wales can have no role in how the examiners exercise their professional judgment as medical practitioners. Secondly, we are enabling regulations to specify what is required to demonstrate independence.

We expect that the requirements will include the definition and two important protocols. First, a national  protocol will be prepared in consultation with the coroners, the royal medical colleges, the British Medical Association and others setting out the minimum level of scrutiny that must be completed for different combinations of care setting, stated cause of death and circumstance. Secondly, a local protocol agreed by the PCT in consultation with the senior coroner for the area will determine the minimum distance between the medical examiner and a death that he or she is allowed to scrutinise. Distance in that context could refer to the nature of any personal, professional or fiduciary relationship that the examiner and the deceased person might have or the attending doctor or the consultant for whom a hospital-based attending doctor works. The appropriate distance has to be a local matter to reflect the different configuration of the NHS in each community.

Finally, it does not follow that the chief coroner should be head of the medical examiner service. It is the job of coroners—and therefore the chief coroner—to focus on violent or unnatural deaths and deaths of unknown causes that occur in custody or other state detention. That amounts to 115,000 or so deaths each year where a post mortem is carried out rather than the 350,000 deaths that require no further action. I am not saying that there is not scope for further clarification of the accountability and leadership arrangements for medical examiners at a national level. The Department of Health is actively looking at such matters in the context of the health service, and I hope that by the time we discuss the Bill on Report—certainly while the Bill is undergoing its parliamentary process—I can provide further detail on what the Department of Health envisages in that context. In the meantime, I ask Opposition Members to withdraw the amendment.

Henry Bellingham (Shadow Minister, Justice; North West Norfolk, Conservative)

I am grateful to the Minister for her explanation of the clause, but I am not satisfied. We are discussing an important part of the Bill and it is essential to have extra safeguards in place. The hon. Lady quoted my hon. Friend the shadow Health Secretary who was talking about how medical examiners would operate on a day-to-day basis, not about their appointment. My argument is that, of course, they will be part of the PCT and will be playing an essential role on a day-to-day basis, working alongside other doctors within the PCT and the local health boards. However, their actual appointment does need to be one stage removed. I am sorry that the Minister cannot go along with us on that, so I shall press amendment 360 to a Division.

Jennifer Willott (Cardiff Central, Liberal Democrat)

I beg to move amendment 115, in clause 18, page 9, line 29, at end insert

‘to the minimum standards as laid down for time to time by the National Medical Adviser to the Chief Coroner,’.

Roger Gale (North Thanet, Conservative)

With this it will be convenient to discuss the following: New clause 14—National medical adviser to the chief coroner

‘(1) The Secretary of State for Health may appoint a person as the National Medical Adviser to the Chief Coroner.

(2) The Secretary of State for Health must consult the Lord Chancellor and the Lord Chief Justice before making an appointment under this section.’.

New clause 15—Regulations about training (medical examiners)

‘(1) The National Medical Adviser to the Chief Coroner, after consulting the Chief Coroner, may, with the consent of the Secretary of State, make regulations about the training of—

(a) medical examiners;

(b) medical examiners’ officers and other staff assisting persons within paragraph (a).

(2) The regulations may (in particular) makes provisions as to—

(a) the kind of training to be undertaken;

(b) the amount of training to be undertaken;

(c) the frequency with which it is to be undertaken.’.

New clause 16—Regulations about standards (medical examiners)

‘The National Medical Adviser to the Chief Coroner, after consulting the Chief Coroner, may, with the consent of the Secretary of State, publish minimum standards relating to the service to be provided by medical examiners.’.

Jennifer Willott (Cardiff Central, Liberal Democrat)

The amendment and group of new clauses relate specifically to the establishment of a national medical adviser to the chief coroner. The Minister referred to such an appointment in her response to the previous group of amendments, but our proposals would establish a national medical adviser to the chief coroner so that the system of the chief coroner and senior coroners in local areas would be paralleled by a national medical adviser to the chief coroner and a series of medical examiners throughout the country. The two operations would run in parallel.

The establishment of the chief coroner is placed in statute, as are the medical examiners, so I am unclear why the role of a national medical adviser to the chief coroner is the only part of the jigsaw puzzle not in the Bill. In its evidence to the Committee, the Royal Society of Pathologists made it plain that it had been speaking to the Department and was of the understanding that the post would be established. It is clearly worried that it is not mentioned in the Bill, and that the position is not made clear.

Jennifer Willott (Cardiff Central, Liberal Democrat)

Why the national medical adviser to the chief coroner is the only role not in the Bill is unclear. The role is critical to how the new system will operate. The amendments and, particularly, the new  clauses that we have tabled would establish the post of a national medical adviser and enable the adviser, in consultation with the chief coroner and the Secretary of State, to make regulations around training, staffing levels, service provision and so on that would be expected of the medical advisers, laying out the minimum standards expected of medical examiners and requiring the local PCTs and health boards to fund that minimum level of standards.

The proposed provisions would ensure that training and basic minimum standards were common across the whole of the United Kingdom, tackling some of the problems that the coroner system has experienced up to now—as discussed, the widely varying levels of expenditure, support and what is expected of the system from the local authorities. Establishing the role of national medical adviser, with the power to make regulations regarding those minimum standards, would at least establish medical examiners and ensure that they are not starting out with the handicap that coroners have been experiencing. Given that, all members of the Committee recognise that there are a number of challenges for coroners based on the unevenness of funding and support across the country. It seems a shame to set out a new structure that does not get around some of the difficulties right from the start. The chief coroner will clearly have an important role in managing and ensuring consistency across the country for senior, area and assistant coroners in the various regions. It is critical that the establishment of the medical examiner system should have a similar central figurehead and organisation that is able to ensure the consistency of funding, standards and training across the UK, in parallel with the chief coroner.

It has also been highlighted that, in the same way as medical examiners will be important as a source of advice and support for senior coroners in their local area, the chief coroner will similarly need central medical advice to enable them to fulfil their role in operating the coronial system successfully across the UK as a whole. I would be grateful if the Minister explained why that is the one role not in the Bill, given that it is such a fundamental part of how the system will operate. It seems a strange omission.

Bridget Prentice (Parliamentary Under-Secretary, Ministry of Justice; Lewisham East, Labour)

I understand the hon. Lady’s concerns about the leadership of the medical examiner service, but I do not believe it necessary to have the medical examiner role in the Bill as she has described. That is partly because of what I said in the previous debate about the role of the chief coroner being solely responsible for violent or unnatural deaths, or for deaths from an unknown cause or during state detention and so on. The chief coroner and the senior coroner will not have jurisdiction over natural deaths, so the remit of the medical adviser to the chief coroner ought not to stray into the generality of deaths, except to the extent that I described.

On several occasions, the hon. Lady said that the national medical adviser’s job is the only one not included in the Bill, but other jobs relating to the chief coroner are not covered, including the legal adviser and some of the training specialists. I would be very concerned by the idea that the chief medical adviser should have a role in setting the regulations and I would not want to look at that at the moment.

The Department of Health will be introducing secondary legislation, as set out in the clauses on death certification, and the role of the national medical adviser in relation to medical examiners will be better defined in that legislation. Our intention is that the national medical adviser will be involved in agreeing protocols on the levels of scrutiny that medical examiners must complete and how medical examiners will interact with coroners, as well as agreeing job descriptions and being consulted on the curriculum for the training that is required. The national medical adviser will also be consulted on disputes that might arise between coroners and medical advisers and on any conflict of views in particular cases.

I ask the hon. Lady not to press her amendments, but if there is a strong feeling in the Committee that the role of the national medical adviser should be included in the Bill, I will certainly consider the issue to see whether it would be appropriate to return to it at a later stage. However, the national medical adviser’s position does not need to be statutory, and many others in similar circumstances are not. That is why the national medical adviser is not included in the Bill at the moment, but I will not set my face against including them later.

Jennifer Willott (Cardiff Central, Liberal Democrat)

The Minister’s comments about the difference between the role of coroners and the remit of the national medical adviser in terms of deaths that are investigated could easily be clarified in the Bill or in regulations. The remit of medical examiners will clearly be significantly broader than that of coroners, but both are included in the Bill, so there is no reason why the national medical adviser could not also be in the Bill. The issue could be clarified in regulations or in whatever way the Minister chooses.

On the regulations, I must confess that I am somewhat bewildered. The chief coroner is to have the ability to lay out training requirements and minimum standards in regulations, and I do not understand why there should be a difference between the chief coroner’s powers and the national medical adviser’s powers in that respect. Both have a similar role in overseeing the two parallel parts of the system, and it is somewhat lop-sided for the chief coroner to have powers in one area, when the national medical adviser does not have similar powers.

One of the big issues with the coroners system over the past few decades has been the lack of consistency. One issue flagged up by a number of the witnesses who gave evidence to the Committee was the welcome for an overseeing body in the form of the chief coroner, who would be able to ensure some consistency. It would be a missed opportunity, in setting up the medical examiners system, if we did not ensure that we had a similar central body to ensure consistency across the UK.

However, given the Minister’s comments about the ongoing discussions with the Department of Health and the fact that things are still being developed, I am happy not to press the provisions, although I hope that the Minister will come back to us on Report with some progress. If not, we may press the matter to a Division. I beg to ask leave to withdraw the amendment.