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

I beg to move amendment 359, in clause 19, page 10, line 43, at end insert—

‘(ca) provision allowing any medical practitioner to notify the coroner of any concern over the circumstances in which a person has died;’.

Roger Gale (North Thanet, Conservative)

With this it will be convenient to discuss amendment 104, in clause 19, page 11, line 3, at end insert

‘, including an investigation into the drugs the deceased had been taking prior to his or her death;’.

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

The purpose of the amendment is to ensure that all medical practitioners have the right to report their concerns over the death of a patient to the coroner, which would be an extra safeguard in the post-Shipman era. The draft charter for the bereaved entitles the relatives of a deceased person to report their concerns over the circumstances of the death to the coroner. There needs to be a similar right for medical practitioners to convey their concerns to the coroner. As framed, the reporting mechanism to the coroner under the Bill is confined to the attending doctor and the medical examiner. There must be a provision to enable other practitioners, such as nurses or other medical attendants, to make reports about their concerns regarding the death of a patient to the coroner. That is what our amendment is about, and I hope that the Minister will look at it sympathetically and take on board what we have said.

I trouble the Committee briefly with two other concerns that I have on the death certificating process, in particular, death certificates. I raise the case of Doreen Morris, which has been brought to my attention by two local MPs who are concerned with her case—my hon. Friend the Member for Clwyd, West (Mr. Jones) and my hon. and learned Friend the Member for Beaconsfield (Mr. Grieve). Doreen Morris was discovered dead in a badly burnt-out shell of a house, and her body had been totally incinerated. The pathologists could not give a precise cause of death because the body was too badly burnt, but there was a need for the body to be released for burial, which happened about a month after the tragic fire. A suspect was arrested and charged with her murder in the following month. In July, an inquest was opened, but it was adjourned because criminal proceedings had started. In the mean time, a death certificate was issued, and the cause of death on it was recorded as “not ascertained”. At the trial, the suspect was subsequently acquitted—although Mr. Justice Scott Baker concluded that Mrs. Morris had been brutally murdered, and that she suffered an incredibly cruel and callous killing.

So there is no doubt about the arson, or whether it was an unlawful killing—the only doubt was about the identity of the culprit. The family was very upset indeed; they wanted closure of the tragic case, and the death certificate to be amended to read “unlawful killing”, because that undoubtedly was what happened. They wanted closure, but there was a problem, because the coroner had to adjourn the inquest for obvious reasons.  The certificate that was issued and sent to the registrar could only state that the cause of death as was known as the time, which is why it had to use the words “not ascertained”; it was not possible at that stage to give a medical cause. The coroner decided not to resume the inquest because it was impossible to ascertain exactly how Mrs. Morris was killed—I believe that it is common practice for the coroner not to resume the inquest in such circumstances; but having said that, there was overwhelming evidence of an unlawful killing.

There are two possible courses of action open. The first is for the inquest to be resumed, which the coroner decided not to do. Even if the inquest had been resumed, the outcome would not have been particularly satisfactory, because the only possible way that the coroner could have gone some distance in satisfying the family would have been to place a correction in the margin of the entry—in other words, it would remain that the cause of death was not ascertainable, but in the margin it would read “unlawful killing”. Alternatively, the family could apply to the High Court, with the consent of the Attorney-General, to have the original inquiry quashed, and have the High Court direct the coroner to carry out a new inquest. Getting the support of the Attorney-General and going through the whole process would be incredibly time-consuming and difficult.

In fact, as the Minister knows—someone wrote to her about the case—the Attorney-General examined the case carefully. A letter from the Attorney-General dated 21 October 2008 says that it is for her to determine, based on the material provided, whether it is desirable in the interests of justice that an inquest should be held. She said that in this case, there is no issue over the identity of the deceased or where or when the bereaved person’s mother died, and that the question of how is normally interpreted narrowly to mean the cause of death. She goes on to say that, regrettably, there was no evidence at the time and there remains none as to the exact medical cause of death. She said that, none the less, that does not prevent a coroner from making a finding that the deceased had been unlawfully killed, providing he is satisfied about the matter beyond reasonable doubt. The Attorney-General held out a chink of hope, but decided not to give consent for the family to go to the High Court.

We are not talking about the odd case. I have obtained a copy of the Home Office statistical bulletin, supplementary volume two, on crime in England and Wales 2006-07, dated 31 January 2008. Tables 102, 103 and 109 respectively show that in the 12 years to 2006-07, 1,353 offences initially recorded as homicide currently have no suspect; the apparent method of killing is not known in 477 offences currently recorded as homicide; and 2,228 suspects were indicted for homicide when the outcome of proceedings did not result in a conviction for that offence. Over the 12-year period, there were a total of 4,058 cases in the categories that I extracted from table 102 of the bulletin out of a total of 8,671 cases currently recorded as homicides over the same period. In other words, just less than half current recorded homicides have the potential to give rise to the situation that I am talking about.

The matter is of public interest and concern. I have not tabled an amendment yet, but I reserve the right to  do so on Report. The Minister must look at the matter, which is of great concern to families. It was raised in the evidence-taking sessions at the beginning of the Committee, when I asked AndrÃ(c) Rebello and Professor Furness about changing the death certificate. Professor Furness said:

“In future, the certificate would not be issued until the relatives have had the opportunity to discuss it with the medical examiner. One of the key questions the medical examiner will be expected to put to the relatives is whether anything on the proposed death certificate is a concern.”

The Bill is going some way to sorting out that particular problem. AndrÃ(c) Rebello then said:

“What I would do in those circumstances is hold an inquest after ordering the post mortem and before getting the result. I would then use the result to conclude the inquest, and a new death certificate would supersede the old one.”——[Official Report, Coroners and Justice Public Bill Committee, 3 February 2009; c. 55, Q119.]

That would work if criminal proceedings did not intervene, but it would not work if the inquest were adjourned because of criminal proceedings. I would be grateful if the Minister took a close look at the matter.

I have another concern based on a case that, again, I have had permission to raise from the family involved. Sue Willis wrote to me from Pilton in Somerset. Her husband, John, a reasonably young, incredibly fit and active man, was admitted to hospital on 17 March last year with a suspected inflamed gall bladder. They could not discover what was wrong with John, and his health went downhill rapidly. On his 16th day in hospital, he tragically lost his battle for life. What happened next? Sue Willis wrote:

“I was informed that I was required to register my Husband’s death within a few days. To my surprise I was immediately issued with a death certificate despite the fact that the cause of death had not been established. I asked my Husband’s consultant about this and he informed me that, in such circumstances, it was general practice to put their ‘best guess’ on the death certificate to expedite the funeral arrangements...In our case, their ‘best guess’ turned out to be completely inaccurate. The death certificate stated a heart condition as the main cause of death however the post-mortem revealed it to be a Large B cell Lymphoma. I approached the registrars at Southmead Hospital to request an amended death certificate and was provided with almost the same certificate stating the incorrect cause of death with a small annotation noting the post mortem result”

in a column at the bottom of the certificate.

Sue Willis wrote to her MP and various other people. The Home Office Identity and Passport Service wrote back to her, stating:

“I appreciate that the circumstances surrounding your late-husband’s death have been distressing. As far as the registration is concerned everything has been carried out in accordance with statute. The marginal note at the foot of the registration, which is repeated on any certificates issued, shows that following post-mortem without inquest the cause of death was found to be large B-cell lymphoma.”

That note has been put in the margin, but the certificate puts down the cause of death as the result of a heart attack in hospital.

This is a severe and serious problem that the Minister must address. I appreciate the difficulties regarding death certificates, but I want to ask how often medical practitioners use the best-guess formula. In the future, medical examiners will be appointed, and presumably the chances of best guesses being put on the certificate  will be greatly reduced. A medical examiner will want to look at the matter, investigate it and talk to the family—I am probably making the Minister’s case for her. However, there might still be the odd case where the certificate gives the wrong cause of death, a subsequent post-mortem indicates the exact cause of death and the family are distressed.

Regarding large B-cell lymphoma, what will happen in one or two future generations’ time when the relatives of John want to check medical conditions?

Tim Boswell (Daventry, Conservative)

Does my hon. Friend agree that that matter might be of some concern to an insurance company?

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

That is a very good point. I am thinking perhaps of John’s grandchildren who will certainly want to check their DNA framework and look for any history of medical illness. The first thing that they will do is look at the death certificate and although they might see the note in the margin, they will look primarily at the principal cause of death on the certificate. I hope that the Minister will address that case, which I have been given leave to mention by the family.

I also hope that the Minister will look at the point about death certificates and at the other case involving Doreen Morris, the correspondence that has flowed from that and the cumbersome process that is currently available to a family. Families must persuade the coroner to reopen the inquest, and it would be rare for that to happen when there has been a criminal trial and no new evidence has come to light. Going to the High Court requires the consent of the Attorney-General, and perhaps we could make that process more family-friendly. There could be something in the charter for the bereaved to address that. Either way, the ongoing problem illustrated by those two cases will be carried into the Bill unless something is done.

Tim Boswell (Daventry, Conservative)

Briefly, I am sensitive to the points made eloquently by my hon. Friend. I suspect that there is a wide variation in practice relating to death certificates and the certification of the medical causes of death, not least because those will often be multiple and the hierarchy of the symptoms will not necessarily be clear.

I touched on this point when I intervened on my hon. Friend about insurance. If we are considering systemic illnesses of an occupational or other nature—I use mesothelioma as an example, although not necessarily conclusively—it is important to have full and accurate reporting on a consistent basis, so that we can get an idea about the incidence of such things.

With respect to everyone, the Minister included, I do not think that the Committee is able or medically qualified to systematise everything in terms of medical reporting. However, it is important for us to try to get a better understanding of practice, and I hope that the chief medical examiner will lead on that.

I was amazed by the reticence of my hon. Friend the Member for North-West Norfolk on amendment 359, which I have signed, and I wonder whether it goes far enough. In suspicious circumstances—for shorthand let us call them Shipman-like circumstances—it enables any medical practitioner to notify the coroner of any concern over the circumstances in which a person died. I have revisited that matter, and it occurs to me that that might not cover the full range of people. “Medical  practitioner” could include professions allied to medicine, and perhaps the Minister will comment on that.

Could somebody who cares for, or has regular dealings with, the person, and who has reasons to enter any reservations, make them to the coroner? No doubt it happens from time to time that somebody writes anonymously or from cold to the coroner saying, “I don’t like what I’ve seen”, or “I think I know something about this”, and no doubt they could be called as a witness at the inquest. Some might also have dealings with the police. However, I wonder whether it is possible to extend the very modest terms of the amendment tabled by my hon. Friend the Member for North-West Norfolk, which I support, at least to include circumstances in which somebody else who was close to the patient—a carer, for example—felt that something was wrong.

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

I have no problem with the proposition underpinning the amendment tabled by the hon. Member for North-West Norfolk. If a medical practitioner suspects, or has reason to believe, that a person died a violent or unnatural death, or that the cause of death is uncertain, we would, of course, want the case referred immediately to a coroner for further investigation. However, I suggest to him that his amendment is unnecessary, because under clause 17(1), the

“Lord Chancellor may make regulations requiring a registered medical practitioner, in prescribed cases or circumstances, to notify a senior coroner of a death of which the practitioner is aware.”

Essentially, that covers that same ground as his amendment. Also, it covers the variety of people who could be described as medical practitioners, whether nurses, doctors or so on.

I shall turn briefly to the two cases mentioned by the hon. Gentleman. Medical practitioners can take their concerns to the coroner, as indeed can anyone else, including the family or registrar—I think that that is what the hon. Member for Daventry was alluding to; they would be covered, too. The reformed appeal system will obviously help in at least one of the cases raised by the hon. Member for North-West Norfolk by allowing the family to appeal to the chief coroner to look at the inquest again. Also, as of 1 January this year—I realise that that came after the cases that he has raised—the registration provisions have been amended to allow fresh registration after a coroner’s adjournment for criminal proceedings. Since 1 January, such cases can return to the coroner and be registered.

Clause 19(1)(c) provides for an attending practitioner to issue a fresh certificate if invited to do so by the medical examiner. The cases mentioned by the hon. Gentleman are excellent examples of when that could happen. If he wishes, I shall reconsider those cases—obviously the families concerned need closure, having suffered great loss—to see whether we can do anything to help to rectify their situations in the meantime. I recognise his comments about future generations looking at death certificates for their own health reasons and so on. However, I think that the provisions introduced this year, as well as the appeals system under the new regulations, should ensure that those in such situations will have some form of redress in the future.

Brian Iddon (Bolton South East, Labour)

I want to discuss amendment 104, which would add to subsection (1)(e) the words

“including an investigation into the drugs the deceased had been taking prior to his or her death”.

One of the reasons why we are here today is that Dr. Shipman could write anything on death certificates to hide the truth about the murders that he perpetrated with controlled drugs, which were readily available to him. Dame Janet Smith has written extensively on that. Since her report came out, controls have been tightened on the storage and prescription of drugs such as heroin and morphine.

However, I am still concerned about doctors writing death certificates without investigating the cause of death adequately. I therefore strongly welcome the fact that medical examiners will undertake that duty. It is my understanding from the Bill and the explanatory notes that the medical examiner will not only examine the medical notes and perhaps talk to some of the medical staff, but talk to the family, relatives and friends to get to the bottom of what caused a person’s death.

My amendment refers not only to prescription-only medicines but to over-the-counter medicines, controlled drugs available on the street and, indeed, alcohol and other substances, all of which can play an important role in a person’s death. Anecdotal stories have come to me in my role as chairman of the all-party parliamentary group on drugs misuse, such as that if a heroin addict is found in the street—not all, but most people sleeping rough take drugs of one kind or another—the real cause of death will probably be ascertained and recorded properly on the death certificate as an overdose of heroin. However, if a person in a rather well-to-do household has become a heroin addict, their parents may not want heroin addiction appearing anywhere on the death certificate, and respiratory depression or anything else might appear instead, in which case we cannot get to the root cause of the death of all people.

Not all drugs, of course, come out of a pharmacy. People buy them on the street, where they are often contaminated. Some heroin is purer than other heroin. I also refer to internet sale, which is becoming a bigger nuisance than ever. Some 10 per cent. of all medicines obtained on the internet are counterfeit, so people who take them do not have a clue what they are taking—it might be Viagra, but it could be anything else. The same applies to medicines available from certain pharmacies on the internet. I am not saying that all internet pharmacies are bad. Some are highly regulated, particularly in Britain, but if a person has been abroad, it is certainly another story.

In care settings, it is not unknown—in fact, there have been several cases—for medical staff, including nurses, to overdose patients—generally older patients or patients who are vulnerable in some other way—with medicines. That has happened in hospitals and residential homes, as right hon. and hon. Members know. I am therefore pleased that the medical examiners will be able to talk to people and perhaps ascertain the real cause of death.

There are other reasons why I am interested in proper medical certificates and an investigation into the drugs that a person may have been taking immediately or perhaps some time before their death. One of them is that the national programme on substance abuse deaths, which is based in the centre for addiction studies at St. George’s hospital medical school here in London, has been collecting and publishing data on drug-related  deaths for several years now from all the coroners’ jurisdictions across Britain. I have a copy of one of those reports, “Drug-related deaths as reported by coroners in England and Wales”.

Those reports are extremely useful to the national treatment agency and to others involved in the misuse of drugs—they are interesting to me—because they show the rapidly changing scene in the illicit drug market. Perhaps Peterborough is a hot spot today; next year it may be Blackpool. The reports show which towns and cities across England and Wales have the greatest drug misuse problems by recording such information. However, it was difficult for St. George’s hospital to start collecting the material, partly because coroners did not originally comply with requests, although that has now been overcome, but mainly because the death certificates have not always been accurate, as I have already explained.

The second reason why it is important to know the real cause of death and whether drugs, illicit or otherwise, were involved—that is often difficult to get to the bottom of, because such activities can be covert, as I shall explain—is that epidemiologists look at death certificates as well, and they, too, are interested in trends of why people are dying and what is causing those deaths.

Tim Boswell (Daventry, Conservative)

I want to reinforce the hon. Gentleman’s comment by reporting some correspondence that I received this weekend from a constituent who is concerned about ketamine abuse—the first time that I had ever heard of the phenomenon. Ketamine is a class C drug, and my constituent has asked me to make representations to the Home Office about that. My constituent makes the point that the use of ketamine is now prevalent in, for example, my market towns and, in terms of her daughter’s health, it is extremely damaging. I suspect that if, sadly, her daughter were to lose her life as a result, it would be so diffuse and difficult to pin down ketamine as the underlying cause of the medical presentation and cause of death that it would probably never be picked up by anyone.

Brian Iddon (Bolton South East, Labour)

I accept that it is often difficult to get to the bottom of the real cause of death.

As I have said, I am chairman of the all-party parliamentary drugs misuse group, which has just published an interesting report on physical dependence and/or addiction to over-the-counter medicines, which one can buy by walking into a chemist’s shop, and to prescription drugs. The main body of evidence concerns benzodiazepine misuse. However, let me stick to codeine-based products, which are the commonest that can be bought in a shop—some of them have “plus” or “extra” at the end of their names and are vigorously advertised on television.

In the evidence that we have collected, we have come across patients taking between 30 and 70 analgesic or anti-inflammatory tablets. I do not want to mention any brand names, but they are in our report. A lot of the substances are co-medications, by which I mean codeine at a fairly high dose level—12.5 mg per tablet, which is higher than the normal dose in other products—is co-medicated with other medicines such as ibuprofen. The United Nations international narcotics board has already highlighted in its reports that the misuse of over-the-counter and prescription medicines is now  exceeding the abuse of controlled drugs, such as heroin, cocaine and the others, which is a remarkable statement. When the United Nations say that, it is getting serious.

The United Nations also says that, by taking enough codeine, the same buzz can be obtained legally, at a much cheaper price than buying heroin illegally on the street. However, the problem is that quite a lot of tablets have to be taken to get that buzz. If taking ibuprofen at the same time, the inevitability is that someone will suffer serious gastro-intestinal bleeding leading to death. Unfortunately, such activities are covert. The wife in a family may be doing that, unknown to children and husband, and they may suddenly die at quite a young age. It is important that we look into those problems in more detail than ever before.

I also want to mention poly-drug use. Let us say that someone is taking cocaine at the same time as drinking considerable volumes of alcohol. They may be on other substances as well, which complicates the issue even further. However, just cocaine and alcohol will produce a very toxic material called cocaethylene. If no one asks whether the person was drinking alcohol or what they were doing in the night or week before they died, those problems may not be picked up by doctors, the medical examiner or the coroners.

The analysis of drugs is very easy. It need not even be intrusive. One can cut off a piece of a person’s hair, subject it to a chemical process called mass spectrometry and readily find out which drugs are in that sample of hair. One can go further, of course, and use body fluids such as blood.

The Samaritans has sent a second document to the Committee picking up that problem:

“Some relatively important items are often not recorded, e.g. contact with psychiatric services, date of last contact with GP, blood levels for drug overdoses, source of drugs taken in overdoses”

and so on. It strongly recommends

“the development of further measures which could improve the development of data collection for the purpose of informing research and strengthening suicide prevention strategies.”

I look forward to hearing what my hon. Friend the Minister has to say in response to the amendment.

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

It is with trepidation that I rise to speak following my hon. Friend, who has given the Committee very detailed information on some of the serious problems that people around the country have in taking medication, whether legal or otherwise. I commend what he and his all-party group do in highlighting those problems and not only raising them in this debate but bringing them to the attention of the wider public.

My hon. Friend the Member for Bolton, South-East is right that the information included by the attending practitioners on medical certificates of cause of death is an important source of data for a number of organisations, partly because it will give us more information about mortality rates generally associated with particular diseases, but also because it will be invaluable to people such as clinicians, to those responsible for planning and managing health services, to the general population—not just the relatives of those who have died, but those who could be at risk of specific diseases—and to people such as my hon. Friend and the all-party group, who can then do further research in these areas in order to help to persuade the Government on how best to tackle those problems.

The introduction of scrutiny of the cause of death by medical examiners will, I believe, lead to a significant improvement in the quantity, quality and consistency of the data on the death certificate. The inquiries undertaken by medical examiners when they are undertaking medical scrutiny will reflect different combinations of care setting, stated cause of death and circumstance, which my hon. Friend the Member for Bolton, South-East has referred to. That will include discussions about the medical history and other relevant information, such as what the person had been doing, who they had been associating with and so on, including any medication that they had taken before death. It would not be appropriate, therefore, to highlight any single element of those inquiries in the Bill.

I hope that I can reassure my hon. Friend by saying that if a death has resulted from the misuse of drugs or illicit drug use, it would almost certainly be reportable to a coroner, in which case the coroner could obviously call for a post-mortem. Then the coroner, not the medical examiner, would ensure that all the conditions and events that contributed to the death are properly recorded. The medical examiner, of course, could recommend to the coroner the types of examinations, such as a full toxicology report to establish the substances in the body. I hope that the Bill, which gives both medical examiners and coroners the power to investigate further on a much wider spectrum, will give my hon. Friend some reassurance.

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

I am grateful for the Minister’s response. I look forward to hearing from her in writing about the two tragic cases that I mentioned, and I commend her on the way in which she responded to them. The Bill will go a long way to sorting out some of the problems that have arisen, although it might not solve the immediate problems faced by the families. Hopefully, she will consider my comments and will come back to me with some ideas on how to address the situation. I beg to ask leave to withdraw the amendment.