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?

See this speech in context