No one could reasonably say that coroners' courts are not important. When the Harry Stanley inquest said that Mr. Stanley was unlawfully killed, it threw into crisis the whole of the Metropolitan police's armed police response in London. When the coroner in the inquest on Joseph Scholes' death wrote to the Home Secretary requesting a public inquiry, it cast a spotlight on the dangers of suicide when we lock up children in detention. If our system for registration of deaths and coroners' investigations is inadequate, the impact can be severe. To illustrate, I pose this question: could we not have detected sooner the murderous activities of the general practitioner Harold Shipman? I add immediately that the third report of the Shipman inquiry made it clear that it was not the individuals working in the system who were to blame for Dr. Shipman's long run of murdering patients in Hyde, but the system itself.
I asked for this debate precisely because coroners' courts are important. Alongside the registration of deaths, they should provide a reliable system for collecting data on deaths and monitoring trends in deaths. They should provide an adequate investigation into suspicious deaths, to uncover wrongdoing or to provide reassurance as appropriate. They should provide also a thorough and sensitive service for the relatives of those who die suddenly and unexpectedly. Indeed, they should provide advice and guidance to us all on how to prevent avoidable deaths. They should provide the means of dealing with inquiries into mass deaths after major disasters.
The present system does not have the appearance of a modern and effective service able to respond to public concerns over deaths, whether of individuals or of groups, and to command public confidence. Nor does the Government's response to the reports that have exposed the failings of the present system and made recommendations for reform, which I shall come to, suggest that they are giving to the improvement of the system the priority that its importance demands.
In criticising the current state of the system for registering deaths, investigating them and holding inquests, I am not making any adverse judgment on the 120 or so coroners—their number fluctuates, but there are 23 full-timers—and their support staff and investigators. I am sure that most of them are hard-working and dedicated, but they are working with statutory powers and procedures that were established in a different era.
It is my case that there are serious and obvious flaws in the current arrangements, and that those have been drawn repeatedly to the Government's attention, yet the Government have not acted to put them right with the urgency that the situation requires. Action is required at two levels, legislative and administrative. I can understand that securing a slot in the Government's legislative programme may take time, but there is no reason why the urgency of the need for change cannot start to be met by administrative actions straightaway.
I move on to the reports that show the need for reform. I shall call the first one the Luce report, after Mr. Tom Luce, the former head of social care policy in the Department of Health, who chaired the review team for the report called "Death Certification and Investigation in England, Wales and Northern Ireland—The Report of a Fundamental Review 2003", Cm. 5831. At the front of the report is printed the review team's letter to the Home Office, dated
"During the last three-quarters of a century, the Government has twice commissioned reviews of these subjects, in 1936 and 1965. Very little happened in response to their reports. The services are showing the consequences of this neglect."
The first lines of the report read:
"The systems in England, Wales and Northern Ireland for the certification of most deaths by doctors and the investigation of others by coroners have been seriously neglected over many decades. They must undergo radical change if they are to become fit for the purposes of a modern society and capable of meeting future challenges. The need for reform is widely recognised and supported."
I would add to that that there are other high-profile cases that demonstrate the need for an effective system to be in place. I have already mentioned the case of Harold Shipman, whose unlawful killings were counted in hundreds. To that I would add great disasters like the Bowbelle/Marchioness incident, and more recently the rail crashes at Ladbroke Grove and Potters Bar.
In addition to these obvious demands for a modern service there are linked issues demanding a strategic response from a modern coroner system. For example, article 2 of the European convention on human rights is about a state's obligation to protect the lives of its citizens, which the courts have ruled implies an obligation to investigate deaths. There is the White Paper entitled "Civil Registration: Vital Change", and registration changes are happening now. A more weighty inquiry is needed where there are deaths capable of causing serious damage to public confidence—for example, the death of the Government scientist, David Kelly. Perhaps not everyone appreciates this, but the Hutton inquiry into the allegations surrounding the death of David Kelly was also the inquest into his death, thanks to an addition to the Access to Justice Act 1999 that was well secured by my hon. Friend Mr. Dismore.
Most recently, the inquiries into the Shipman deaths provide more evidence for my arguments. The third report surveyed the present state of the coroners service and described coroners' resources as varying widely. It mentioned that some coroners worked from home. It describes a situation in which there is virtually no training, and the training that is available is not compulsory. It says that coroners operate in isolation, and receive little advice or guidance. There is no leadership structure and no reasonable process for complaints and appeals. In fact, a coroner's inquest can be challenged only through judicial review. The Shipman inquiry said that coroners should have consistent quality standards, training, leadership, a wider range of investigative methods and greater powers.
As for handling of the reports in the media, an article in The Guardian on the Luce report carried the headline, "Coroners face big shake-up after 800 years". It said that the report recommended a package of sweeping reforms—bereaved relatives would have much stronger rights at inquest, and coroners would be able to deliver fuller verdicts. It talked about the "forgotten" coroner service, and pointed out that it needed radical change after decades of neglect. My hon. Friend the Under-Secretary of State for the Home Department, Paul Goggins, who will respond to the debate tonight, is quoted as saying:
"The shortcomings in the current system have been increasingly evidenced and it is essential that we build an effective, supportive and transparent system that commands public confidence".
The Guardian began an article on the third report of the Shipman inquiry thus:
"All deaths, including those that do not appear suspicious, must be investigated to ensure that murders such as those committed by Britain's worst serial killer, Harold Shipman, do not go undetected".
Dame Janet Smith, who presided over the inquiry, identified an urgent need for a more focused, professional and consistent approach to coroners' investigations. She said:
"There must be radical reform and a complete break from the past, as to organisation, philosophy, sense of purpose and mode of operation".
In a joint statement, the Home Secretary and the Secretary of State for Health said that work was already under way to identify how best to reform the coroner system.
Eventually, in March this year the Home Office produced a position paper proposing a coherent system based on full-time coroners with legal qualifications, closely supported by appropriate medical expertise, together with tighter rules for death certification, notification of all deaths to coroners and stronger support for scrutinising cases and investigation where necessary. A coroner and burial team was set up. In a news release, the Minister said:
"The proposals outlined today will introduce a new system that will combine an independent check on all deaths and a professional oversight of death patterns with, for the majority of cases, the minimum of bureaucracy".
A BBC news report on the Home Office plans suggested that those changes had taken place. It said that all deaths would be referred to an independent medical examiner and that a wide-ranging review would result in the numbers falling from 127 part-time coroners to a total of 40 to 60 full-time coroners. Coroners have been handed new powers to seize documents, and the reforms will change the way in which verdicts are recorded, doing away with terms such as "suicide" and "misadventure" and replacing them with a short narrative account of the facts of the death.
The Minister was reported as saying that the proposals would prevent an individual doctor from being able to ensure that someone was buried without any further scrutiny within the system. He said that that was "a huge step forward". What has happened since March 2004, and what urgency has been ascribed to this policy area by the Home Office? In September the independent support group INQUEST described the position paper as "aspirational" and drew attention to the lack of clearly stated commitments. It expressed concern because any changes were expected to take place within existing budgets and without any new money. The Luce report, however, recommended a series of reforms which, it estimated, would cost an additional 10 per cent. over and above the current £70 million budget for coroners' courts.
Will the Minister explain what has been done since March 2004? Which of the proposals in the position paper have been put into practice? What is still to be done before new legislation is introduced? The Luce report helpfully includes a section on what can be done without waiting for a new Act of Parliament. NHS doctors could be allocated to work in an advisory capacity with the registration service and local coroners. The existing coroners' rules could be changed to reflect the recommendations on the outcome, conduct and scope of inquests. The registration service, the Home Office and the chief medical officers could give guidance on the use of autopsies. Here I interpose that in the third report of the Shipman inquiry, it is said that the immediate resort to autopsies by coroners is undesirable, and some coroners' autopsies are "seriously deficient".
As further examples of what can be done now, a new charter of standards of service to families could be produced. Training programmes for coroners' officers should be introduced with some support from central funds, and the development of new training arrangements for coroners themselves could be started. Informal piloting of death certification changes could be started. A new coronial council could be appointed on an informal basis and asked to oversee progress with the reforms. That is an excellent idea. The report states on page 219:
"All these changes could be made in advance of new legislation and all would be very worthwhile."
I am asking for reassurance. Will my hon. Friend the Minister reassure me and the public at large? I am talking about the relatives of those who die tragically in suspicious circumstances, in the custody of the state or in a terrible disaster; the technical and expert groups such as the Office for National Statistics, which collects and publishes the data on deaths, and the Health and Safety Executive, which has responsibility for preventing avoidable deaths at work; the organisations that work professionally with the coroners, such as doctors, police and prosecutors; and the media and all those who have a legitimate interest in the process and outcome of coroners' investigations?
When will we have a modern coronial jurisdiction with national coherence? Will we have a standing rules committee, a coronial council and an inspectorate? Will we have a nationally consistent complaints procedure, an appeals process and compulsory training? Can my hon. Friend tell me that defects in coroners' powers as identified in the reports that have been published will be remedied, and that in future coroners will not solely be reactive, but will be able to investigate any death or group of deaths on their own initiative, making recommendations that may avert further deaths from similar causes in future?
Can my hon. Friend tell me that in future, coroners will have the back-up that they need for expert medical input and effective investigations, and that families will by right have access to reports and to investigators, and that they will be accorded the assistance and the respect to which they are entitled throughout the investigative process, including at an inquest, if one is held? Will he tell me when all this will happen? Can he tell me that that will be soon? It is urgent. Can he tell me that the media will be able to report those actions as fact, because they will be fact?
When my hon. Friend says that he remains committed to taking urgent action, when he reassures all those with an interest in the coroners' court system, especially the families of the deceased, the coroners and their staff, that he is constantly on their case, and when he says that he is determined to see through radical reform in a timely and cost-effective way, I will be satisfied that this debate is worth while, and that some good will come of it.
I congratulate my hon. Friend Mr. Kidney on securing the debate and putting the case for reform of the coronial system in a thorough and persuasive way. There is one aspect that I shall mention briefly—the Luce recommendation about bringing the coronial courts into line with the ordinary courts system, where there is a structured system of appeal.
The issue was brought home to me about a year ago, when one of my constituents, a Methodist minister, was criticised by a coroner after a death outside his church. It is neither appropriate nor possible for me to go into the details, but when my constituent sought my advice, all I could say was that he could challenge the finding by judicial review, or possibly by getting the Attorney-General to support a High Court application. Neither course of action was practical, given the cost involved. Ultimately, the coroner was prepared to enter into correspondence with me, and at the end of the day my constituent and I felt that justice had been done. I urge my hon. Friend the Minister to recognise that this is an important issue, on which the agenda must move forward quickly.
I congratulate my hon. Friend Mr. Kidney on obtaining this debate and giving us the opportunity to discuss the important issue of the reform of the coroner service. He is clearly knowledgeable about the issue and, as my hon. and learned Friend Ross Cranston pointed out, he spoke eloquently and persuasively. I also welcome my hon. and learned Friend's contribution to the debate.
I have been a Minister long enough now to have my earlier remarks quoted back at me. I have also been a Minister for long enough to know that it is a long way from a position paper to a fully reformed system. However, I agree that the issue is important. I reiterate the need diligently to follow through on it and again place on record my determination to do so.
The coroner's office and death certification are, thankfully, places and systems to which we do not often have to go. When we use them, we may be upset and distressed, which is all the more reason why the Government need to ensure that the systems are reliable and effective. As my hon. Friend the Member for Stafford said, the system goes back many hundreds of years. It functions as well as it does largely because of the dedication and professionalism of the staff involved. I assert that we owe it to them and the wider public to modernise the system so that it is fit for purpose and fully effective.
The Government set out our proposals for reform in the position paper that we issued in March this year. As we said then, our intention is to issue a White Paper early next year. The work undertaken by Dame Janet Smith, which is contained in her third report from the Shipman inquiry, and by Tom Luce, in the fundamental review he carried out on behalf of the Home Office, has been crucial in helping to inform and work out our proposals for the way forward. We need a system that is simple to understand and easy to run. We need to close any gaps that could be exploited by those who have criminal intent or who fail to provide proper care. In particular, we must do all we can to ensure that horrific crimes such as those carried out by Harold Shipman can never happen again.
To do that, we must connect a number of different but associated systems, such as the registration service and arrangements for forensic pathology. In addition, we will also need strong links between coroners and health services. It is essential that we learn from deaths of all kinds and use that knowledge to prevent avoidable and unnecessary deaths. We must also make sure that the public have a better understanding of how the system operates.
We plan to reform not only the coroner system, but the arrangements for death certification. New procedures to verify the fact of death will be introduced, and the system will be the same for all deaths, whether there is to be a cremation or a burial. We will also ensure much stronger medical oversight. The new system will mean that in future all deaths, whether or not they need to be reported to the coroner, will be reviewed by medically trained professionals based within the coroner's office.
Those trained doctors—in the position paper, we call them medical examiners—will review the medical certificates of the cause of death in all cases. They will have new powers to call for supporting documentation and make any inquiries that they see fit in order to satisfy themselves that each death is properly certified and that there is no reason for a coroner's investigation. They will also need to be able to review cases as quickly as possible, so that our new procedures do not lead to delay and additional distress for the bereaved.
Each medical examiner will be properly trained in death certification and will work full-time in fulfilling their duties. The checks that they make will be much more effective, and the availability of that additional medical expertise will assist lawyer coroners to interpret and understand the medical information about a death and the details of any medical treatment and procedures that the deceased may have been receiving prior to the death. All that will help coroners to decide what action they may need to take in each case. In turn, we expect that better medical information, and the greater competence and confidence it brings, to lead to a reduction in the number of post-mortem examinations.
Families will have a crucial role in this reformed process. I know, not least from the consultations we have carried out, just how important it is for families to have an opportunity to provide information, to raise questions and to express their own views. Under our proposals, families will have new rights to receive information about a death and to challenge anything that seems to them to be wrong. Their views will also be taken into account when key decisions are taken about the investigation of a death. There will be new and more accessible opportunities to appeal such decisions. Although I cannot at this stage go into the details of that, I hope that my hon. and learned Friend the Member for Dudley, North will appreciate that we are committed to ensuring that families have more opportunities for redress.
I thank my hon. Friend for all that he is saying. The main complaints from families concern great delays in getting an inquest at all and difficulties in getting access to the investigator's report to the coroner. Can those matters be dealt with without the need for legislation, and can my hon. Friend promise that they will be dealt with soon?
Later in my remarks I will show how, under plans to develop a family charter, we want to share more information with families. Of course, we want to speed up the inquest system, although in our current system it is hard to do that in cases where coroners have a backlog of cases, with all the difficulties that that entails. We need to carry out the fundamental reform, but there are things that we can do now and we will continue to do so.
In rural areas, there are sometimes very few suitable venues for coroners to hear their cases. Will the Minister lean on the Lord Chancellor and his Department when people who run the Crown courts, magistrates courts or county courts seek to oust a coroner from using a court although no suitable alternative accommodation is available?
I am aware that sometimes locating a suitable venue for an inquest can be problematic. That remains a responsibility for the local authority. None the less, in Government we do of course try to assist and support coroners where they have a particular difficulty. All they need do is approach us, and if we can help, we will.
As all Members have emphasised, we have much to learn from the experiences of families. Indeed, some of the most instructive and compelling evidence that I have received came during two discussions that I was fortunate enough to have with the families of Harold Shipman's victims—people who have more reason than most to know of the shortcomings of the present system and who expressed themselves to me with remarkable clarity and calmness given the circumstances. I am extremely grateful to my hon. Friend James Purnell for arranging those important opportunities for me to meet them.
Under our proposals we will, for the first time, have a national system to oversee all deaths. In order to provide focus and direction for that new service, we will create a new post—a chief coroner, who will lead the service by setting and driving up professional standards, deploying coroners within the national service, and, where necessary, undertaking the most complex cases himself or herself. The chief coroner will also have statutory powers to give directions to coroners in the interests of consistency and good practice.
There will also be a chief medical adviser, who will have particular functions in relation to the medical examiners and will ensure that the new service has access to the best possible medical expertise.
The chief medical adviser will provide top level medical advice to the chief coroner and link the new service with the regional directors of public health, who will provide additional oversight and scrutiny.
As I said earlier, we plan to publish a White Paper early next year. That will set out the basis on which we intend to legislate—as soon as parliamentary time is available—for a unified and reformed system.
We are carefully considering the resources that we will need. My hon. Friend the Member for Stafford mentioned that. Our position paper expressed the hope that, in broad terms, the changes would be cost-neutral. Further detailed analysis suggests that there may be a need to identify further funding, over and above the blocks of funding that local authorities and the police allocate to the coroner service and coroners' officers. Given that those funding arrangements were designed to cope with around 200,000 deaths a year, while the new service will be required to deal with approximately 500,000, that should not be too surprising. We are, of course, examining the efficiency savings that will accrue.
We are also considering some of the payments made in the current system, including, for example, the £30 million paid privately to doctors for providing certificates prior to cremation, to ascertain whether some of that money could help to improve the scrutiny that families clearly expect. All that will be clearly set out in the White Paper.
As my hon. Friend said, we can do a great deal in advance of a fully reformed system and some of that work has already started. We are working closely with coroners to increase the focus of the service on bereaved families—many coroners already consult families as a routine part of their investigations. I am delighted with the way in which several coroners are taking that work forward. They are seriously considering the way in which families and others receive information about a death and how communications can be improved. I know that some coroners are reviewing the leaflets that they provide and are in discussion with groups and others who work with the bereaved to ascertain what improvements they could make.
In the longer term, building on such work, we will develop a family charter to set out the service standards that can be expected throughout England and Wales. We are also promoting the sharing of good practice. Using modern techniques developed by the Coroners Society of England and Wales, coroners are already making far more use of each other's experience. At the Home Office-funded training courses for coroners, we are making sure that sharing good practice is built into each course.
I pay tribute to the coroners for the way in which so many have made real strides in ensuring that their work and that of their staff meets the increasingly high standards that the public and central Government now expect. Working with local authority funders and local police forces, many coroners have made significant progress in their case management systems and their approach to inquests—especially those that take a long time to arrange—in reviewing their performance and making sure that they work closely with other local services. For example, many coroners have been actively reviewing the number of post mortems that they request, and others have been developing important new links with registrars and primary care trusts as well as with voluntary groups who can support the bereaved.
As I explained earlier, the next milestone in our programme is publication of a White Paper. That will set out the details of our reform programme. We will need primary legislation to give us the powers that we need and we will also need to develop the necessary professional leadership in the form of a chief coroner and a coroners council.
I reiterate the Government's full commitment to the delivery of fundamental coroner and death certification reform at the earliest opportunity—
The motion having been made after Seven o'clock, and the debate having continued for half an hour, Mr. Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order.
Adjourned at thirteen minutes past Eight o'clock.