Baroness Chakrabarti:

Moved by Baroness Chakrabarti

40: Clause 38, page 53, line 12, at end insert—“(4) After subsection (2), insert—“(2A) The coroner is not to decide that the investigation should be discontinued unless—(a) the coroner is satisfied that no outstanding evidence that is relevant to the death is available,(b) the coroner has considered whether Article 2 of the European Convention on Human Rights is engaged and is satisfied that it is not,(c) there are no ongoing investigations by public bodies into the death,(d) the coroner has invited and considered representations from any interested person known to the coroner named at section 47(2)(a) or (b) of this Act (“interested person”), and(e) all interested persons known to the coroner named at section 47(2)(a) or (b) of this Act consent to discontinuation of the investigation. (2B) If a coroner is satisfied that subsection (1) applies, and has complied with the provisions at subsection (2A)(a) to (d), prior to discontinuing the investigation, the coroner must—(a) inform each interested person known to the coroner named at section 47(2)(a) or (b) of this Act of the coroner’s intended decision and provide a written explanation as to the reasons for this intended decision,(b) explain to each interested person known to the coroner named at section 47(2)(a) or (b) of this Act that the investigation may only be discontinued if all such interested persons consent, and(c) invite each interested person known to the coroner named at section 47(2)(a) or (b) of this Act to consent to the discontinuation of the investigation.””Member’s explanatory statementThis Amendment would ensure that certain safeguards are met before a coroner can discontinue an investigation into a death and that family members and personal representatives of the deceased are provided with the coroner’s provisional reasons for why the coroner considers that the investigation should be discontinued, helping ensure that family members make an informed decision as to whether to consent to the discontinuation.

I am conscious that the Committee is valiant and well into the third hour of today’s proceedings; nevertheless, the next is a very important group. We are now in Chapter 4 and we are not talking even about £25 million; we are talking about life and death, bereaved families and the vital work of our coroners’ courts. We are talking about provisions that will broaden the circumstances in which coroners may discontinue their investigations. We are talking, once more, about the power to hold inquests on the papers, in writing only, and we are talking about the wider use of remote hearings. Amendments 40, 42 and 43 are in my name and I am honoured to share those with my noble friend Lord Ponsonby and maybe even my noble friend Lady Chapman of Darlington as well—I am doubly honoured. I also have the support, I am delighted to say, of the noble Lord, Lord Thomas of Gresford, for the Liberal Democrats.

Further amendments in this group are about providing an appeals process for families who disagree with discontinuance, about ensuring that there are no audio-only inquests, even within the class of remote inquests—no telephone or audio-only inquests—and to ensure that remote hearings are still accessible to the public. Amendment 53 ensures pre-implementation consultation before the remote inquests come into effect. The noble Lord, Lord Thomas of Gresford, supported by his noble friend Lord Marks of Henley-on-Thames, has a very important amendment to ensure a right of address for bereaved families. I do not see the right reverend Prelate the Bishop of St Albans in his place, but he may appear in the way that only the Lords spiritual can, and his Amendments 50A and 50B contain important provisions in relation to cases of death by suicide. The indefatigable Minister will speak to his provisions on the register of deaths, which will be important; there are things to tidy up there where an inquest has been discontinued.

I turn to Amendments 40, 42 and 43 in my name. Amendment 40 is about ensuring vital safeguards before a coroner can discontinue an investigation into a death. I hope I do not need to go into too much detail about why safeguards are important in such a scenario, but these include ensuring that family members and personal representatives of the deceased get at least a provisional indication of why this is to be the case, so that they can evaluate whether they support the discontinuance of an inquest. Amendment 42 ensures that inquests will not be held without a hearing—in other words, not on the papers only—if this is against the wishes of the bereaved family. Amendment 43 ensures safeguards before there can be a remote hearing, including by giving interested persons the reasons for that judgment.

I say to the Committee that we need to remember the position that bereaved families, in particular, and other interested parties are in when there is an unexplained or unnatural death. I commend the briefing that will have been provided to, I hope, all members of the Committee by the NGO Inquest. It has done vital work in this area for many years. I remind the Committee that legal aid is not available to these families, and it has often been inquests, over the years, that have been the sole source of support and advice to them. Sometimes these will be deaths in custody, deaths in hospital or deaths in other circumstances where people were very vulnerable and looked after, especially by the state to begin with, before that unnatural and unexplained death happened.

On my Amendment 40, we are really concerned that there must be some testing of evidence. It is all very well to suggest that the reasons for the death have become clear, but under the current law they become clear because of a post-mortem; they are now to be clear for other reasons and other evidence. Perhaps that evidence has not yet been tested. I remind the Committee, as briefly and succinctly as I can, that it is in no small part in our coroners’ courts that the system does its best to comply with the United Kingdom’s obligations under Article 2 of the European Convention on Human Rights. If that jurisdiction is overly eroded we will be in trouble, because we will not be providing adequate investigation in relation to unexplained deaths. We will then not comply with the right to life, which means the right to an investigation into an unnatural and unexplained death under Article 2.

Legal provisions and human rights conventions notwithstanding—there are controversies down the track about how much we care about all that—surely we all care about bereaved families. Any citizen in this country, any ordinary member of our community, regardless of their attitude towards activist lawyers, human rights conventions and international law, would understand why bereaved families are in an unusually tragic situation. Those who have meagre or no means and who are not highly legally literate will be very concerned about any erosion of the possibility of a full inquest in which they can adequately participate. The nature of the coronial system and of inquests means that answers are found not just for those family members but for the wider community. This has been proven to be the case time and again when scandals have been exposed relating to inadequate provision in hospitals or, dare I say, in custody and so on.

I listened as carefully as I could to the extensive debate on the previous group on the need to deal with backlogs after the pandemic to save money, to be speedy and efficient and all that, but coroners’ jurisdiction is a very special case. It is not normal civil, let alone commercial, justice that we are discussing, so this group needs particularly important attention before we go too far down the streamlining, online, no hearings and remote hearings road.

That was my best attempt to be as succinct as possible, because I know other Members of the Committee will want to say more about each of the new provisions in this group. For now, I beg to move.

My Lords, the office of the coroner has evolved over 1,000 years since William the Conqueror introduced it. There were too many dead Normans lying about attacked by Saxon villeins. The coroner inflicted a fine called murdrum on a community where a dead body was found. The deceased was presumed to be Norman under the presumption of Normanry, unless the community, by the presentment of Englishry, could avoid the fine by showing that the deceased was English, in which case it did not matter.

The problem is that traces of these ancient procedures continue to dog the present and to provide cover to government not to recognise the realities of coroners’ proceedings today. Coroners today will tell you that their duties are confined to determining who the deceased was and how, when and where they came by their death. But it is not as simple as that. The thread that runs through this chapter on coroners in this Bill is the lack of concern for the interests of the bereaved, particularly the involvement of the family. The Commons Justice Committee reported last year, and Section 3 of its report is entitled:

“Putting bereaved people at the heart of the Coroner Service”.

This Bill does not even begin to do that.

The evidence given at an inquest and the decision of the coroner or a coroner’s jury has many consequences. When the family of the deceased arrive at the coroners’ court, they will frequently find that skilled advocates are representing a hospital, the police if there has been a death in custody, the insurers of a potential defendant in a road accident or insurers where there may be defects in a stadium, a block of flats or other structure. The evidence given on oath before the coroner may be crucial in determining an allegation of assault or negligence or, where the suggestion is suicide, whether life insurance will be paid out to the dependants. A finding in a coroners’ court frequently determines whether the dependants of the deceased can settle a claim for compensation quickly and without stress or whether they have to go through the agony of a court case.

I turn to Amendment 40. Currently, as the noble Baroness, Lady Chakrabarti, said, the coroner can discontinue an inquest only after the results of a post-mortem have been delivered to him unless he suspects a sudden and violent death or a death in the custody of an organ of the state, such as the police. Clause 38 of this Bill now extends his discretion to discontinue by the use of wide words: if the

“cause of death becomes clear” before inquest. Under this Bill, all the family receive is a statement of reasons. The purpose of this amendment is to ensure that, before the coroner makes his decision to discontinue, he has made all proper inquiries, and ensured that there are no ongoing investigations into the death, such as a hospital inquiry, and crucially that the family have been given the opportunity to make representations and actually consent to the discontinuance.

I think the Explanatory Notes are disingenuous when they suggest that an inquest adds to the distress of the bereaved family. Certainly, there is distress, but a decision to discontinue, taken above their heads and without their participation and consent, may very well cause much greater distress.

I come to Amendment 41. We are all aware of the struggles of many families to obtain an inquest through the courts by way of the discretionary remedy of judicial review. Amendment 41 provides for rules to establish an appeals process for those who disagree with the decision to discontinue. To succeed in the Bill as currently drafted, they would have to establish that the cause of death is not clear. What does that mean? What may seem clear to the coroner may not be clear to the family at all. If Amendment 40 is carried, the need for appeal would be considerably lessened since all interested persons known to the coroner would have been notified of his intention to discontinue prior to the inquest and would have consented to it. Appeals could then be brought only by interested persons who had been overlooked. That is possible but very rare.

I turn to Clause 39 and Amendment 42, where the theme continues. The decision of a coroner to determine that a hearing is unnecessary and may be determined in writing should also involve the consent of the bereaved: put the bereaved at the heart of the coroners service. Proposed new subsection (2)(a), to be inserted by Clause 39(2), requires the coroner to invite representations from known interested parties before he makes his decision, while (2)(b) deals with situations where no representations have been made and (2)(c) deals with situations where there is a disagreement between interested parties. That is what the Bill talks about, but nothing is contained in the clause about the position where all the interested parties oppose the coroner’s notification of his intent to determine the issues in writing on the papers, much less a requirement that they all consent. Amendment 42 would deal with those omissions.

Amendment 43 to Clause 40 again seeks to involve the family in the decision to hold remote inquests. First, they should consent. Secondly, the coroner should be assured that such a hearing is in the interests of justice, in particular that the issues are not too complex and interested persons are able to use to technology involved. Thirdly, the coroner should give his reasons in writing. However, a remote hearing has this disadvantage: the family are not open to the support services that would be available at a live hearing. The Commons Justice Committee recommended at paragraph 66 of its report that

“local volunteers in the Coroners’ Courts Support Service” use their skills to assist the bereaved and commented that that service is not centrally funded, nor available everywhere.

Amendments 44 and 45 emphasise the public interest in inquests. If held remotely, they should not be held simply by telephone and absent the public. The rules require that inquests be held in public, except for reasons of national security.

Amendment 50, after Clause 42, is an amendment in my name to delete Rule 27 of the 2013 rules, which states:

“No person may address the coroner or the jury as to the facts of who the deceased was and how, when and where the deceased came by his or her death.”

I have been present at a number of inquests and have always found this to be quite extraordinary. Deborah Coles, the director of Inquest, told the Justice Committee about her experience of a culture of “defensiveness” on the part of public bodies:

“Very often, those lawyers are working as a team to try to reduce the scope of the inquest, to try to limit the number of witnesses or argue against questions being left to a jury, if indeed there is one, or argue against a coroner making a prevention of future death report … There is much more concern for reputation management, rather than a meaningful search for the truth.”

In my experience, it is much the same with employers who seek to limit their liabilities. “Well,” you might say, “so much the better if they cannot address the coroner.” However, they often make submissions on facts dressed up as submissions on process. Where both sides are represented, the coroner should be helped by submissions made by both sides to clarify issues of fact and make points about the evidence that has been heard; those points may be crucial to the issue of liability. Whether both sides are represented and there is equality of arms is a matter that we shall come to in the debate on the next group.

My Lords, I agree with many of the points my noble friend has made. He made a particularly forceful point about addressing the jury at an inquest. It seems an absurdity that the law is in that state; I will come back to the encrusted historical nature of the law on coroners in a second.

I will add to what my noble friend said, although it might seem a slightly conflicting point. It is simply that the circumstances can be very different in so many of these cases. From my experience of inquests and dealing with families going to inquests, I have often come across the circumstances so vividly described by the noble Baroness, Lady Chakrabarti, of those who do have any equality of arms and are dealing with a major public sector body or a private organisation with great resources. There are other families for whom an inquest is just another liability they do not want at a time of maximum grief. If there are no grounds for holding an inquest or drawing them into that procedure, we do not want to make life more difficult for them at a time of very real grief.

If you want to know how encrusted with history the law is, you need look only to Clause 42 of this Bill. Would you believe it? It is not apparent from the clause, but it sets up a procedure so that a local authority can reorganise coroners’ areas within its own area, and can do so partially if there is a coroner who does not agree, who can stay until he retires. That is a product of history and the judicial nature of the coroner’s office, which makes this area difficult to deal with. I strongly support what my noble friend said but also want consideration to be given to not imposing unnecessary processes on a family where there is no doubt as to how the death was caused, as the family simply wants to be left to cope with it.

I strongly agree with the noble Lord, Lord Beith, but I understand that he does not contest any of the propositions put forward by my noble friend Lady Chakrabarti and the noble Lord, Lord Thomas of Gresford. They are dealing with cases where people are desperate to find out what happened and want a proper hearing.

I underline the point made by the noble Lord, Lord Thomas of Gresford, which is that the key issue here will be in the next group dealing with the provision of legal aid, where appropriate, in cases where there is a dispute. We are not talking about that now, but it is vital to there being a level playing field.

This group of amendments is, in effect, trying to bring the coronial system into line with its current role to allow a proper contested hearing, where appropriate, if there is an issue about the cause of death, rather than it being the administrative process it previously was. There needs to be that change.

The biggest example of why these amendments are right and the Government’s position is wrong is in the Amendment proposed by my noble friend Lady Chakrabarti on what is currently Clause 38. Clause 38 amends Section 4 of the Coroners and Justice Act 2009. The 2009 Act allows the coroner to stop an investigation where the cause of death becomes clear after a post-mortem examination. Section 4 also provides that the coroner can, if asked, give reasons after he has discontinued the investigation. That is not apparent in this Bill, but comes only in Section 4 of the 2009 Act.

Based on not just a post-mortem examination but any other matter the coroner thinks relevant, if he is satisfied that the cause of death has become so clear that he thinks an inquest is no longer appropriate, he can simply stop the whole investigation, without reference to the family, even if they are desperate for an inquest. The coroner’s only obligation is to explain why he or she did that after the event. That is the effect of Clause 38, so my noble friend Lady Chakrabarti is absolutely right to say there should be safeguards, and the key safeguard is that proposed in Amendment 40, subsection (4)(2A)(d):

“the coroner has invited and considered representations from any interested person”,

which would include the family. Why do the Government not think there should be such a requirement? What is the purpose of a justice system that can reach a decision without hearing from interested parties, and whose only obligation is to explain why it took that decision after it has been made, without giving the family the opportunity to comment?

My Lords, I commend my noble friend Lady Chakrabarti for tabling these amendments so quickly; I am pretty sure we would have tabled something almost identical. She is right in everything that she said, and she did so succinctly but effectively. I shall address Amendments 40, 42 and 43 in her name as well as Amendments 41, 44, 45 and 53 tabled by my noble friend Lord Ponsonby.

As the noble Lord, Lord Thomas of Gresford, said, there is a theme running through this group: putting families at the heart of this process. There are long-standing concerns about the way that the process often takes place. It is unfortunate that the Government have not taken this opportunity to consider the issue as fully as they could have done. We are worried that efficiency and streamlining of processes should not in any way bring about a sense that these matters are to be treated with less solemnity or seriousness than they should be. We are very nervous that the Government are permanently changing procedures because of a backlog following Covid-19; we understand that that needs to be dealt with, but the needs of families must be central to the Government’s thinking here and at the moment I do not think they are.

We all appreciate that there is widespread inconsistency with coroners and that something of a postcode lottery is developing. I recommend the Justice Select Committee’s report to Members of the Committee. It is a thorough and excellent piece of work; the Government would do well to consider it and implement more of its recommendations. One of the suggestions that the Select Committee made was the introduction of a national service. As I say, the Government have missed an opportunity to go much further than the measures before us, which I am afraid seem motivated predominantly by a need to make up ground after the pandemic.

The current law, the Coroners and Justice Act 2009, holds that where a coroner has commenced an investigation, they must proceed to an inquest unless the cause of death becomes clear in a post-mortem examination. The Government are arguing now that cause of death can be established by what they call “other means”, and they give the example of medical records. They need to be incredibly careful not to create a situation where the justification for discontinuing is based on evidence that cannot be challenged by the family or by others.

My good friend Andy Slaughter in the other place gave a long list of examples, which he probably got from inquest, showing clearly the need for safeguards, particularly the need to allow the family to consent to discontinuation and for such consent to be properly informed. I shall read from Hansard an example that he gave, of Laura Booth. It will just take a minute to read it, but I think it will help us to appreciate the seriousness of the issues that we are considering:

“Laura sadly died on 19 October 2016 at the Royal Hallamshire Hospital in Sheffield. Laura went into hospital for a routine eye procedure, but in hospital she became unwell and developed malnutrition due to inadequate management of her nutritional needs. The coroner overseeing the investigation into Laura’s death was initially not planning to hold an inquest because the death was seen to be from natural causes. However, Laura’s family and BBC journalists fought for the coroner to hold an inquest. The inquest reached the hard-hitting conclusion that Laura’s death was contributed to by neglect. A prevention of future deaths report issued by the coroner to the Royal Hallamshire Hospital noted serious concerns about the staff’s lack of knowledge and understanding of the Mental Capacity Act 2005, and recommended that families should be better consulted in best-interests meetings.”—[Official Report, Commons, Judicial Review and Courts Bill Committee, 18/11/21; col. 334.]

So this really matters. Inquests play a vital role in making sure that loved ones understand the reasons for a death.

Amendment 41 would provide that the Lord Chancellor should establish an appeals process for families who disagree with the decision to discontinue an investigation. We think that is an important safeguard, and it would rightly respect the interests of those whose closest have died. We see it as an anomaly that no right of appeal exists for families in that situation.

Amendment 44 would prevent an inquest being conducted by telephone or other means that were audio-only. We think that audio-only risks hindering engagement with families, and it may be inappropriate in these circumstances.

Amendment 45 would ensure that remote inquest hearings and pre-inquest hearings were still be held in a manner accessible to the public. We think this is important for public confidence, for scrutiny and for challenge. We are worried that measures in the Bill designed to streamline processes will make it more difficult for families to be active participants in the process when all the evidence is that we should be taking steps to help their participation.

We strongly support Amendment 42, which would ensure that inquests were not held without a hearing if that was against the wishes of the family. To do so, as well as being incredibly insensitive, would deprive the family of the opportunity to explore all available evidence and limit their ability to scrutinise the accounts provided by relevant authorities, including by hearing oral evidence and questioning key witnesses. I am sorry the Government are taking the route that they are taking, and I am sure we will want to continue to press them on this as we progress.

My Lords, the amendments in this group relate to coroners’ inquests, and include government and non-government amendments. I will begin with those tabled by noble Lords who have spoken and then come to the government Amendment at the end.

Before I do that, I should inform the Committee that the right reverend Prelate the Lord Bishop of St Albans has kindly sent me a note, because his Amendments 50A and 50B are in this group. As he is serving elsewhere, in Committee on the Building Safety Bill, he is unable to join this Committee this afternoon. I do not know whether this is normally done, but unless the Committee objects, I propose to write to him setting out substantially what I would have said had he been here and I will circulate the letter, because even though the amendments are not formally moved, the right reverend Prelate raises points which he has raised in the House on previous occasions.

Subject to the views of the Committee, that sounds eminently sensible. In case it is necessary, perhaps I might say that I support those amendments and would not want to deprive the right reverend Prelate of the opportunity to bring them back to the House at a later stage.

I was not seeking to take any procedural point. Rather than take time this afternoon, because we have not had a debate on the amendments, I will set out the position in writing and copy the letter appropriately.

Before taking the amendments in turn, perhaps I may make an important point which is central to this discussion, which is that coroners—

I am sorry, I know that we are pushed for time and there are important matters that we want to get on to. I do not know about other noble Lords, but I would appreciate hearing the Government’s position on Amendments 50A and 50B. Is that possible?

It certainly is. I had prepared to respond to the amendments and am happy to do so if the Committee finds that more helpful. I see some nodding heads, in which case I will do it that way instead. I will obviously direct the right reverend Prelate to Hansard. I am very grateful.

A central point which is really important is that coroners are judicial office holders—whether they go back to William the Conqueror is not directly relevant for these purposes, although it was interesting. That point is important: they are not administrators or decision-makers; they are judicial office holders. Ultimately, it is therefore up to the coroner, circumscribed by statute, how to conduct their investigations and inquests. I respectfully ask the Committee to bear that in mind when considering a number of these amendments, to which I will now turn.

Let me start with Amendment 40, in the name of the noble Baroness, Lady Chakrabarti, and Amendment 41 in the name of the noble Lord, Lord Ponsonby. They both deal with the new power that the Bill gives coroners to discontinue an investigation in certain circumstances, seeking to add additional safeguards and an appeal process. Section 4 of the Coroners and Justice Act 2009 provides that a discontinuance does not apply where there is reason to suspect that cause of death is by violent or unnatural causes, or where a death was in custody or otherwise in state detention. So, for example, families whose relatives have died in prison custody or a mental health setting would still have an inquest even if the cause of death was revealed to be natural causes. The intention behind this measure is to support the drive to reduce unnecessary procedures in coroners’ courts, thereby reducing delays and distress to bereaved families. In most cases where the cause of death is revealed as being natural causes, the bereaved family will be relieved that the investigation can be discontinued at that point.

Section 4(4) of the 2009 Act also provides that coroners who discontinue an investigation into a death must, if requested, provide a written explanation as to why an investigation has been discontinued. I would certainly expect coroners to work sensitively with all interested persons, whether family members or others, and I would also expect them to address any concerns those persons may have in relation to the discontinuance decision. I am also able to confirm that the Chief Coroner will provide guidance to coroners accompanying any law changes, should this provision pass into legislation.

I turn to Amendment 41. Interested persons who are not content with a coroner’s decision to discontinue an investigation already have the right to challenge that decision through judicial review or, in certain circumstances, through application to the High Court with the authority of the Attorney-General. So, we do not think an appeals process is appropriate, because the family is not a party in the sense that we use that word when we are talking about adversarial litigation. Coroners are inquisitorial, not adversarial, and we do want to preserve that. That is something that the Chief Coroner, I know, is very focused on. We do not want coroners’ inquests to become adversarial proceedings; we want them to remain inquisitorial.

The Minister has said we want coroners’ inquests to remain inquisitorial. In practice, they are adversarial. The ancient position of a coroner does not allow the proper adversarial safeguards to be in place. I would like the Government to rethink that position and consider whether it is appropriate at this time.

I can accept two points there. I can accept that I and the Government will reconsider it. We certainly will think about it. This is a bit of a chestnut point, if I may say so; it has been discussed on a number of occasions. But the Government’s current position is that we want coroners’ inquests to be inquisitorial and not adversarial. Secondly, I accept, as a consequence of that, that we do not have adversarial safeguards. But that is consequent on the first point; the inquests are not adversarial.

There is a real problem, I would suggest, in changing the nature of a coroner’s inquest to being adversarial. I accept there will be particular inquests where it is appropriate for people to be legally represented. I do not want to mix the groups up, but we will discuss in the next group the issues of legal aid, exceptional case funding, et cetera. But the central fact is that the inquest is there to determine who the deceased is, where he died—I will say he—when he died and how he died, but not why he died. That is an important point.

We are getting to the heart of it, in a sense, because the Government contend that these processes are not adversarial. I understand why they are doing that. However, I am increasingly of the impression that what the Minister has just said has absolutely no grounding in reality. The lived experience of extremely vulnerable people in this context reveals that the processes are deeply adversarial. Their experience does not align with what the Minister has just said. It is unfortunate that the Government do not seem able to appreciate this in their consideration of these amendments.

Of course I understand that point, in the sense that I too have read the material of people who have been involved in inquests. I have read some of the material from the various groups which have been lobbying for changes in this area. I hope that I have set out the Government’s position fairly. As we all recognise, the point being made to me is fundamental. I do not want to keep repeating it in response to each Amendment, but I certainly accept that what I have just said underpins the Government’s response to a number of these amendments. Therefore, I absolutely accept and understand the noble Baroness’s position; that is, because she disagrees with me on this fundamental point, necessarily she will disagree with me on a number of these amendments because they are underpinned by the same point—

Whether the process is inquisitorial or adversarial, surely you are entitled to basic fairness. This means you are entitled to having a say on what is going on and an opportunity to make proper representations. This is the case whether you are either a family member saying, for example, that your loved one is the victim of a criminal offence by the police, or you are a police officer being accused of manslaughter. Indeed, the Minister has just said that there would be a coroner at the inquest. Therefore, I am not sure why—whether it is inquisitorial or adversarial —you are to be deprived of that basic fairness.

The fundamental point is: who is the “you”? Who are the parties to an inquest? As I was saying earlier, you do not have “parties” in inquests, in the same way that you do in adversarial proceedings. Of course, there are inquests where legal aid is provided and family members—or, indeed, other people—turn up with lawyers. However, as a Government, we certainly do not want the general inquisitorial procedures, in the normal run of an inquest, to become adversarial. I understand that this is a point of principle between us; this is not a point of detail.

This point will underpin a number of the responses which I am going to give. I turn to Amendment 42, which would require the coroner to obtain consent from interested persons, including bereaved families, before determining whether to deal with an inquest on the papers. Clause 39 has been designed to give coroners the flexibility to conduct inquests without a hearing, where there is no need to hold one. They would exercise that power judiciously, because they are judicial officeholders, in cases where they consider them to be non-contentious, where there is no concern about the cause of death, or where the family have indicated that they do not wish to attend a hearing.

To return to the point I started with: because coroners are independent judicial officeholders, introducing the concept of consent into their decision-making process would cut across their judicial independence and fetter their discretion. The coroner would still be required to hold inquests with a hearing, in cases which require one. The Chief Coroner would issue guidance to coroners on how they should exercise their discretion.

Amendments 43, 44, 45 and 53 all relate to remote hearings. The purpose of Amendment 43 is to ensure that additional safeguards are met before a coroner can hold a remote hearing. The position here is that coroners have always been able to conduct hearings with virtual elements, but the coroner and the jury, if there is one, must be physically present in the courtroom. Clause 40 allows all participants to participate in a remote hearing.

As we have said on previous groups about magistrates and jurors, throughout the pandemic, coroners’ courts have also worked very hard to keep their services running. They have taken advantage of the benefits of remote hearings to keep inquest participants safe. Key witnesses, who often could be front-line doctors, have been able to focus on their primary role and attend remotely. Clause 40 ensures that coroners can continue to operate remotely, when they regard it as appropriate. Again, we expect that, being judicial officeholders, coroners would work with interested persons to address any concerns that they may have regarding remote hearings. Again, the Chief Coroner is expected to provide guidance on any law changes.

Amendment 44 deals with remote hearings. The short point here is that there may be instances where participants might prefer or need to participate in a remote hearing only by audio, without video; perhaps that is the only way that they can participate if they are based abroad, for example, and there are technical limitations to how they can access the hearing. As we understand it, the amendment would exclude those participants from participating in the hearing remotely—

That is not the intention; it is that the hearing in its entirety should not be conducted by audio only. The Amendment would not prevent someone participating by audio only.

I am grateful for that clarification, but the same point would apply. If the only people who are interested—I am using that word in the technical sense—in the inquest can participate only by audio link, the coroner would have to either not hold the inquest and adjourn it or hold it, so to speak, in a room, despite those interested people not being able to be there. I will consider again whether what the noble Baroness has said resolves my concerns, but I do not think that it does. Certainly, we are concerned to make sure that an inquest can still go ahead when, for some reason, everyone relevant can participate only by way of audio.

I assure the noble Lord, Lord Thomas of Gresford, that what underpins this and Parliament giving coroners these powers is concern for families. We want people to be able to participate, and we are conscious that some people may only be able to participate through technical means or audio only.

Amendment 45 seeks to ensure that remote inquest hearings and pre-inquest hearings are heard in a manner that is accessible to the public. In this regard, Clause 40 is designed to complement Clause 166 of the Police, Crime, Sentencing and Courts Bill, which is currently in the other place. Clause 166 provides for wider remote participation in court proceedings, under the direction of the court, and it covers a number of courts, including coroners’ courts. So, Clause 166 will ensure that justice remains accessible to the public, regardless of how the hearing is conducted. Again, the Chief Coroner will provide additional guidance on the use of remote hearings to ensure that coroners’ inquest hearings remain accessible to the public, as set out in Rule 11 of the Coroners (Inquests) Rules 2013.

Amendment 53 would require the Government to review and consult on the potential impact of remote hearings before the provision is implemented. I can assure the Committee that the Coroners (Inquests) Rules 2013 would need to be revised to set out the detail of how remote hearings will operate in practice, and we will consult with key stakeholders to take their views into consideration as we do that.

Let me now turn to Amendment 50, which seeks to repeal Rule 27 of the Coroners (Inquests) Rules 2013. I respectfully empathise with the reasons the noble Lord, Lord Thomas of Gresford, gave for questioning the rationale for the provision. I understand, if I may put it this way, where the noble Lord is coming from. It brings me back to my earlier point: inquests are designed to be inquisitorial, so that the coroner and any jury start without preconceptions and can elicit the true facts about a person’s death. Interested persons are entitled to participate fully in inquests. They have a statutory right to examine witnesses and they can give evidence themselves if required by the coroner. A bereaved family may also be permitted to provide pen-portrait evidence about their loved one which speaks to who the deceased was and helps to humanise—if I can put it that way—the deceased person in the inquest process. Allowing interested persons, however, to make submissions on the facts, rather than limiting them to providing and examining evidence, would, I suggest, make the inquest adversarial. I repeat: the Chief Coroner has time and again said publicly that one of his key objectives is to protect the inquisitorial nature of the inquest process. As I have set out, the Government are keen to support him in that.

I was going to turn next to the Government amendments, but let me set out what I was going to say in response to the amendments proposed by the right reverend Prelate the Bishop of St Albans, and I will take them as formally moved, so to speak. He tabled two amendments relating to death by suicide. I thank him in his absence for his tireless commitment on this issue; over the last couple of years, he has put down a number of related questions and Private Member’s Bills. We recognise the need to collect quality information on the circumstances that lead to a suicide in order to help prevent future deaths and support better outcomes. We do not think that these amendments would lead to the desired effect. Section 5 of the Coroners and Justice Act 2009 sets out the scope of the coroner’s role, which, as I said earlier, is to determine who died and how, when and where they died.

During the investigation, the coroner may be made aware of factors as to why a person may have taken their own life, but it is not within the coroner’s remit to look deeper or investigate further, as this could lead to seeking to attribute liability, which is more properly the preserve of other legal jurisdictions. In addition, the coroner may gain information from a wide range of sources—family, partner, friends or the police—who might mention different risk factors as issues when understanding the circumstances of a death. This would lead to data being incomplete or inconsistent in quality, which would not then be useful in delivering better outcomes or interventions.

The Government remain committed to understanding the circumstances which lead to self-harm and suicide, including gambling addictions. In March last year we published the fifth progress report on the national suicide prevention strategy, and this included a refreshed cross-government suicide prevention workplan that included factors such as gambling. There has also been an increase in funding for suicide prevention through the NHS long-term plan, with an additional £57 million by financial year 2023-24 to support local suicide prevention plans and develop suicide bereavement services in every area of the country.

On gambling specifically, which I understand to be the right reverend Prelate’s particular focus from his previous interventions, the NHS long-term plan commits to expanding the geographical coverage of NHS services for people with serious gambling problems. In addition to the existing National Problem Gambling Clinic in London, the NHS has committed to opening an additional 14 new problem gambling clinics in 2023-24. I was going to invite the right reverend Prelate not to move his amendments; I invite the noble Baroness, Lady Chakrabarti, to do so on his behalf.

I turn to the government amendments, which are quite technical but none the less important. I am grateful to those Members of the Committee who have engaged with me on the detail of this. The current position is that there are provisions that enable a coroner to authorise the disposal of a body so that families may hold a funeral prior to any formal death registration being completed. These provisions are successful in avoiding unnecessary delays. They reduce the stress on the bereaved when the coroner is involved. The problem is that, admittedly in a small number of cases, these provisions seem to have the unintended consequence of taking away the incentive for the death to be registered as it may be perceived, often by the family, that nothing further needs to be done once the funeral has taken place. I understand why people take that approach; it is incorrect, but I understand why they do.

The problem is that, unless the coroner undertakes a full investigation or an investigation is suspended, those deaths can be registered only if an informant qualified to do so by legislation provides the registrar with information relating to the deceased. The qualified informants are primarily family members. That is the problem. The death can be registered only after the coroner has considered whether a full investigation should be carried out or discontinued, by which time a funeral may already have taken place and family members may no longer be interested. As I said, I am not blaming anybody; it is just human nature: the funeral has taken place so they regard the matter as concluded.

It is not just human nature; it is the practical difficulty of registering deaths and making appointments in coroners’ offices, because registrars’ and coroners’ offices have very limited not just opening hours but opening days. This has been particularly marked during the pandemic.

I understand that, certainly from my postbag. I should say that coroners work extremely hard, but the pandemic has caused a real problem. I do not want to go back to the online discussion, but we hope that enabling people to do that sort of thing online will help. I certainly take the noble Lord’s point.

To solve this, the amendments in my name will enable a coroner to provide the registrar with the information required for the registration to take place on the basis of that information. I should make it clear that we are not introducing new duties on coroners or removing the duty on qualified informants to provide information. It is intended to be used in those exceptional circumstances where qualified informants are unable or unwilling—often for good reason, as the noble Lord, Lord Beith, said—to discharge their duties. The effect will therefore be that the death will not go unregistered. We think that about 200 of these cases happen a year. They affect the accuracy of records, but there is also the potential for fraudulent use of the identity of an unregistered deceased person, since the identity has not been closed by the death being registered. It is not quite Day of the Jackal territory, but there is potential for fraud there. We want to close that.

For those reasons, I invite noble Lords not to press their amendments and I will move mine when the time comes.

My Lords, I am grateful to every Member of the Committee who participated, in particular to the noble Lord, Lord Thomas of Gresford, and my noble and learned friend Lord Falconer of Thoroton, for crystallising the fundamental inequality of arms that exists in so many inquests. Regardless of jurisprudence or terminology, that is how it is and how it feels for these families.

I am grateful, too, to my noble friend Lady Chapman of Darlington for making it crystal clear that evidence that cannot be challenged is going to be a huge problem, not least for compliance with Article 2, and for reminding us of the tragic case of Laura Booth, which is in the Inquest briefing in case noble Lords want to read it at leisure. There are other tragic cases of that kind, where, but for close scrutiny and the testing of evidence that initially seemed very straightforward, some real public interest problems, whether in our hospitals or elsewhere, would not have been revealed.

I am only slightly disappointed that the very busy right reverend Prelate disappointed my hope that it would be possible for a Lord spiritual to be in two places at the same time. None the less, I am very happy to take care of his amendments and ensure that he has the opportunity to bring them back next time. I think that is the right thing to do.

The Minister will forgive me, I hope, for being disappointed in the 100% defensive rebuttal of every single concern raised in this Committee. He reminds us that coroners are judicial officers and not mere administrators; of course, he is right about that. But he says that in total rebuttal of every safeguard and gentle constraint suggested—for example, the discretion to discontinue these vital investigations.

I cannot help but point out the contrast in the Government’s approach to this part and, for example, to Clauses 1 and 2. In Clause 1 we are told that it is perfectly acceptable for the legislature to constrain judicial thinking and discretion in quite convoluted ways, but here, when we want to put the needs and concerns of families into the equation, we are told that it is somehow an inappropriate constraint on the wonderful, inquisitorial, coronial province. We are reminded that coroners are inquisitorial and not adversarial, as if these terms of art are set not in aspic but in stone. I do not really care whether these are technically inquisitorial or adversarial—you can call them “Doris” as far as I am concerned. There are vital rights and interests being explored in this jurisdiction.

I am sorry to say that I do not know whether the government position is science fiction or space fantasy. In many cases these proceedings are tantamount to very difficult quasi-adversarial proceedings, but one side is silent. One side is silent because it does not have the language and resources to put its side of the picture. This is exacerbated in cases where very defensive public authorities, understandably, are heavily represented by Silks and so on. We cannot say that the full answer to that problem will be a technical, jurisprudential definition of inquisitorial versus adversarial proceedings. That is not reality at this moment in the 21st century.

I gently ask the Minister to consider meeting some representatives of the unrivalled NGO Inquest before Report. That organisation and those working within it have done so much work over the years with a number of bereaved families. I am sure they would at least help illuminate the Minister’s understanding of what some of these most difficult inquests are like for ordinary people. That would be my request to him. None the less, for the moment—but only for the moment, because having heard from my noble friend Lady Chapman and from the Liberal Democrats, I suspect that the Committee will want to return to this group on Report, and I obviously preserve the position for the spiritual Benches opposite—I beg leave to withdraw the Amendment.

Amendment 40 withdrawn.

Amendment 41 not moved.

Clause 38 agreed.

Clause 39: Power to conduct non-contentious inquests in writing

Amendment 42 not moved.

Clause 39 agreed.

Clause 40: Use of audio or video links at inquests

Amendments 43 to 45 not moved.

Clause 40 agreed.

Clauses 41 and 42 agreed.