Mr.
Bellingham: I will give way to the hon. Gentleman as he
has tabled a similar amendment. Hopefully between us, we will be able
to make some progress, perhaps even by voting on one of the
amendments.
Mr.
Kidney: Does the hon. Gentleman agree that his amendments
do not include the sanction that Mr. Rebello pointed out is
not in the Bill? What does he think would be the best
sanction?
Mr.
Bellingham: We do not include a sanction, but our
amendment includes a statutory duty. Legal action could then result
from that. I am tempted by the hon. Gentleman’s suggestion that
a firmer sanction should be laid down in the statute. There should be a
statutory duty on the coroner to report at the end of each year to the
chief coroner, who would then present a report to Parliament. It is
vital that the knowledge gleaned from those inquests does not go to
waste. Liberty
is another organisation that has briefed us at some length. It talks
about schedule 4 and says
that “A
senior coroner who believes that action should be taken to prevent the
reoccurrence of fatalities may report the matter to the relevant
authorities.” Our
amendment would replace the word “may” with
“must”. Liberty goes on:
“There
is no responsibility to report findings, and there are no guidelines on
cases where recommendations should be made. Furthermore, coroners have
no power to ensure their recommendations are implemented, and there are
no duties on the part of other agencies to respond or institute
changes. In
the past coroners have been found to be making identical findings and
recommendations which were not
implemented.” Anyone
who has been following the coronial system over the past few years will
know that to be the case. Liberty goes on:
“The
previous draft Coroners Bill gave a nod towards this problem with
provision made for the Chief Coroner to report to Parliament so that
contentious issues could be
scrutinised.” I
submit that our amendment takes care of that, although not with quite
the same wording as the draft Bill. What we are saying in our amendment
is that the senior coroner must, at the end of the year, forward all
reports
and updates to the chief coroner, who must then present them to
Parliament. There would be an annual report from him and he would be
able to identify the different types of lessons that can be learned
from a multiplicity of types of deaths—for example, on the road,
drowning or other accidents that take place and result in tragic
deaths. If one
considers what happens elsewhere—for example, in New South
Wales— recommendations are an integral part of the inquest
process and are logged in a detailed document at the end of the
inquest. The document is then available to the public and is tabled in
Parliament. Doing so obviously exerts substantial political pressure on
the Government to take action. In Ontario, for example, the inquest
jury gives a verdict and makes recommendations, which are published
centrally and sent to all the parties involved. Implementation is
monitored annually by a department of the chief coroner’s
office. Although our amendment does not go as far as the provisions in
Victoria, New South Wales or Ontario, it is a sensible move in the
right direction. It would put a statutory duty on the coroner to make
those reports. It would put the duty on the person involved—the
Government agency, the Department or whatever it might be—to
respond. That would mean that the report came through to
Parliament.
As the Bill
stands, there is nothing that will enable that to happen. My concern is
that lessons will not be learned. I shall conclude with another example
from my constituency. Norfolk is well known for its long sandy beaches,
but the tides can be fairly perilous. On a beach at Brancaster,
drownings have resulted from youngsters taking a risk and going out to
different sand banks. One particular sand bank has an appealing
shipwreck on it. A tragic case of drowning took place during the time
that my predecessor George Turner was MP for North-West Norfolk. He
raised the matter in Parliament and was determined that lessons should
be learned. Of course, there was an inquest and the coroner made
various recommendations, but that is where it ended. I do not believe
that any of the key authorities—whether it was the Crown Estate,
Natural England, the National Trust or the parish council—were
given any proper advice about how to prevent drownings in future.
Perhaps advice could have been given on signage, how to work with other
parish councils or how to look at best practice elsewhere in the
country. Mercifully,
that tragedy has not been repeated, but the lessons that could and
should have been learned from that incident were not properly learned
or processed in a way that reassured the family. Above all, the family
want closure and for lessons to be learned to prevent future deaths.
Let us improve the Bill so that that can be
achieved.
Mr.
Kidney: It is a pleasure, Mr. Cook, to serve on
the Committee under your fair and firm leadership. Clause 5
is subject to paragraph 6 of schedule 4. As the hon. Member for
North-West Norfolk said, where a coroner conducts an inquest and feels
that lessons could be learned from a particular death under
investigation that, if applied more generally, could reduce the risk of
deaths in the future, further action should follow. My amendment is in
part to make sure that further action does follow, so that we can
reduce the risk of death in future cases. I am sure that the public
would want us to do so.
Amendment 93
is my own work and I have had no outside help, so I instantly accept
that there are probably flaws in the drafting. There are two points to
my amendment. I intervened on the hon. Gentleman in relation to the
first point, which is the question of sanctions. Since S.I. 2008/1652
was introduced by the Under-Secretary of State for Justice, my hon.
Friend the Member for Lewisham, East last year, there has been a duty
on people who receive a report from a coroner to say something in
response, but so what?
What if
people do not respond to the coroner’s report—and some
people are not responding to it at present? In theory, if the Bill
became law, the chief coroner could go to the High Court and seek an
injunction to make someone comply with the duty and give an answer.
Having spent thousands of pounds of taxpayers’ money, the chief
coroner could get the answer, “Thank you, we have received the
report, we are going to do nothing about it.” We need to make
people sit up and take notice, so my proposal is that it should be a
criminal offence not to respond to the coroner’s report. That
might sound a bit harsh, but it would get people’s attention and
mean that in most cases we would get a response. That does not go as
far as the Liberty proposal, for example, and make people carry out the
coroner’s recommendations, but we should hear the other
side’s response before we conclude what more should be done. It
is important to have their attention and to make them
respond. My
amendment is inadequate in that it does not specify who the criminal is
if the offence is proved. If the criminal were a hospital trust or a
multinational corporation, who would be convicted? I have not dealt
with that detail. That is something that I would have to rely on the
Minister, with her hoards of civil servants, to take care of, if she
agreed with the principle of it being a criminal offence.
One
alternative, of course, would be to go down the route of a civil
penalty and say that someone who does not respond could have a civil
penalty imposed on them. That may be the more modern and progressive
way. It would perhaps not have the negative implication of someone
ending up with a criminal record. However, it would open up further
questions about who would impose the civil penalty. I find it difficult
to envisage that the chief coroner would welcome such a
role.
Mr.
Boswell: By way of a helpful suggestion, has the hon.
Gentleman even considered the possibility that the coroner’s
court, or the coroner, might be able to hold the person in contempt for
not
responding?
Mr.
Kidney: That is a helpful point. I like the idea of the
coroner summoning someone to court to explain why they did not respond
and to make them give their answer in the court. Such inconvenience
might get their attention too, so there are many ways to do it. The
point is that the Bill, as drafted, has no sanction at all. I would
like the Minister to take account of the many people who have said that
it should.
On the issue
of reporting, it is important that the public, decision makers and
policy makers understand the trends behind the facts that coroners are
unearthing. It is vital that Parliament sees the results of the
coroner’s recommendations, the person’s responses and any
analysis
of trends that the chief coroner is able to give. It is vital that
Parliament has a report from the chief coroner that shows that to us.
It may be that an annual report is too restrictive, because if
something is urgent and action is urgently required, it would be
reasonable for the chief coroner to alert Parliament to a particular
set of circumstances, or a particular trend, in a short space of time.
The chief coroner should not have to wait for an annual report in order
to alert us to
it. In
the draft coroners Bill, in clause 59, there was a provision for the
chief coroner to deliver an annual report to the Lord Chancellor and an
obligation on the Lord Chancellor to lay that report before Parliament.
It is disappointing to see no reference to that provision in the Bill.
The House of Commons Library, in its research paper 09/07, says that it
is the Government’s
intention “that
this would be dealt with in regulations under clause
33(3)(d)”. That
is drawn in the most general of terms and does not specifically cover
this point.
If the
Minister is happy to leave it to statutory instruments to require the
chief coroner to give the Minister a report, that is fine—the
Minister can have that option. However, I represent Parliament and the
people, and Parliament wants its report on the face of the Act, whether
or not the Minister makes statutory regulations requiring that a report
be made to the Minister.
The last line
of my amendment says that the chief coroner must give the report to
Parliament. That is particularly important. Even if the Minister does
not want primary legislation to receive the report herself, can she
bear it in mind that Parliament wants
it?
Jenny
Willott: Somewhat worryingly, I agree with almost every
word that the hon. Gentleman has just said. I also agree with almost
everything that the hon. Member for North-West Norfolk said. There are
clearly issues here which have broad support on both sides of the
Committee. Particularly with regard to the group of amendments relating
to reports by coroners, there is a strong view on both sides of the
Committee that, at the moment, what is in the Bill does not go far
enough. We all have different ways of suggesting how it could be
changed, but there is a strong view that the provision needs to be
beefed up in some way and
strengthened. 12.15
pm First,
I want to return to the issue of narrative verdicts. The reference in
clause 5(2) that enables juries and coroners, when looking into article
2 deaths, to make a narrative verdict is welcome, but it does not go
far enough. We have had a lot of evidence from witnesses last week, and
I am sure that members of this Committee have spoken to constituents
who have been affected. There is a general desire for a lot more
flexibility—more than the Bill currently provides—to be
built into the
system. Narrative
verdicts—when a jury or coroner expand on the information that
is provided—can be incredibly valuable both for the family of
the victim, and also for those who have an interest in the case. They
help in genuinely understanding what happened, why and what the
circumstances were. The hon. Member for Bridgend
has raised the issue of psychological inquests. In some ways, it is a
similar idea that a broader amount of information should be provided
and that, following an inquest, there should be flexibility for that
information to come out and be published, so that the first level of
lessons being learned can start to take place. It is clear
with article 2 deaths that there is a requirement for the Government to
allow, where necessary, broader narrative verdicts. That relates to,
for example, whether there are systematic failings that were a factor
in the death or, in the case of a suicide that takes place in the hands
of the state, if that happened because the danger was not recognised by
authorities. There are a number of other cases, and although they were
not in the hands of the state, there may have been circumstances and
incidents in the past that should have been identified. That could be
where somebody was at a particularly high risk of suicide and it did
not get picked up, or where somebody has died in such a way that
significant lessons could be learned. Given that, we are proposing in
amendments 112 to 114 to enable juries and coroners to provide a
narrative verdict where they feel that there is a need to or that they
want to. That is not a requirement—it is making additional
flexibility and giving juries and coroners the ability to do
that. That
goes hand in hand with amendment 70 which deletes lines 3 to 9 on page
4. It is, in our view, an unprecedented gagging order, which basically
restricts juries from expressing views or explaining the circumstances
of a death beyond the bald facts laid out in paragraphs (a) to (c). I
believe that it is not justifiable to gag a jury or a coroner. By
definition, jury inquests consider the matters most relevant to wider
public interest, because of the type of deaths where jury inquests are
initiated. I feel that clause 5(3) interferes with the ability of
juries to undertake what should be considered as their function and
duty, sitting in coroners’ courts. Removing it would enable
narrative verdicts to be introduced, when the jury feels that it is
necessary. I
want to highlight that we intend to press amendment 114 to a
Division, because it is an area that we feel strongly about. We have
had a lot of evidence that narrative verdicts can offer significant
benefits, and we would like to flag up to the Government that the Bill
is too restrictive. We would like to enable coroners and juries to make
their own decision about whether to expand on a verdict, when they feel
that that is
necessary. On
the issue of the senior coroners’ reports, which has already
been discussed at length, there is a clear need to identify patterns of
problems and systemic failings. There are strong views on both sides of
the Committee that that is an issue that needs to be beefed up. As I
commented on an earlier clause, given that there is no national coroner
service, there is an even greater need to ensure that there are
measures in the Bill for recommendations and reports to be centralised
in either a database or some sort of system, so that patterns can be
identified. Our proposal is that senior coroners’ reports would
include recommendations that would be sent to the chief coroner, who
would maintain it centrally, and it would be reported to the Lord
Chancellor annually. The hon. Members for Stafford and for North West
Norfolk have advanced other proposals, all of which attempt to achieve
the same end, and we are happy to support whatever measure achieves the
ultimate goal.
On the point
made by the hon. Member for Stafford, since bodies are supposed to
respond to coroners’ reports, we should—if that is done
fully—be able to start gathering a full picture and identify
where there are problematic patterns of behaviour and broad health and
safety breaches that are repeated across the country. There has been a
problem—I am sure that all hon. Members agree with
this—with the implementation of some recommendations made in
previous public inquiries, where there was no proper monitoring to
ensure that they were implemented. We have fantastic public inquiries
that come up with strong recommendations, which are then not
implemented, and there is very little monitoring of what happens. The
amendments would ensure that that would not happen in coroners’
courts, and nobody could get away with not noticing that something had
not happened. Recommendations would be gathered centrally, and the
chief coroner would have to report to either the Lord Chancellor or
Parliament, so that there would be better accountability and
transparency of what is happening to the reports and the responses on
the recommendations that have been
raised. From
my experience of talking to and dealing with coroners, I know that they
are extremely experienced and are very good at spotting patterns,
consistent problems and systematic failings. At the moment, we are not
taking advantage of their expertise and knowledge. The
amendments—whichever ones the Government may like to
make—would enable that knowledge and expertise to be better
utilised and the recommendations to be better implemented and
monitored. That would enable Parliament and the Government to have a
much better understanding of the lessons that need to be learned and to
be able to see which public bodies are not implementing the
recommendations. I hope that the Government will take into account the
views that have been expressed on both sides of the Committee, and we
will press amendment 114 to a
vote.
| 
