Mr.
Boswell: I have little to add to the debate except warm
assent to almost all the points that have been made on both sides of
the Committee. On the utility—or otherwise—of an inquest,
the self-evident point that sometimes needs to be gently put into the
minds of bereaved people is that whatever process we have, it will not
reverse the process of death. The rather more general point is that the
inquest may either be unable to reach a firm conclusion or reach one
where perhaps there are no villains and nothing can be generalised from
the particular proceedings. However, I think that the concern of all
members of the Committee who have spoken is that if a pattern is
building up, it should be the subject of a report. There should be a
system that eventually produces at least an opportunity to capture the
attention of Parliament.
As I have
mentioned at least once in these deliberations, I have had a fairly
long association with the British Lung Foundation and have taken an
interest in mesothelioma. Much of this debate is about good practice.
We will not really, in debating legislation, be able to introduce the
requirements for good practice, except that I hope that the Minister
has noted
them. The
British Lung Foundation identified a particular issue in one of its
inquiries. Two years ago, in February 2007, it published a report
called “An unnatural death”. One of the striking things
about it was that it highlighted
the lack of consistent practice among coroners in responding to deaths
from mesothelioma. There is a variety of circumstances, but the point
that is germane to this debate is that there needs to be some
consistency of reporting, so that the nature of what is happening is
clearly available to the chief coroner and to the decision
makers. I
happen to know that the Department for Work and Pensions has an
elaborate model and a database relating to all mesothelioma deaths and
is able to predict the likely pattern of mortality over perhaps the
next 40 or 50 years. If that were to be questioned by what was
happening at inquests, and if the coroners’ accounts were
sufficiently coherent to build up a pattern of a change in the
epidemiology, it would be a matter of public
interest. Clearly,
if we can use these narrative judgments or reports in the widest
possible context, we can draw the attention of people in government or
in public life to a variety of circumstances in which things might be
better in the future, but one needs the facts to do that, so one needs
a certain coherence in reporting. One needs a readiness to report and
then, as the hon. Member for Stafford, among others, has said so
clearly, an ability to respond on the part of the various interested
persons for whom that report was made. The world is littered with White
Papers and good intentions, none of which has ever been acted on
because we have moved on to the next thing. I would take the process a
stage further back and say that we need consistency and coherence in
reporting. The
only other point that I shall add, which again is more a matter of
administration than legislation, is that the chief coroner needs to be
very alert. The chief coroner possibly needs a chief information
officer to complement his activities and to look at the pattern of
information as it comes in, to be able to analyse and cross-analyse it
and to draw people’s attention to what is developing. Let me
give an example. It is often easier to say that cars are all the same
these days, but there might be a particular pattern of failure in a
particular marque. Perhaps some component is wrong, or it might be
brake failure or whatever—something more than one would normally
expect by the nature of the accident. That should be flagged up and
then someone should do something about it. I think that there is a
common will on both sides of the Committee—I certainly wish to
include the Minister in this, in anticipation of her remarks—to
do something about that, but we should set up the best possible
arrangements.
Mrs.
Moon: It is difficult to rise to speak in this Committee
when one is not a lawyer and one is surrounded by so many lawyers who
speak so wisely and graphically about their involvement with the law.
My background is much more with individuals and their personal
experience of life. That is what I draw on when I consider the
discussion that we have had
today. When
I talk to families who have experienced inquests, I find that part of
what they looked for from the inquest is some resolution to their
grief. They look for answers and explanations as to
“why”. It has been suggested that narrative verdicts are
a particularly helpful way of providing that, in that they give a
longer discussion and explanation of what may have occurred. Equally,
narrative verdicts have caused distress—as have open
verdicts—to
families that were distressed by things that were said and placed in the
public domain without a full understanding of the individual, their
life and their
background. 12.30
pm I
urge caution on seeing open and narrative verdicts as potentially
useful ways forward. They also have risks in terms of suicide data
collection, because in the case of narrative verdicts, they are not
recorded as suicide and in the case of an open verdict it is down to a
clerk in the Office for National Statistics to trawl through the
information and decide whether it was a death by suicide. We have some
problems there. I heartily concur with the suggestion that someone must
be held to account and that where we can identify patterns of
information and patterns of failure, someone clearly needs to be
responsible for taking action. Bridgend was identified as a centre
where there had been a cluster of suicides. In fact, Bridgend did not
have the highest number of suicides across Wales—it was quite
low down. What we had was a huge problem building up across Wales that
was not being
identified. I
also urge caution regarding the suggestion that the report must always
come to Parliament. With devolved Administrations, health and transport
are devolved issues. If the area of problematic behaviour or failure
that needs to be identified is not within the purview of Parliament but
within that of a devolved Administration, such as the Welsh Assembly,
there may well be difficulties if the report comes only to Parliament,
and we need to take that into
account. While
I am on my feet, I must quickly mention the charter for the bereaved,
which is extremely welcome. Families have told me that the judicial
atmosphere of the coroner’s court—we have heard the
description of the court based in central Cardiff—is horrendous.
Imagine going there within six months, eight months or a year of the
death of a close family member and having to face the welcome of a desk
sergeant who tells one where to go, a judicial atmosphere, a sense of
stigma and almost a sense of guilt. Families have talked to me about an
invasion of privacy. Because of the need to pull together social and
personal information, there is a feeling that there is almost a desire
to find the dysfunctional nature of a family or individual, which can
be particularly distressing in the full glare of media
coverage.
I
particularly welcome clause
5(3): “Neither
the senior coroner conducting an investigation under this Part into a
person’s death nor the jury (if there is one) may express any
opinion”. Certainly,
families have expressed concern about the following difference in
procedure, and I would welcome a comment from the Minister. A coroner
can express an opinion—and, indeed, hold a press conference in
which to give an opinion—whereas a judge hearing a court case
cannot do that. If, as my understanding is, that provision would
preclude a coroner from doing that, families who have spoken to me
would welcome
it. Briefly,
on delayed inquests, particularly when there has been a tragic death,
we must be mindful of intruding into the grieving process and of the
fact that, for some families, the process is delayed and damaged by the
need to return to court—sometimes, two or three years
later—to hear graphic details of their family member’s
death. There must be greater awareness of the damage that we can do to
individuals through delayed inquests. The charter is an opportunity to
help and prepare families prior to the inquest, and an opportunity to
give them guidance and support through it, which is something that we
must all welcome. David
Howarth (Cambridge) (LD): May I comment briefly on
amendment 70? It addresses the principle of the matter, which is the
restriction—the muzzling—of the jury. As the hon. Member
for Bridgend has said, in some circumstances a jury’s extended
account of the circumstances in which the death came about, or further
information about how such deaths might be prevented in the future,
might not always help. However, the question is whether the jury should
be told that it should never be allowed to do anything of that sort.
The hon. Lady shakes her head, and I think that she agrees that the
jury should have that power, as should the coroner in cases without a
jury. That is the principle of the debate about clause 5. I shall ask
for a vote on amendment 70, so if my hon. Friend the Member for
Cardiff, Central would be so kind as to withdraw her request for a vote
on amendment 114, it would help, because amendment 70 is far more the
matter of
principle. The
hon. Member for North-West Norfolk mentioned amendment 39, the meaning
of subsection (2) and the question raised by Mr. Rebello at
our evidence sessions. Mr. Rebello is wrong, however. The
Bill makes sense, although it is rather mean. It tries to provide for
minimal compliance with human rights standards for the time being.
Mr. Rebello read subsection (2) as meaning that when the
Bill was passed, we would somehow decide the human rights requirements
for an article 2 hearing—we would fix them—and tell
coroners’ courts what they must do. He felt that that would be a
rigid way of doing it, and that it would not necessarily comply with
human rights law. But that is not what the provision in
subsection (2) means. It means that a coroner conducting an
investigation must apply human rights law as it stands, so there is no
list of human rights requirements that is drawn up once and for all.
The subsection also applies to every investigation, so a coroner making
an investigation must ask himself whether the restrictions in
subsection (1) would violate the human rights standards for the time
being. If they would, the coroner would have to apply subsection (2)
and go beyond it to ask in what circumstances the death occurred, which
is the broader requirement in the Middleton
case.
Mr.
Boswell: May I use the hon. Gentleman’s comments as
an opportunity to ask the Minister whether any training on the human
rights convention and standards is envisaged for coroners? It is a
complex field, and it may not be within their normal purview of
activity.
David
Howarth: That is an interesting question. I suspect that
coroners, like all members of the judiciary, receive human rights
training already. Magistrates certainly do, so I would be surprised if
coroners did not. All public officials are bound by the Human Rights
Act. Mr. Rebello’s criticism of clause
5(2)—that it is inflexible—is incorrect. If there is a
criticism, it is that it is minimalist. Instead of admitting the
general principle that the broader circumstances of a death should be
investigated,
at least where the state is involved, but possibly in other cases as
well, clause 5(2) effectively states, rather mean-spiritedly,
“Well, if not going further would violate human rights, go
further, but otherwise just stick to clause 5(1).” That is the
criticism, not the argument that Mr. Rebello stated in the
evidence session and that the hon. Member for North-West Norfolk
repeated just
now.
The
Chairman: May I ask the hon. Gentleman to resolve the
differences with his colleague while the Minister is responding to the
debate? In any case, any amendments requiring a Division will need to
be moved formally, at which point a decision can be
made.
Bridget
Prentice: I shall attempt to respond in some detail and
explain what clause 5 is about. In so doing, I hope that I can give
some succour to some of the amendments, although not all of
them. Clause
5 outlines the matters that a coroner is legally obliged to ascertain
during the course of the investigation. It does not prescribe what
opinions he may express as a result of that investigation. People might
have that impression because they are focusing too narrowly on clause 5
and not taking it in conjunction with clause 10 and paragraph 6 of
schedule 4. In that context, it can be seen that coroners may make such
comments at the end of their investigations. However, the purpose of a
coroner’s investigation is not to apportion blame, but to
ascertain fact. Any inquest forming part of an investigation is
inquisitorial and collaborative; it does not seek to apportion blame or
to establish legal
liability.
David
Howarth: Clause 10 puts in place yet another restriction
on what the coroner or jury can say. Clause 10(2) states
that whatever is said
cannot “be
framed in such a way as to appear to determine any question
of...criminal...or...civil
liability.” The
clause seems to be restrictive, rather than
expansive.
Bridget
Prentice: I just said that the purpose of a
coroner’s investigation is not to establish criminal liability,
but fact, so I do not think that I am being
inconsistent. Amendment
39 relates to article 2 of the European convention on human rights and
the Human Rights Act 1998. The hon. Member for Cambridge is right that
there was a misunderstanding among some coroners giving evidence to the
Committee. Subsection (2) provides the necessary flexibility to take
into account future judgments changing or extending the circumstances
in which convention rights apply. Coroners are already being trained in
the application of the convention and being kept up to date with case
law and so on. Also, regulations will be made dealing with training,
which we can discuss under clause
28.
Mr.
Boswell: To state the obvious, has the Minister not
noticed that the fact that the senior coroner giving evidence to this
Committee, who presumably is as skilled as, if not more skilled than,
many of his colleagues, has difficulties interpreting the clause
suggests that more attention needs to be paid to training and
information than has hitherto been the
case?
12.45
pm
Bridget
Prentice: I accept the hon. Gentleman’s comments.
Perhaps some revision and homework may need to be done in order to
ensure that coroners fully understand what article 2 and the convention
are
about. By
their very nature, article 2 inquests probably need to be more
wide-ranging than ordinary inquests. There are between 200 and 300
inquests that involve article 2, which is about 1 per cent. of all
inquests that are heard each year. Such inquests are expected to
address matters relating to the broad circumstances surrounding the
death, rather than merely the “who, where, when and how”
that would be required in the course of a normal inquest. If we were to
remove clause 5(2), that would leave the Bill lacking in clarity as to
what is required in article 2 inquests over and above what is normally
required. Also, by removing clause 5(2), we would be ignoring existing
case law. I hope that the hon. Member for North-West Norfolk withdraws
that particular
amendment. Amendment
70 would remove from the face of the Bill the obligation not to express
an opinion with respect to the matters to be ascertained under
subsections (1) and (2). That obligation is there because those matters
are matters of fact. There should be no room for additional opinion in
determining those matters. Additionally, coroners should probably not
be giving press conferences to discuss individual cases. They may, of
course, talk about policy in general, but it is usually bad practice to
be having press conferences about individual cases, regardless of the
circumstances of those
cases. Subsection
(3) contains the proviso that it is
“subject to
paragraph 6 of Schedule 4.”
That means that
coroners can make reports regarding the action to be taken to prevent
future deaths, which is similar to reports that are currently under
rule 43. That gives the coroner sufficient scope to make detailed
reports on things that they think should be brought to the attention of
those who have the power to take action to prevent further
deaths. There
is also scope within the associated rules under clause 34 for narrative
verdicts, for which the hon. Member for Cardiff, Central made an
eloquent plea. However, my hon. Friend the Member for Bridgend gave an
equally eloquent response on why such verdicts might not be
particularly helpful to bereaved families. Given that the central aim
that we are looking to achieve here is to make sure that the grieved
families get the best possible service, it is a difficult area, because
in some instances a narrative verdict can cause further distress.
However, I accept that phrases such as “death by
misadventure” do not really tell anyone very much about exactly
what happened. Therefore, we have to give coroners some flexibility to
express exactly what happened in a more rounded fashion than short
versions such as “death by misadventure” or even
“death by
suicide”. Not
surprisingly, amendments 112 to 114 take the coroner further down the
road of expressing an opinion, possibly even attributing blame and
assigning civil or criminal liability. That is not the purpose of a
coronial
investigation.
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