Mr.
Bellingham: I am grateful to the Minister for her
explanation of the clause, but I am not satisfied. We are discussing an
important part of the Bill and it is essential to have extra safeguards
in place. The hon. Lady quoted my hon. Friend the shadow Health
Secretary who was talking about how medical examiners would operate on
a day-to-day basis, not about their appointment. My argument is that,
of course, they will be part of the PCT and will be playing an
essential role on a day-to-day basis, working alongside other doctors
within the PCT and the local health boards. However, their actual
appointment does need to be one stage removed. I am sorry that the
Minister cannot go along with us on that, so I shall press amendment
360 to a
Division. Question
put, That the amendment be made.
The
Committee divided: Ayes 5, Noes
9.
Division
No.
3] Question
accordingly negatived.
Jenny
Willott: I beg to move amendment 115, in
clause 18, page 9, line 29, at
end insert ‘to the minimum
standards as laid down for time to time by the National Medical Adviser
to the Chief
Coroner,’.
The
Chairman: With this it will be convenient to discuss the
following: New clause 14— National medical adviser to the
chief coroner ‘(1) The
Secretary of State for Health may appoint a person as the National
Medical Adviser to the Chief
Coroner. (2) The Secretary of
State for Health must consult the Lord Chancellor and the Lord Chief
Justice before making an appointment under this
section.’. New
clause 15—Regulations about training (medical
examiners) ‘(1) The National
Medical Adviser to the Chief Coroner, after consulting the Chief
Coroner, may, with the consent of the Secretary of State, make
regulations about the training
of— (a) medical
examiners; (b) medical
examiners’ officers and other staff assisting persons within
paragraph (a). (2) The
regulations may (in particular) makes provisions as
to— (a) the kind of
training to be undertaken; (b)
the amount of training to be
undertaken; (c) the frequency
with which it is to be
undertaken.’. New
clause 16—Regulations about standards (medical
examiners) ‘The National
Medical Adviser to the Chief Coroner, after consulting the Chief
Coroner, may, with the consent of the Secretary of State, publish
minimum standards relating to the service to be provided by medical
examiners.’.
Jenny
Willott: The amendment and group of new clauses relate
specifically to the establishment of a national medical adviser to the
chief coroner. The Minister referred to such an appointment in her
response to the previous group of amendments, but our proposals would
establish a national medical adviser to the chief coroner so that the
system of the chief coroner and senior coroners in local areas would be
paralleled by a national medical adviser to the chief coroner and a
series of medical examiners throughout the country. The two operations
would run in parallel.
The
establishment of the chief coroner is placed in statute, as are the
medical examiners, so I am unclear why the role of a national medical
adviser to the chief coroner is the only part of the jigsaw puzzle not
in the Bill. In its evidence to the Committee, the Royal Society of
Pathologists made it plain that it had been speaking to the Department
and was of the understanding that the post would be established. It is
clearly worried that it is not mentioned in the Bill, and that the
position is not made
clear. 4.45
pm Committee
suspended for a Division in the
House. 5
pm On
resuming—
Jenny
Willott: Why the national medical adviser to the chief
coroner is the only role not in the Bill is unclear. The role is
critical to how the new system will operate. The amendments and,
particularly, the new
clauses that we have tabled would establish the post of a national
medical adviser and enable the adviser, in consultation with the chief
coroner and the Secretary of State, to make regulations around
training, staffing levels, service provision and so on that would be
expected of the medical advisers, laying out the minimum standards
expected of medical examiners and requiring the local PCTs and health
boards to fund that minimum level of
standards. The
proposed provisions would ensure that training and basic minimum
standards were common across the whole of the United Kingdom, tackling
some of the problems that the coroner system has experienced up to
now—as discussed, the widely varying levels of expenditure,
support and what is expected of the system from the local authorities.
Establishing the role of national medical adviser, with the power to
make regulations regarding those minimum standards, would at least
establish medical examiners and ensure that they are not starting out
with the handicap that coroners have been experiencing. Given that, all
members of the Committee recognise that there are a number of
challenges for coroners based on the unevenness of funding and support
across the country. It seems a shame to set out a new structure that
does not get around some of the difficulties right from the start. The
chief coroner will clearly have an important role in managing and
ensuring consistency across the country for senior, area and assistant
coroners in the various regions. It is critical that the establishment
of the medical examiner system should have a similar central figurehead
and organisation that is able to ensure the consistency of funding,
standards and training across the UK, in parallel with the chief
coroner. It
has also been highlighted that, in the same way as medical examiners
will be important as a source of advice and support for senior coroners
in their local area, the chief coroner will similarly need central
medical advice to enable them to fulfil their role in operating the
coronial system successfully across the UK as a whole. I would be
grateful if the Minister explained why that is the one role not in the
Bill, given that it is such a fundamental part of how the system will
operate. It seems a strange
omission.
Bridget
Prentice: I understand the hon. Lady’s concerns
about the leadership of the medical examiner service, but I do not
believe it necessary to have the medical examiner role in the Bill as
she has described. That is partly because of what I said in the
previous debate about the role of the chief coroner being solely
responsible for violent or unnatural deaths, or for deaths from an
unknown cause or during state detention and so on. The chief coroner
and the senior coroner will not have jurisdiction over natural deaths,
so the remit of the medical adviser to the chief coroner ought not to
stray into the generality of deaths, except to the extent that I
described. On
several occasions, the hon. Lady said that the national medical
adviser’s job is the only one not included in the Bill, but
other jobs relating to the chief coroner are not covered, including the
legal adviser and some of the training specialists. I would be very
concerned by the idea that the chief medical adviser should have a role
in setting the regulations and I would not want to look at that at the
moment.
The Department
of Health will be introducing secondary legislation, as set out in the
clauses on death certification, and the role of the national medical
adviser in relation to medical examiners will be better defined in that
legislation. Our intention is that the national medical adviser will be
involved in agreeing protocols on the levels of scrutiny that medical
examiners must complete and how medical examiners will interact with
coroners, as well as agreeing job descriptions and being consulted on
the curriculum for the training that is required. The national medical
adviser will also be consulted on disputes that might arise between
coroners and medical advisers and on any conflict of views in
particular cases.
I ask the
hon. Lady not to press her amendments, but if there is a strong feeling
in the Committee that the role of the national medical adviser should
be included in the Bill, I will certainly consider the issue to see
whether it would be appropriate to return to it at a later stage.
However, the national medical adviser’s position does not need
to be statutory, and many others in similar circumstances are not. That
is why the national medical adviser is not included in the Bill at the
moment, but I will not set my face against including them
later.
Jenny
Willott: The Minister’s comments about the
difference between the role of coroners and the remit of the national
medical adviser in terms of deaths that are investigated could easily
be clarified in the Bill or in regulations. The remit of medical
examiners will clearly be significantly broader than that of coroners,
but both are included in the Bill, so there is no reason why the
national medical adviser could not also be in the Bill. The issue could
be clarified in regulations or in whatever way the Minister
chooses.
On the
regulations, I must confess that I am somewhat bewildered. The chief
coroner is to have the ability to lay out training requirements and
minimum standards in regulations, and I do not understand why there
should be a difference between the chief coroner’s powers and
the national medical adviser’s powers in that respect. Both have
a similar role in overseeing the two parallel parts of the system, and
it is somewhat lop-sided for the chief coroner to have powers in one
area, when the national medical adviser does not have similar
powers.
One of the
big issues with the coroners system over the past few decades has been
the lack of consistency. One issue flagged up by a number of the
witnesses who gave evidence to the Committee was the welcome for an
overseeing body in the form of the chief coroner, who would be able to
ensure some consistency. It would be a missed opportunity, in setting
up the medical examiners system, if we did not ensure that we had a
similar central body to ensure consistency across the UK.
However,
given the Minister’s comments about the ongoing discussions with
the Department of Health and the fact that things are still being
developed, I am happy not to press the provisions, although I hope that
the Minister will come back to us on Report with some progress. If not,
we may press the matter to a Division. I beg to ask leave to withdraw
the amendment.
Amendment,
by leave, withdrawn.
Clause 18
ordered to stand part of the Bill.
Clause
19Medical
certificate of cause of
death
Mr.
Bellingham: I beg to move amendment 359, in
clause 19, page 10, line 43, at
end insert— ‘(ca) provision
allowing any medical practitioner to notify the coroner of any concern
over the circumstances in which a person has
died;’.
The
Chairman: With this it will be convenient to discuss
amendment 104, in
clause 19, page 11, line 3, at
end insert ‘, including an
investigation into the drugs the deceased had been taking prior to his
or her
death;’.
Mr.
Bellingham: The purpose of the amendment is to ensure that
all medical practitioners have the right to report their concerns over
the death of a patient to the coroner, which would be an extra
safeguard in the post-Shipman era. The draft charter for the bereaved
entitles the relatives of a deceased person to report their concerns
over the circumstances of the death to the coroner. There needs to be a
similar right for medical practitioners to convey their concerns to the
coroner. As framed, the reporting mechanism to the coroner under the
Bill is confined to the attending doctor and the medical examiner.
There must be a provision to enable other practitioners, such as nurses
or other medical attendants, to make reports about their concerns
regarding the death of a patient to the coroner. That is what our
amendment is about, and I hope that the Minister will look at it
sympathetically and take on board what we have said.
I trouble the
Committee briefly with two other concerns that I have on the death
certificating process, in particular, death certificates. I raise the
case of Doreen Morris, which has been brought to my attention by two
local MPs who are concerned with her case—my hon. Friend the
Member for Clwyd, West (Mr. Jones) and my hon. and learned
Friend the Member for Beaconsfield (Mr. Grieve). Doreen
Morris was discovered dead in a badly burnt-out shell of a house, and
her body had been totally incinerated. The pathologists could not give
a precise cause of death because the body was too badly burnt, but
there was a need for the body to be released for burial, which happened
about a month after the tragic fire. A suspect was arrested and charged
with her murder in the following month. In July, an inquest was opened,
but it was adjourned because criminal proceedings had started. In the
mean time, a death certificate was issued, and the cause of death on it
was recorded as “not ascertained”. At the trial, the
suspect was subsequently acquitted—although Mr.
Justice Scott Baker concluded that Mrs. Morris had been
brutally murdered, and that she suffered an incredibly cruel and
callous
killing. So
there is no doubt about the arson, or whether it was an unlawful
killing—the only doubt was about the identity of the culprit.
The family was very upset indeed; they wanted closure of the tragic
case, and the death certificate to be amended to read “unlawful
killing”, because that undoubtedly was what happened. They
wanted closure, but there was a problem, because the coroner had to
adjourn the inquest for obvious reasons.
The certificate that was issued and sent to the registrar could only
state that the cause of death as was known as the time, which is why it
had to use the words “not ascertained”; it was not
possible at that stage to give a medical cause. The coroner decided not
to resume the inquest because it was impossible to ascertain exactly
how Mrs. Morris was killed—I believe that it is
common practice for the coroner not to resume the inquest in such
circumstances; but having said that, there was overwhelming evidence of
an unlawful
killing. There
are two possible courses of action open. The first is for the inquest
to be resumed, which the coroner decided not to do. Even if the inquest
had been resumed, the outcome would not have been particularly
satisfactory, because the only possible way that the coroner could have
gone some distance in satisfying the family would have been to place a
correction in the margin of the entry—in other words, it would
remain that the cause of death was not ascertainable, but in the margin
it would read “unlawful killing”. Alternatively, the
family could apply to the High Court, with the consent of the
Attorney-General, to have the original inquiry quashed, and have the
High Court direct the coroner to carry out a new inquest. Getting the
support of the Attorney-General and going through the whole process
would be incredibly time-consuming and
difficult. In
fact, as the Minister knows—someone wrote to her about the
case—the Attorney-General examined the case carefully. A letter
from the Attorney-General dated 21 October 2008 says that it is for her
to determine, based on the material provided, whether it is desirable
in the interests of justice that an inquest should be held. She said
that in this case, there is no issue over the identity of the deceased
or where or when the bereaved person’s mother died, and that the
question of how is normally interpreted narrowly to mean the cause of
death. She goes on to say that, regrettably, there was no evidence at
the time and there remains none as to the exact medical cause of death.
She said that, none the less, that does not prevent a coroner from
making a finding that the deceased had been unlawfully killed,
providing he is satisfied about the matter beyond reasonable doubt. The
Attorney-General held out a chink of hope, but decided not to give
consent for the family to go to the High
Court. 5.15
pm We
are not talking about the odd case. I have obtained a copy of the Home
Office statistical bulletin, supplementary volume two, on crime in
England and Wales 2006-07, dated 31 January 2008. Tables 102, 103 and
109 respectively show that in the 12 years to 2006-07, 1,353 offences
initially recorded as homicide currently have no suspect; the apparent
method of killing is not known in 477 offences currently recorded as
homicide; and 2,228 suspects were indicted for homicide when the
outcome of proceedings did not result in a conviction for that offence.
Over the 12-year period, there were a total of 4,058 cases in the
categories that I extracted from table 102 of the bulletin out of a
total of 8,671 cases currently recorded as homicides over the same
period. In other words, just less than half current recorded homicides
have the potential to give rise to the situation that I am talking
about. The
matter is of public interest and concern. I have not tabled an
amendment yet, but I reserve the right to
do so on Report. The Minister must look at the matter, which is of great
concern to families. It was raised in the evidence-taking sessions at
the beginning of the Committee, when I asked AndrĂ(c) Rebello and
Professor Furness about changing the death certificate. Professor
Furness said: “In
future, the certificate would not be issued until the relatives have
had the opportunity to discuss it with the medical examiner. One of the
key questions the medical examiner will be expected to put to the
relatives is whether anything on the proposed death certificate is a
concern.” The
Bill is going some way to sorting out that particular problem.
AndrĂ(c) Rebello then
said: “What
I would do in those circumstances is hold an inquest after ordering the
post mortem and before getting the result. I would then use the result
to conclude the inquest, and a new death certificate would supersede
the old one.”——[Official Report,
Coroners and Justice Public Bill Committee, 3 February 2009;
c. 55,
Q119.] That
would work if criminal proceedings did not intervene, but it would not
work if the inquest were adjourned because of criminal proceedings. I
would be grateful if the Minister took a close look at the
matter. I
have another concern based on a case that, again, I have had permission
to raise from the family involved. Sue Willis wrote to me from Pilton
in Somerset. Her husband, John, a reasonably young, incredibly fit and
active man, was admitted to hospital on 17 March last year with a
suspected inflamed gall bladder. They could not discover what was wrong
with John, and his health went downhill rapidly. On his 16th day in
hospital, he tragically lost his battle for life. What happened next?
Sue Willis
wrote: “I
was informed that I was required to register my Husband’s death
within a few days. To my surprise I was immediately issued with a death
certificate despite the fact that the cause of death had not been
established. I asked my Husband’s consultant about this and he
informed me that, in such circumstances, it was general practice to put
their ‘best guess’ on the death certificate to expedite
the funeral arrangements...In our case, their ‘best
guess’ turned out to be completely inaccurate. The death
certificate stated a heart condition as the main cause of death however
the post-mortem revealed it to be a Large B cell Lymphoma. I approached
the registrars at Southmead Hospital to request an amended death
certificate and was provided with almost the same certificate stating
the incorrect cause of death with a small annotation noting the post
mortem
result” in
a column at the bottom of the certificate.
Sue Willis
wrote to her MP and various other people. The Home Office Identity and
Passport Service wrote back to her,
stating: “I
appreciate that the circumstances surrounding your
late-husband’s death have been distressing. As far as the
registration is concerned everything has been carried out in accordance
with statute. The marginal note at the foot of the registration, which
is repeated on any certificates issued, shows that following
post-mortem without inquest the cause of death was found to be large
B-cell
lymphoma.” That
note has been put in the margin, but the certificate puts down the
cause of death as the result of a heart attack in hospital.
This is a
severe and serious problem that the Minister must address. I appreciate
the difficulties regarding death certificates, but I want to ask how
often medical practitioners use the best-guess formula. In the future,
medical examiners will be appointed, and presumably the chances of best
guesses being put on the certificate
will be greatly reduced. A medical examiner will want to look at the
matter, investigate it and talk to the family—I am probably
making the Minister’s case for her. However, there might still
be the odd case where the certificate gives the wrong cause of death, a
subsequent post-mortem indicates the exact cause of death and the
family are distressed. Regarding
large B-cell lymphoma, what will happen in one or two future
generations’ time when the relatives of John want to check
medical
conditions?
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