Coroners and Justice Bill

Amendment 2 stands in this group and is in my name and that of my noble friend Lady Finlay of Llandaff. I strongly support the point on clarification that the noble Lord, Lord Kingsland, has just made. I look forward to hearing the Minister’s response. Amendment 2 would add to the Bill, ""or when the coroner has reason to believe that the circumstances of the death were such that, in the public interest, the death should be investigated"." At the beginning of 2008, following the delays in implementing many of the recommendations that arose from the murder of patients by Dr Harold Shipman and the subsequent murder in 2002 of patients at Leeds General Infirmary by the nurse Colin Norris, I tabled a series of Questions to the Government. The Shipman murders had led to an inquiry, which published six reports and 228 recommendations at a cost to the public purse of some £21 million. Weaknesses were discovered in the death certification process; the requirement for one doctor alone to certify a death and decide on referral to a coroner; and the failure to cross-reference notified deaths and look for trends and patterns. Among the 228 recommendations were many other proposals to strengthen the system of public protection. After Shipman’s trial, the inquiry, chaired by Dame Janet Smith, decided that there was enough evidence to suggest that Shipman had probably killed around 250 people, of whom 218 could be identified. About 80 per cent of his victims were women. In the case of Nurse Colin Norris, on 8 March 2008, he was convicted of murdering four elderly patients and attempting to murder another. Mr Justice Griffith told Norris, in sentencing: ""You are, I have absolutely no doubt, a thoroughly evil and dangerous man. You are an arrogant and manipulative man with a real dislike of elderly patients. The most telling evidence was that observation of one of your female patients, Bridget Tarpey, who said, ‘He didn’t like us old women’"." On 25 March 2008, the noble Lord, Lord Darzi, in responding to my Written Questions about these events, stated: ""I understand that the Yorkshire and Humberside Strategic Health Authority is arranging for an independent investigation of the events at Leeds General Infirmary and it would therefore be inappropriate to comment further at this stage".—[Official Report, 25/3/08; col. WA81.]" Later, on 21 May 2008, the noble Lord replied to my Written Questions about the Shipman recommendations, stating: ""Clauses implementing these important reforms will be included in the coroners and death certification Bill announced as part of the Government’s draft legislative programmes for 2008-09"." He also stated: ""The Government believe that these proposals represent a transparent, proportionate, consistent and affordable response to the weaknesses identified by the Shipman inquiry that will provide greater protection for the public and improve the quality and accuracy of death certification".—[Official Report, 21/5/08; col. WA196.]" I recognise, as I told the noble Lord, Lord Bach, at Second Reading, that this Bill goes a long way in trying to prevent a repetition of these appalling crimes that took place in the north of England. However, there are still anomalies in the law that could allow cases such as those that I have described to slip through. At Second Reading, I asked the Minister how many of the 228 recommendations of the Shipman inquiry had been incorporated into this legislation, and what further measures would be needed to deal with the failings identified by the Norris inquiry. Last week I called the Minister’s office to indicate that I would pursue the question today. I hope that it will now be possible to answer that inquiry. For the sake of clarity, I inform the Committee that I met Dame Janet Smith with my noble friend Lady Finlay of Llandaff. We discussed the amendments that I have tabled to the first part of the Bill. They have been tabled in consultation with Dame Janet Smith and try to close the gap that still exists in the legislation. Out of courtesy, I copied details of the amendments in advance to the noble Lord, Lord Kingsland, and the noble Lords who represent the Liberal Democrat Front Bench. I believe that the incorporation of the amendments standing in my name would improve this legislation and go a long way to answering Dame Janet’s concerns. In particular, I take the Committee to page 54 of the Ministry of Justice document published on 21 May 2008 entitled, Statutory Duty for Doctors and Other Public Service Personnel to Report Deaths to the Coroner, (CP(R) 12/07). Paragraph 6 states: ""Coroners have a broad duty to investigate unnatural deaths, as well as all deaths which occur in custody or other state detention or during the course of police operations. There was a general consensus that the right categories of deaths were included in the consultation paper flowing from this general definition. Many helpful suggestions were put forward to help clarify the detail. Following the consultation process, we believe that the following categories of cases that should be referred to the coroner will provide the basis for further work and consultation"." I shall give the Committee details of what appears in that list. I know that the Government have an inbred dislike of including lists in legislation so I am not inviting them to include the entire list but these were the conclusions that were registered by the Government themselves in answer to the consultation paper. My amendment seeks to take the list and in a generic way provide a trigger mechanism for investigating any deaths that might fall into these categories. The list in the document refers to: ""death resulting from self harm and neglect (excluding deaths from alcohol or nicotine abuse where the death would not be investigated but for those reasons); death resulting from neglect or abuse where there is an established duty of care by a public authority, other organisations and individuals; death occurring during or shortly after a period of detention; death caused or contributed to by the conduct of the police or any other state authority or public organisation; death relating to past or present employment; death resulting from lack of care or appropriate treatment, defective treatment and adverse reaction to prescribed medicine; death of a child where it is unexpected; death where a violent crime is suspected; sudden and accidental death, and deaths resulting from traffic incidents; where a death has not been certified as the doctor is unable to identify with any confidence the cause of death; death where there is reason to believe it may have been caused or contributed by a disease or condition that has been specified as being reportable to the coroner because of ""regional social history, for example lung disease caused through working in the coal industry; and death associated with pregnancy and childbirth"." Let us take that last category alone, ""death associated with pregnancy and childbirth"," or deaths in hospitals through, say, the outbreak of MRSA, or a disease such as sepsis where bereaved families might well believe that a loved one has died through negligence and yet the cause of death might not appear to be unnatural. I refer the Minister to page 18 of the response to the consultation document and the specific request of Dame Janet Smith and Her Honour Mrs Justice Swift, who specifically asked that some of the categories to which I have just referred should be incorporated in the legislation as a way for people who feel that the system has not responded to their concerns to be assured that the matter will be addressed. This amendment is designed to provide a catch-all for all those categories in the list I mentioned which are not spelt out in the Bill. It would remedy the disconnect between what the doctor has to report and what may warrant an investigation in the public interest. I have with me a copy of the final death certificate issued by Harold Shipman. It was given to me by Dame Janet and details the death of Mrs Kathleen Grundy. She died at the age of 81 on 25 June 1998. The day before her death this elderly but sprightly and healthy lady had provided hospitality for her elderly friends at a club she attended. Her death certificate simply records that "old age" was the, ""disease or condition directly leading to her death"." We owe it to the memory of victims of Shipman such as Mrs Grundy to get this right. We also owe it to Dame Janet and her outstanding colleagues who have provided such a remarkable public service in their meticulous and comprehensive inquiry. I hope that the Minister will feel able to respond positively to the amendment that I have laid before your Lordships’ House.