Coroners and Justice Bill

We come now to Clause 5 and my Amendment 7, which is grouped with other amendments. The amendment would replace the words, ""how, when and where the deceased came by his or her death"." The purpose of the amendment is to bring Clause 5, and with it the statutory framework of the coroners system, into line with the recent jurisprudence of the Judicial Committee of your Lordships’ House. Under Article 2 of the European Convention on Human Rights, on the right to life, Governments are required to, ""establish a framework of laws, precautions, procedures and means of enforcement which will, to the greatest extent reasonably practicable, protect life"." The European Court of Human Rights has interpreted this as mandating independent official investigation of any death where public servants may be implicated. In the landmark House of Lords case of R v Her Majesty’s Coroner for West Somerset ex parte Middleton, their Lordships ruled on 11 March 2004 that in cases where Article 2 of the European Convention on Human Rights is engaged, the outcome of the inquest as currently provided for in the England and Wales coroners rules by the phrase, ""how the deceased came by his death"," should be interpreted as, ""in the broader sense previously rejected, namely as meaning not simply ‘by what means’ but by what means and in what circumstances"." Those are the words that I tabled and that appear in the Marshalled List. Their Lordships were essentially seeking to imply a clearer, wider and more robust requirement upon the coroner’s investigation into a contentious or complex death to look at the circumstances around the death in addition to its factual cause. This amendment takes verbatim the very words contained in that judgment—"what means and what circumstances"—and places them into a statutory requirement upon the coroner. Like Amendment 2, which I moved earlier, this amendment arises from a proposal put forward by Dame Janet Smith following her own experiences with the Shipman inquiry, which she chaired. It rests on Article 2 of the Human Rights Act, which imposes the duty I have mentioned to undertake a full investigation of the cause of death. In the case of Middleton, to which I referred, our courts have spelt out when Article 2 needs to be engaged and the way in which words such as "how" are to be construed. In meeting that requirement I have used the old rubric, ""by what means and in what circumstances"." Those are the words that my amendment seeks to incorporate in the interests of clarity. There are a couple of instances where the absence of this rubric might militate against the interests of the victim or their family. For example, a road traffic accident might initially appear straightforward, but what if the accident occurred because of negligence in maintaining the motorway or some other corporate failing? Detailing the circumstances in which a death occurred is manifestly important. What if a seemingly natural death in a hospital were in reality caused by dismal hygiene or neglect by the NHS? I cite the specific example of Stafford Hospital, which was highlighted in March. I quote from a BBC report entitled "Failing hospital ‘caused deaths’". It said: ""A hospital’s ‘appalling’ emergency care resulted in patients dying needlessly, the NHS watchdog has said. About 400 more people died at Stafford Hospital between 2005 and 2008 than would be expected, the Healthcare Commission said. It said there were deficiencies at ‘virtually every stage’ of emergency care and managers pursued targets to the detriment of patient care"." The then Secretary of State, Alan Johnson, ""said a review of Mid Staffordshire NHS Foundation Trust, which runs the hospital, would be carried out, focusing on the years 2002 to 2007"." I deliberately mention the long period of time that the Secretary of State’s review is covering because clearly these were not instances that were picked up in coroners’ investigations carried out during that time, as I think we would all agree they should have been. I agree with Mr Johnson when he says, ""there was a complete failure of management to address serious problems and monitor performance. This led to a totally unacceptable failure to treat emergency patients safely and with dignity"." Such failings will undoubtedly occur again. It is in the nature of the way that we run our hospitals and our public services that awful serial mistakes can sometimes be made with tragic consequences for all those involved. Part of what the Shipman inquiry tried to identify in the case of a doctor who had been taking the lives of his patients was that where a pattern emerges, it should be identified at a very early point. By not having in the Bill these words, which appear in the European Convention on Human Rights, we are perhaps failing to recognise a gap that needs to be plugged. That is why it would be good to incorporate these words in the Bill which Dame Janet Smith, who carried out the inquiry, believes to be necessary. I hope that the Minister, who has sat patiently throughout our proceedings and listened to this speech, will think carefully about this and even if he cannot accept the terms of the amendment today, perhaps he will give it further thought between now and Report.