Coroners and Justice Bill

I will speak to a number of amendments in this group in my name and that of my noble friend Lord Thomas of Gresford and in the names of other noble Lords. There are two elements to the consideration of Clause 5. The first is what people—particularly the bereaved and the family affected—generally expect of a coroner and a coroners’ court. They expect that, in an experienced, thoughtful and wise non-adversarial investigation, someone with judicial qualities will be able to get to the bottom of what happened and explain that to them. Many of these issues are complex and highly unlikely to be fully described or properly conveyed with a narrow, diagnostic mandate. The second consideration is that we have been faced, as the noble Lord, Lord Alton, has pointed out, with decisions of your Lordships’ House in a judicial capacity that show that the human rights convention requires us to go much further than would have been the case in the past. Those are two important components. What is somewhat disappointing about this clause is that it appears to be saying that, although we have to accommodate the human rights convention, we will do so as narrowly as we possibly can, rather than opening it up and giving as wide as possible opportunities for the coroner to explore things and to describe them for the benefit of the family and the community and of wider knowledge. The noble Lord, Lord Alton, and the noble Baroness, Lady Finlay of Llandaff, have begun to try to open up the thinking and the possibilities that might be available to the coroner. In these amendments, we have tried to add to conformity with the human rights convention the interests of justice. We should be doing things not just because we are being forced into it—because we have signed up to the convention—but because it is the right thing to do and opens things up in the interests of justice. What things could reasonably be considered? We have tried to enumerate a few, but the list is not exhaustive. For example, to what extent were systemic failings a factor in the death, or what appropriate precautions could have been taken? If a person takes their life, was the risk of their doing so not recognised, whether whole or in part, by people who were acting on behalf of the state? There are other factors of this kind, but I often find it useful in these circumstances to give an example. Here, I declare an interest as a consultant psychiatrist working in the National Health Service. I shall go back to a fairly early experience of my own. A man was in hospital in an extremely distressed, depressed and psychotic state. He believed that he was responsible for all sorts of terrible things that had been happening. There had been a disco disaster in another country, with a terrible fire and a lot of people killed. He believed that his thoughts had contributed to this terrible business. He was not very forthcoming to the staff in general, but, as a young doctor, I spent some time with him and he was prepared to talk a bit more to me. I realised that this man was very disturbed and very likely to kill himself. I explained the situation to my consultant boss. He said, "Well, I think we need to make sure that nobody allows this man out of the ward. This is very dangerous; he’s going to harm himself". Rather foolishly, 100 years or so previously, those who had designed the hospital had put it not very far from a railway line, so we knew that there was a serious risk to this man. When the man said to one of the nursing staff, who was a very kind person, "Look, I’m very anxious; I’m in a terrible state and I just want to go over to the hospital shop to buy myself some cigarettes to help myself calm down", the nurse felt that it was not a wholly unreasonable demand. But the man never returned to the ward. He went straight down to the railway line and threw himself on top of the next train. To describe that simply as a man who was an in-patient in a hospital and committed suicide is not very helpful. It does not tell us what happened; it does not tell us what could have made sure that it did not happen; it does not tell us whether systemic failings or professional failings were to blame. We should know not because we are out to attribute blame and liability but because, if we understand what actually happened, that often helps the family and it could help hospital staff and others to deal more appropriately with things. Unfortunately, Clause 5(3) gives a fairly robust indication that nobody should say anything except the least that they can say—the coroner and the jury if one is involved should be very careful about what they say—whereas in many ways we should try to encourage people to be as openly thoughtful as they can be. There are of course reasonable and proper, as well as professional, limits to what people should say and do. The amendment suggests that, rather than simply saying that the human rights convention has forced us down a particular road, we should embrace it and ask whether we can open up our verdicts to be more narrative and explanatory in their design and approach, taking some responsibility to point up any of the systemic or other failures or problems that have arisen during an appropriate investigation. This is not an adversarial but an investigatory system of judgment, which can bring help and comfort to families and enable them to understand more of what has happened, as well as helping the system to develop and improve by learning from sometimes painful experience.