Coroners and Justice Bill

I rise to speak for the first time on the Bill. I was unable to be present at Second Reading, but I want to express my thanks to my noble friend Lord Patel for his generosity in incorporating my main points in his Second Reading speech. I turn to this group of amendments, in which I have two with slightly different implications. We come to address the rules that deal with when a coroner must call a jury. The amendments would ensure that all deaths in custody in state detention, including deaths of those detained under the Mental Health Act and those held under the Immigration Acts, were automatically investigated at an inquest held before a jury, including those where death is presumed to be of natural clauses. I should declare at the outset an interest in this point as a psychiatrist and a former Mental Health Act commissioner who spent far too many months of my life on various inquiries into homicides, untoward incidents and quality-of-care examinations in special hospitals’ regional secure units and local psychiatric units. It seems that the new legislation weakens the current position in some respects, where some inquests following deaths in custody are held before a jury, although not all in the case of detained patients. The jury is at the coroner’s discretion but is held where the death occurred, ""in circumstances the continuation or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public"," a phrase that has encouraged a coroner to call a jury where there is a suspicion of contributory neglect. It is, however, still common for a coroner to decide not to call a jury in the case of the death of a detained patient. It is worth reminding ourselves at this point that juries are convened in only about 4 per cent of coroners’ inquests and the amendments would not extend that percentage much. The new provision states that inquests into deaths occurring in detention and custody will take place only before juries where the death was violent or unnatural, where the cause of death is unknown, where a member of the police is involved and where the death was due to a notifiable accident, poisoning or disease, or otherwise where the senior coroner believes that there is sufficient reason for doing so. It is therefore possible that significant numbers of deaths that would previously have been investigated before a jury will not automatically receive the same scrutiny. On the face of it, the provision seems sensible. It means that apparent deaths of natural causes of aged people with terminal illness or those who are otherwise expected to die within a short time will not be dealt with in this way. I hope to convince noble Lords that that should not be the case and that there are good reasons for having a jury when people are in closed, locked institutions. My anxieties arise from a current case, which I will mention, and from working as a psychiatrist in the past in mental health units remote from district general hospitals—indeed, all special hospitals and regional secure units, and many psychiatric units are remote—where I and many other psychiatrists experienced difficulties in getting adequate physical healthcare for our patients. I have had experience of sitting on inquiries and also of the reports made voluntarily to the recently defunct Mental Health Act Commission of the deaths of detained patients. We also know from social research about poor access to healthcare and the very high mortality rates of mental health patients. A current case I want to mention is that of Mrs Sandra Allen, a 61 year-old woman who was detained in a north London psychiatric hospital under Section 3 of the Mental Health Act for a recurrence of her manic depressive illness. She died of natural causes—a heart attack—in 2006. The inquest was held without a jury. The coroner ruled that she died of natural causes which were unavoidable, but her children are challenging the verdict because they believe that their mother’s death could have been avoided with better care. They claim that she was neglected. The circumstances were as follows: Mrs Allen, who was 61, died from a heart attack after choking on a sandwich which she had been left to eat unattended. She had no dentures and a long history of choking, possibly as a result of medication she was taking. The staff were inexperienced in dealing with the situation; they were unable to clear her airways and did not know how to operate the oxygen canister which was provided on the ward. She was still choking when the ambulance arrived; it waited several minutes outside the unit because the security guard was asleep and the ward was locked. The ambulance staff simply did not get in to help her in time. Her family has argued that the coroner was wrong to reject its request for an inquiry before a jury, since it felt that much of the psychiatric and physical care she received was unacceptable and contributed to her untimely death. I can remember another very similar case: a patient of mine needed urgent coronary angioplasty; he was difficult to manage but I believe he could have been cared for on a normal hospital ward with psychiatric advice. The cardiac surgeon procrastinated under circumstances in which any other patient would have been treated as a matter of urgency. The patient died of a heart attack within a couple of weeks. Again, the finding was of natural causes. When I was a practising psychiatrist, I often had great difficulty getting adequate specialist consultant advice for patients. Mental health nursing staff were often inexperienced in dealing with physical conditions and reluctant to refer patients to a district general hospital because of the stigma and fear that the patients generate, sometimes with the best of intentions. Matters have improved considerably, I believe, in special hospitals and regional secure units, but it seems to me to remain crucial that relatives of detained patients who die in state custody, even when it appears to be a completely natural and expected death, should be exposed to a manner of inquiry which gives the public the greatest confidence. I have often been struck by the distress, anxiety and suspicion that relatives have when what is apparently a natural death has not been fully exposed to scrutiny. If the sister of David Bennett—sometimes called Rocky Bennett—had not articulated very clearly before a jury the circumstances of his death in a regional secure unit, I doubt whether the conditions there would have been fully exposed. Reports of the recently defunct Mental Health Act Commission have exposed the difficulties in obtaining adequate care in many units. There are approximately 300 deaths notified to the commission every year from psychiatric units of deaths in untoward circumstances. That is quite a significant proportion of the number of all patients dying in psychiatric units. There is a race and culture dimension to the problem. Black patients currently make up 30 per cent of patients detained in high-security psychiatric hospitals, 40 per cent of those in medium-secure settings. The black population is at much higher risk of diabetes, stroke and cardiovascular disease, and at an earlier age. They therefore have difficult responses sometimes to some of the drugs that are given in psychiatric units. It is crucial, of course, that they have good access to care but that we do not misinterpret deaths of detained patients from natural causes as due to poor care if they have had the best care and advice. Services must not only be doing their best but be seen to be doing their best. The Disability Rights Commission report, Equal Treatment: Closing the Gap, highlighted the profound differences in smoking-related disease and increased mortality of those with learning disabilities and serious mental health problems, an unpredicted doubling of the rate of bowel cancer in people with schizophrenia and the very poor access to healthcare by people with serious mental illnesses and learning disabilities. We need to pick up when care goes wrong in closed units if we are to improve awareness and support families who want to understand what happened to their relatives. Finally, it is worth commenting on the sharp decline in the numbers of deaths of detained patients in psychiatric hospitals, probably not because of better care but simply because the age profile has changed dramatically, and older, long-term patients are now cared for in care homes and nursing homes. This means that the number of patients for whom an inquest with a jury would be required would be relatively small. I listened very carefully to the debates yesterday, and think it is important to make it clear that I am not trying to extend the coroner’s role of finding and establishing the cause of death into the more narrative areas that we were trying to avoid. There is no doubt that finding a cause of deliberate neglect or omission or commission of care is a very important part of a coroner’s fact-finding mission. The public need to have every confidence in a system which is as open as possible, and the public believe in juries. I beg to move.