Beith's Committee accuses Government of "wasting golden opportunity" to reform "Victorian" death investigation system

3.45.00pm BST (GMT +0100) Tue 1st Aug 2006

Berwick MP Alan Beith, Chairman of the House of Commons Constitutional Affairs Committee, has led a review of the system of Coroners' Courts. In a report published today, the Committee accuses the Government of "wasting a golden opportunity" to reform the system of death certification and investigation in England and Wales, which dates partly from Victorian times and partly from much earlier. The Committee's report on "Reform of the Coroners' System and Death Certification", published today, Tuesday 1 August 2006, says that although the Government's recently published draft Bill on Coroners Reform will do much to improve the coronial system, it will do nothing to remedy the "critical defects in the death certification system".

Alan Beith said,

"The system of coroners and death certification is in urgent need of reform on at least two counts: there is enormous variation in standards, and the system failed to detect a major serial murderer. This is therefore an opportunity not to be wasted: we must strongly recommend that the Government rethink its plans, and that it incorporate reform of death certification. Attempting to reform the system without reforming the way it is funded likely to prove a failure. There is also a danger that bereaved families in some areas may have to deal with a less accessible and more remote service.

"We heard evidence from many people, including the Coroner for North Northumberland, Ian McCreath. There is a very real opportunity that experienced staff will be lost - with no certainty about the future for the Coroners' Service, and worries about job security, they may well be applying for other positions."

The Committee's report argues that the coronial system lacks national direction, with wide variations in regional practice, and that under the reforms proposed in the draft Bill the coronial system remains essentially locally resourced. The legal framework for the functions of a coroner is by no means clear. "The police and local authorities provide varying degrees of financial and administrative support for the coronial system, there are also hidden subsidies, the magnitude of which is almost impossible to calculate. The system is beleaguered, with insufficient training for coroners and their staff, inadequate funding, a lack of facilities and uneven distribution of resources, leading to inconsistent levels of service across England and Wales."

The Committee recommends that the Government create a national service with central and adequate funding so that all coroners are able to work to the same high standards. "The proposed reforms lack detail and fail to tackle adequately the resource and structural problems currently facing the existing, outmoded coronial system. A national service would almost certainly involve significant extra cost, but the failure to introduce one will mean that the current inequalities of resource will continue."

The Committee urges Government to revise its policy to not reform death certification, saying it should return to the proposals put forward by the Home Office in 2004, and ensure that they are supported with sufficient resources. At present there is no statutory duty on doctors or police to refer deaths to the coroner, and it can be difficult for them to know in which cases they should. Dame Janet Smith, chair of the Shipman Inquiry, said in her evidence to the Committee that the reforms proposed in the Bill "would go no way at all towards remedying the defects that failed to detect or deter Shipman. If these reforms go through - and they are good in themselves and I have no criticism of them in themselves - there could still be a Shipman out there killing patients".

The Committee concludes that, because neither DCA nor the Department of Health is taking responsibility for death certification, "if anything specific is being done at all, it amounts to tinkering at the edges of a system which has already been deemed unsafe and unsatisfactory by two Government-commissioned reviews".