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Coroners’ System and Death Certification

Volume 457: debated on Thursday 8 March 2007

[Relevant documents: Eighth Report from the Constitutional Affairs Committee, Session 2005-06, HC 902, and the Government’s response thereto, Cm 6943.]

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Cawsey.]

Before we begin the debate, I remind hon. Members that proceedings in coroners’ courts are covered by the House’s sub judice resolution. Reference should not be made to particular cases.

It is a great pleasure to see you chairing the debate, Mr. Weir. You can enjoy listening to discussion of a system that Scotland manages to do very well without—a point to which I shall return.

In July 2006, the Select Committee on Constitutional Affairs published a report on reform of the coroners’ system and death certification, which is the subject of today’s debate. The Government’s draft Coroners Bill on reforming the system was not published until the day before we started our inquiry. We welcomed it in principle, but strongly criticised its details. The Bill did not make it into the Queen’s Speech. This debate therefore provides an opportunity to raise our concerns and to establish what the Government will do now.

The coroners’ system is one of the oldest features of our legal system and has probably been subject to less change than any other part of the system. Its present shape is very much what it was in the 19th century, with coroners exercising a strictly limited geographical jurisdiction in a personal capacity and drawing their very limited resources of support in a variety of ways from local authorities, police authorities or, in rural areas, the offices of their own legal practice.

The system has some strengths. The office of coroner has a recognised authority, drawn partly from its long history. The coroner is usually a locally known and respected figure who serves the same jurisdiction for a long time and enjoys support in the local community. Many coroners’ staff and coroners’ officers, who are often ex-police officers or even serving police officers, are dedicated, considerate and kind in their dealings with bereaved families.

Coroners have been at the forefront of demands for reform and very much welcomed the Government’s declared intention to embark on reform. The system is under severe strain and, in some cases, has been brought almost to the point of collapse by the limitations on its ability to cope with some major problems. The Harold Shipman case severely tested confidence in the coroners’ system and, even more, in the system of death certification and registration.

Those two systems need to be reviewed together. The failure of the Bill to do that led Dame Janet Smith, who conducted the Shipman inquiry, to say that the Bill would not prevent another Shipman. Similar concerns were expressed in Tom Luce’s very thorough, fundamental review, which was entitled “Death Certification and Investigation in England, Wales and Northern Ireland: The Report of a Fundamental Review 2003”.

A series of terrible accidents involving multiple deaths, such as the Marchioness tragedy and the Potters Bar and Paddington rail crashes, have exposed the difficulty of relying on a wholly local system. Such disasters are not new, but public expectations of the coroners’ system in such cases are much higher now than they used to be. The London bombings led to extraordinarily complicated arrangements to deal with the fact that bodies and body parts were located in different jurisdictions.

There has been a particular problem in the Oxfordshire jurisdiction, because almost all those killed on active service in Iraq or Afghanistan have been flown back to Brize Norton, generating a need for large numbers of inquests, some of them raising important and difficult issues, such as the need to obtain evidence from allied forces abroad. Huge delays have built up, resulting in distress to bereaved families of our service personnel. The Minister has sought to help by providing the Oxfordshire coroner with deputies and administrative support, even though it all had to be done informally, with no central legal authority.

The Princess Diana inquest raises issues that cannot be discussed, for the reason that you have explained, Mr. Weir—it is sub judice—but if I may just mention in passing that we now have the oddity of one of the most experienced retired senior judges in the land becoming the assistant deputy coroner of Inner West London, I think you will understand that the case has thrown up some of the system’s problems.

Of much wider significance has been the impact of a variety of changes in the way that we live our lives and the way that public services are provided. The fact that people travel much more, for example, makes the strict geographical limits on jurisdiction unrealistic. To take another example, in the modern health service, it is increasingly unlikely that a doctor is available to sign a death certificate, perhaps at night or at the weekend, who has seen or treated the patient in the past 14 days, which is a requirement and enables the doctor to give a reliable and specific cause of death or to recognise that the case should be reported to the coroner. The way in which health services are delivered now makes it very unlikely that someone can get the same doctor in the same place.

The Government Bill set out to tackle many, although not all, of those problems. It did not tackle the issue of death certification, on which witnesses from both the Department for Constitutional Affairs and the Department of Health seemed unfocused and evasive when they appeared before the Committee. That issue was the subject of a separate statement from the Government in February entitled “Learning from tragedy, keeping patients safe”. That is a welcome step forward, which I shall consider later in my speech. The Minister held a day of consultation with a panel of bereaved people in November 2006, the evaluation of which was published last month. The Minister gave a written statement on 30 January about strengthening the public protection role of coroners.

Where does all that leave us? We should start by identifying what the systems of coroners and of death certification are for. I see the objectives as, first, to establish the cause of death when there is any uncertainty about it and to decide whether the death could and should have been prevented; to draw attention to public protection issues that arise from preventable deaths; to prevent and deter malpractice; and, in the case of the death certification system, to provide statistical information that can guide health policy.

A number of other countries have coroners or comparable systems to achieve those purposes, although the duties are different in several cases. In Scotland, as I mentioned, there are no coroners. Deaths of uncertain cause are reported to the procurator fiscal, who will investigate to establish whether a criminal offence is involved. He can hold a fatal accident inquiry, which is similar to an inquest, but that is done only in very rare cases. Post-mortems are also rarer in Scotland. We asked witnesses whether they saw advantages in that system, but the general view seemed to be that, in England and Wales, the system of coroners holding inquests in a significant number of cases was worth keeping and was important to families and the public.

Dealing first with the structure of the system, the Government propose to put in place a national chief coroner, to oversee and support full-time local coroners. There would be a chief medical adviser, access to medical advice for local coroners, an inspection system and national training. We said in recommendation 8 of our report that that model was not adequate, because it did not remove the limitations of the local system and because it did nothing to resolve the uncertainty about who was to pay for the service. It cannot make sense to go on with a system in which some coroners have to rely on police authorities paying for coroners’ officers or providing them without charge, while those facilities are provided to other coroners by a local authority. Such is the pressure on police and local authority budgets that such uncertainty carries the risk that some funding will be withdrawn, and it offers no basis for major improvement in the service.

One coroner who provided material to us, the coroner for Essex and Thurrock, said:

“The number of reported deaths in Essex has risen steadily but Essex Police have not increased the number of Coroner’s Officers accordingly and have, moreover, withdrawn the provision of deputy Coroner’s Officers to cover periods of leave and sickness. There is no resilience whatsoever in the system which is completely overwhelmed at a time when the pressures upon the service are greater than ever and mounting…this intolerable situation can at times result in more distress for the bereaved.”

Does the right hon. Gentleman agree that the problem is not only lack of capacity locally? There is downright incompetence in some coroners’ offices, which leads to a lot of heartache for relatives who are waiting for inquests to be heard, yet it is very difficult to remove a coroner.

In a sense, it is right that removing a coroner, as a judicial officer, should be difficult—it is difficult to remove a judge, which requires an address of both Houses of Parliament—but it should not be impossible. There should be adequate means of dealing with the low levels of performance that can arise in virtually any profession and that all other professions have had to find ways of dealing with. Similarly, in the case of coroners’ officers, training has been provided very sporadically so far, because it has not been built into the system properly. In respect of both coroners and coroners’ officers, the present system does not deal effectively with the situation that the hon. Gentleman describes, of which a number of us are aware as a result of cases in various parts of the country.

Let me pursue the same issue for a moment. I tried to support victims’ families and survivors after the Marchioness sank. Colleagues might know that the first coroner in that case was the subject of an appeal and that another coroner was appointed, because there was great dissatisfaction with the first coroner’s performance. That was not the first time that such a case was brought. Should there not be a mechanism short of address by Parliament to allow a coroner about whom there is great dissatisfaction to be removed more immediately and effectively? There is real discontent about inequality in the quality of service around the country. Some coroners in charge of their own courts have acted in a way that is entirely unacceptable for public confidence.

My hon. Friend makes an important point. The object of the Government’s reform ought to be to deal with such matters by doing what is done with the judiciary. If a judge is thought not to be the right person to deal with a case, perhaps because he does not have relevant experience or because he has interests that would make doing so inappropriate, another judge can be found; it is a national judiciary. There is no similar system with coroners’ jurisdiction. That is why Ministers have to send High Court judges and senior barristers to be deputy coroners in Oxfordshire. I refer not to the competence of the coroner in that case, but to the overwhelming nature of the task with which he was faced.

There is no central system by which to move coroners around to deal with particular cases. Neither the Minister nor anyone else has the power to do that. There are perhaps two aspects to this issue. I have talked about removing a coroner from office on the grounds of misconduct or unsuitability, which should be difficult, but a national system should be able to fit a coroner to a particularly difficult case and deal with someone who is not capable of handling a certain level of case. I have concerns about the proposed system.

I want to give a very different illustration of the pressures caused by the current system. In rural areas, in my part of the country, it is common for the police officer who happens to be on duty when and where a death occurs to assume the role of coroner’s officer for that case, but it is not certain that chief constables will always be ready to agree to such an ad hoc arrangement. Neither is it certain that the relevant officer has the necessary training to act as a coroner’s officer. He might simply be a local constable who was on duty when a death occurred. The complications of getting someone else to serve as the coroner’s officer have hitherto prevented any other solution.

I am grateful to the right hon. Gentleman for producing a fabulously comprehensive report. I am here at the behest of my local coroner, Mr. Robin Balmain, who wrote to me on this subject. His letter says that he never sends an officer to investigate a death because of the pressure of work—they are all deskbound—and that

“A great many deaths accordingly, are not properly investigated at the time they happen.”

Does the right hon. Gentleman have anything to say on that?

The hon. Gentleman vividly illustrates some of my points—namely, that the system is under severe strain and that coroners are well aware of that and want change, because those difficulties are a constant in their daily lives. Unless we have a system in which both coroners and the resources and staff available to them are properly co-ordinated and of a sufficient standard, we will not solve the kind of problems that he describes and things that should be done will be left undone.

There is another side to all this. Sometimes the system is caught up with things that probably do not need to be done. There are inquests and investigations into cases that frankly do not merit them because there is no uncertainty. The current problems can be solved without a limitless commitment of resources, but the fundamental problem is the lack of a national system.

Our views on this issue were shared by most respondents to the consultation. The Government, in their response, assert their belief that the local system is the “most effective reform model”, but I do not believe that. I think that they believe it is the only model that the Treasury will accept; that is what lies behind this. I believe that there is a better model that they cannot get the Treasury to accept.

If the Government are determined to proceed without creating a national and nationally funded structure, the only alternative is for the provision and administration of support for coroners to become a much more clearly defined local authority responsibility, without dependence on police authorities and with clear responsibilities for the recruitment and training of coroners’ officers and staff. However, local authorities would need additional resources to do that, so police authorities might lose some resources.

Under such a system, coroners would need to retain their independent status and would look to the chief coroner on legal and disciplinary matters. They could rely on nationally agreed levels of support from their local authority or group of authorities. That system is second best, but it is more or less where the Government are heading—and with nothing like enough clarity about who will be responsible and who will pay the bills. While all that is being considered, people who work in the system face severe uncertainty about their future, and experienced people might leave to develop their careers elsewhere, because they simply do not know whether they will have a future in a substantially modified system.

The Committee also pointed out that, although we agree with the introduction of a system of full-time coroners, it will not be possible to retain an accessible service in some rural and remote areas without the support of some locally based deputies. People should not have to travel huge distances to inquests. It is not simply a matter of the proposed coroner for the northern counties driving to Whitehaven or Berwick—journeys of hundreds of miles—to hold an inquest; it is about having accessible coroner’s offices in those communities. That way, families have a point of contact, coroners and their staff can talk things through with families, and unnecessary delays with burials and cremations can be avoided. There are further problems in communities close to the Scottish border, where a coroner’s removal order is required to move a body out of the jurisdiction for burial or cremation. Having a locally based coroner’s office is invaluable to deal with such orders.

At one stage, the Government appeared to accept that there would be a need for part-time deputy coroners, but in her response to the consultation, the Minister said that

“coroner posts will be full-time”.

I ask her to reconsider, because I think that there will be a gap.

I am also curious about the figure that has been given of 60 to 65 full-time coroners. First, does that allow for some part-time deputies? Secondly, why 60 to 65 coroners? Has the Minister done a calculation? If so, will she share it with the Chamber and the Committee? Has she added up the number of man hours worked by full and part-time coroners in the system and calculated them to equal the work of 60 full-time coroners? Or is that figure simply a rough calculation along the lines that there are about 60 million people in the UK and we should have roughly one coroner per million? That is what it sounds like.

It is recognised that coroners need medical support. We have recommended a return to the Government’s 2004 plan for a medical examiner to support the coroner in each area. The Government’s more recent proposal, however, is that apart from the chief medical officer’s guidance on policy and practice, it will be for coroners to obtain medical advice locally. Our recommendation was rejected and the Government turned their back on the earlier proposal.

There is considerable anxiety about resourcing and independence under the present proposals. Clearly, medical advice must be given by someone independent of the hospital trust, practice or service that dealt with the circumstances leading up to the death, but coroners who buy in help locally might have difficulty in securing such independent advice. It is not clear how that advice will relate to the proposed new system for medical examiners who deal with death certification.

Coroners experience various difficulties with autopsies or post-mortems. There are legal difficulties with the use of facilities outside their jurisdiction that need to be dealt with urgently. I have referred those issues to the Minister. Post-mortems might be actively sought by families who are anxious to be certain about the cause of death, but for many families they are a source of delay and additional distress. We recommended the abolition of the rule that the certifying doctor must have seen the patient within the 14 days prior to their death, and we recommended consideration of the Scottish view-and-grant procedure for appropriate cases.

We have two to three times more post-mortems than other countries. Dame Janet Smith pointed out that many of them might be unnecessary as well as distressing. Some religious groups object to post- mortem examinations. Surely, there should be a strong case, such as the possibility of crime or neglect, to justify such intervention when it is against the wishes or convictions of the family and, probably, the deceased. The Luce review made recommendations along those lines, but the Government have not, as far as I know, settled their view on that.

This question derives from the same issue. One of the most distressing aspects of the sinking of the Marchioness was that, before the families knew anything about the treatment of the bodies of their dead relatives, hands had been chopped off. The first time that the families saw the bodies, they were bodies with no hands, despite no permission having been sought and no information having been given. Is it the view of my right hon. Friend and his Committee that, once death has occurred and the next of kin has been identified, requests should be made and agreement given at all stages in respect of any invasive or surgical procedures on any dead body?

That is my view. I do not recall the Committee discussing the matter in such detail, although I remember the circumstances to which my hon. Friend refers. He dealt closely with the families involved. Most families have sensitivities about this; some have very strong views and some religious groups have deep objections of principle. On occasion, those may have to be overridden, but that should not be done without consultation. The process must have consultation built into it. This comes back to the resources at the disposal of the coroner and the coroner’s officers, as well as the training that they receive.

I turn now to death certification, which was central to the Shipman cases. We felt strongly that the two areas of reform that I have mentioned must go together, and we referred to the evasive and vague answers from departmental witnesses on the matter. We criticised the tinkering at the edges of a system that has already been deemed unsafe and unsatisfactory by two Government-commissioned reviews. At last, we now have proposals. They appear to be a very significant improvement; but, as far as I know, no coroners were consulted on them. That does not bode well for the achievement of an integrated solution.

What is now proposed is that each national health service trust—whether a hospital trust or a primary care trust—would have its own medical examiner in the clinical governance team. In addition, all medical certificates of cause of death—MCCDs, which I referred to loosely, but incorrectly, as death certificates—would be subject to scrutiny by the examiner, who would also decide whether to refer the case to the coroner and would set out the reasons for doing so. Medical examiners would have full access to medical records.

The new proposal goes a long way to meeting the Shipman inquiry concerns except, perhaps, in one respect: it is not clear that the medical examiner would be seen as fully independent of the treating doctor. The trust employing the medical examiner would usually have been the trust that supplied the medical treatment. The same trust could have liability if negligence were proved. Families who think that treatment contributed to, or failed to prevent, avoidable death are likely to think that the trust’s doctors will close ranks.

Why not site the medical examiner in the coroner’s office, rather than have a perceived lack of independence, and a potential third stage in which the coroner’s medical adviser considers the medical examiner’s report into the certifying doctor’s certification of the cause of death? Nobody asked for a three-stage medical checking process, but that could be the cumbersome result of siting the medical examiner in the employing trust and not in the coroner’s office. I hope that both the Departments involved will look again at why the medical examiner is being located within the NHS structure. Tom Luce, whom I have consulted, shares my concern. That aside, the proposal seems to be a significant improvement. It needs to proceed alongside, and in step with, reform of the structure of the coroner’s system.

There is clearly a case for much closer co-ordination of coroners’ and registrars’ offices. We would not want a reduction in the local registrar’s office networks, which need to be located as close as possible to where bereaved people live. In centres where co-location is possible, that has significant advantages for families and for the efficiency of the service.

There are many other aspects of our report and of the Government’s proposals that time does not allow me to address. I merely mention in passing that the Government appear to accept our view that public inquests should remain the standard forum for those cases where an inquest is necessary. The charter for the bereaved is a good idea, but it will be of no use if gaps in the reform proposals mean that the expectations that it creates are not met.

Many coroners have great difficulty in getting the use of suitable courts for inquests. Apart from in those cities where a dedicated court in coroners’ offices is the best solution, the Court Service must recognise a responsibility to assist coroners in providing court space, and coroners’ needs should be considered whenever court closures are under consideration, because coroners are users of court premises. Some of those premises are being closed.

We also had concerns that the proposed appeals might overburden the system unless scope were provided and those who could undertake an appeal were more clearly defined. The Government are still considering their view on several issues, including the role of juries, deaths abroad and the legal status of coroner’s officers. I should like coroner’s officers to have a status conferred by statute in the Bill.

I conclude by asking the Government some questions. When will the revised Bill be published? Will it resolve the wide range of issues that the Committee and others have identified? What is the timetable for the remaining decisions? The coroners and death certification systems affect families at their most vulnerable moments when they have lost a loved one. I have experienced such situations extensively. We need to get these hugely important matters right. My Committee and I, along with most coroners, still have serious concerns about gaps in the scheme, but we all want to see progress—surely it can be achieved. If the Minister brings forward a revised Bill to which all the key stakeholders can give their support, I think her chances of getting the Government’s business managers to give it the necessary parliamentary time will be much greater than they were the last time she tried.

I, too, welcome the debate, and I concur with the right hon. Member for Berwick-upon-Tweed (Mr. Beith), who is Chair of the Constitutional Affairs Committee, about the need for a wide-ranging examination of how a draft Bill becomes a Bill and of the particular issues that need to be addressed when that happens.

The draft Bill made great strides forward in several areas, and I hope that the Committee’s report will be read on that basis. The Committee recognised the substantial nature of the changes proposed and how well thought out many of them were in terms of the situation that we face. As the right hon. Gentleman mentioned, it expressed a number of concerns about structural issues relating to those changes. I want to concentrate my remarks on one such area.

The Committee’s inquiry originally wanted to undertake pre-legislative scrutiny of the Bill, but, as has been set out in various documents, the publication date of the original draft Bill made that difficult. Instead, it concentrated on several aspects of the draft Bill, particularly the relationship of its proposals to the inquiries that had preceded it—the Shipman inquiry and the Luce review on death certification.

During the inquiry, a number of issues about the structure and accountability of the coroner service became apparent; in truth, they might not have been as apparent had the inquiry simply consisted of pre-legislative scrutiny. The late publication of the draft Bill perhaps did us a service, in that respect at least. I want to concentrate my remarks on those issues of structure and accountability.

The coroner service occupies a curious position in the structures of local government, central Government and the judiciary, as it always has. It is perhaps because the coronial system generally works well that it has not been much of a matter for attention hitherto. The Committee examined not whether coroners in their actions over the years had or had not been conscientious, professional and expeditious, but whether those conscientious, professional and generally expeditious proceedings needed elements adding to them in the light of what we know from the Shipman inquiry, and whether the coronial system could work in a better way both to expedite justice and, among other things, to take account of the interests and concerns of bereaved relatives. The draft Bill does much to address both those factors.

Coroners have life-time tenure of their position, as do judges. How they conduct their coroner’s court is up to them, but that is where the similarity with the judicial system ends. Coroners are appointed by local authorities, which is a relatively occasional process without clear guidelines. It is undertaken by a panel that probably makes one appointment, and then goes on to other activities. The coroner’s officers are normally provided by the police authority. The accommodation for coroners’ courts may be provided by the local authority or the police authority, perhaps by both, and sometimes by neither. Those facts alone mean that the staffing, accommodation and capacity of coroners’ courts varies throughout the country.

Above all, the proceedings, except for informal arrangements, are effectively paid for by the local authority, but with no hold on the expenses to which they contribute—that is up to the coroner. Not only does the local authority have no say in the expenses that it underwrites, but those expenses may vary if, for example, the police authority decides that it no longer wants to underwrite the informal arrangements that have provided staff or accommodation. If that happens, an additional and unanticipated expense falls on the local authority. Conversely, the coroner has no hold over the expenses that the local authority provides because there is no direct relationship between the two. Likewise, the local authority has no hold over what the coroner does, or how effectively he or she does it. That is generally not an issue, but it can be, and there have recent instances when the ability of the coroner to undertake his or her duties has been called into question.

Does my hon. Friend agree that most elected councillors would be surprised to hear that they are in charge of the local coroner service?

I agree; that would be a great surprise. Most local authorities are unaware of what they provide, except when it comes to budget time and one or two lines turn up. That is the sort of relationship that exists.

A colleague discovered that he had that responsibility when he found himself having to appoint a coroner. He got into trouble with other councillors because he supported the appointment of someone who did not belong to the solicitors’ practice from which the county traditionally chose its coroner.

A number of issues arise in that instance, and another important point to bear in mind is that because such assistance is written into budgets in one or two lines, and, by and large, the level of assistance is not part of a statutory function, it is not entirely beyond the bounds of reason to speculate that if a local authority finds itself strapped for cash in its budget settlement, the eyes of the treasurer might alight on those lines when considering the budget. Again, because there is no formal arrangement, other than the general assumption that the local authority pays the coroner’s bills, there is not much that either side can do about it.

When a coroner’s ability to undertake their duties is called into question, it is not the local authority, as the court’s paymaster, that considers the matter—it is the Lord Chancellor. That problem arose in 2004, when the Teesside coroner, Michael Sheffield, was investigated by a judicial commission because there was concern about the huge backlog of cases that he was presiding over—some 200, 49 of which had been outstanding for six months. Among other things, there were implications of great concern for relatives who awaited the results of inquests, a matter that was assiduously considered during the pre-legislative scrutiny of the draft Bill. The Lord Chancellor issued a severe reprimand, and that might have been that, but a group of local MPs called for the coroner to be sacked. Among them was my hon. and learned Friend the Member for Redcar (Vera Baird), before she became the distinguished Under-Secretary of State for Constitutional Affairs. She wrote to the Lord Chancellor expressing concern at the outcome and said:

“Being reprimanded has bounced off him and the situation is just as bad as it always was”.

In short, as the Select Committee report states:

“Coroners undertake their statutory function in a fragmented and localised system that has remained largely unchanged since the time of Queen Victoria.”

That Victorian status quo is not widely supported. Dame Janet Smith suggested in the third Shipman inquiry report that the coroner service should

“be administered nationally by an executive non-departmental public body associated with the Department of Constitutional Affairs.”

The Luce inquiry also concurred that the system should be based on consistently appointed and trained personnel to operate to national standards across the country.

When the Local Government Association gave evidence to the Committee, it was unhappy about the strange set of arrangements under which local government works in relation to coroners’ courts. It said that

“an independent legal function, accountable to the head of the judiciary yet funded through local taxation, sitting alongside a local authority’s democratic role is an outdated anomaly in a political environment where council leaders, supported by—

Ministers from the then Office of the Deputy Prime Minister—

“are calling for local people to be given more control of public services through devolution of power to communities.”

It expressed a preference for responsibility for coroners’ courts to be devolved to local authorities, and suggested they should either

“be brought fully into the judiciary as set out in the government’s 2004 position paper, or, become a fully integrated part of the local authority, working alongside other statutory agencies, accountable to the local strategic partnership.”

The Association of Chief Police Officers observed:

“It clearly does not make sense that police authorities employ and pay for staff when they have no influence on how these…staff are deployed”,

and favoured making the coroners service a local authority function.

The Committee said that although there were benefits to be obtained from a clear local authority connection, the establishment of a chief coroner, unified training and appointment arrangements, the need to match financial accountability and funding with organisational responsibility meant that a national service was desirable if all the other reforms were to work in the best way. It concluded:

“It is difficult to see how a Chief Coroner can function effectively as a force for standardisation without being part of a national service.”

In the light of what the LGA suggested, a fully integrated local authority service could undertake effectively a number of the roles of a national service, although in many ways it is hard to see exactly what that would produce as a benefit for the local authority if it was effectively operating as an accountable paymaster, but working on the basis of the sort of national accountability, training and organisational arrangements that the draft Bill envisages.

The Department for Constitutional Affairs has, to date, turned away from that powerful logic. It wants to retain the status quo, but at the same time it wants to create a partnership between the chief coroner and local authorities, which it suggests will ensure responsiveness to local circumstances and help to build strong local partnerships with other services, while at the same time providing national leadership and national standards. Those are admirable sentiments, but it is difficult to see how those partnerships could be well forged with the retention of current arrangements. I would go so far as to say that retention of the current arrangements overall is directly inimical to the achievement of the goals of national leadership and national standards to which the Government rightly aspire, notwithstanding the very good standards and good quality partnerships that exist in some parts of the country.

If the coroners’ courts system is to be given the fresh start and modern approach that the Bill promises, it seems odd for the edifice to remain unchanged and, as was described recently,

“fragmented, non-accountable, variable in its processes and its quality, ineffective in part, archaic in its statutory basis, and very much dependent on the good people working in, or resourcing it.”

That statement is a description of the current structure of the service by the Secretary of State in the foreword to the draft Bill.

To go so far in changing the responsiveness and effectiveness of the system, and yet to leave it clothed in administrative arrangements that substantially contribute to the difficulties that the service has encountered in the past, and which is loved by very few, seems, to mangle a phrase, a bridge not far enough. I hope that the Government will reconsider that when the Bill is brought to the House.

It gives me great pleasure to speak in the debate. I very much welcome the draft Bill and the draft charter for bereaved people who come into contact with the coroner service. Those who lose a family member or close friend are in a state of shock, but in addition to coping with the trauma of that loss, they must often also deal for the first time with procedures of which they have no personal experience and of which they know little. There are often also additional pressures, such as the media, the police and perhaps the need to sort out complicated personal business.

Many hon. Members will agree that dealing with the bereaved is one of the most emotionally draining aspects of our work. For me, it has always been humbling to see the dignity and determination of families that are trying to rebuild their lives. We owe particular gratitude to those whose selflessness and concern for others makes them determined to improve circumstances so that families and loved ones need not go through what they themselves have suffered. That may be a private move or involve a very public campaign, such as improving road safety to try to prevent further tragedies.

One such high-profile campaign is that of my constituents Mr. and Mrs. Lucas, whose son drowned in a fast-flowing river in the Swansea city centre marina area. They have campaigned tirelessly to persuade the city and county of Swansea, as well as local businesses, to install safety railings to prevent similar tragedies in the future. Equally important, however, is the much more private campaign to focus on one of the coroner’s procedures.

As I have said, the aftermath of a death is a traumatic time for loved ones, and it is heartening to read the draft charter for bereaved people, which seeks to ensure that the bereaved are treated with dignity and sensitivity. I also welcome the opportunity for the bereaved people’s panel to scrutinise the draft Coroners Bill. That cannot have been an easy task for its members and must have brought back difficult memories. However, their experience and comments are invaluable in helping us to improve the service.

I want to concentrate on a tragic incident in my constituency. Three young people died in a road accident, and the family of one of them contacted me because they were very distressed to discover that the details of their son’s post-mortem had been given to the families of the other two victims. It was extremely distressing for them to think that other people would read details relating to their son; it was a complete invasion of his privacy.

As a result of my constituents’ concerns, I took the issue up with Dyfed-Powys police, who were very sympathetic. They replied:

“The Coroners Officer dealing with this file has reported that all families in connection with this incident were taken a copy of the report personally and it would have been explained to them that the Post Mortem reports on each of the deceased were enclosed. This has been the practice for many years without any previous objections however the Coroners Officer has referred this point to the HM Coroner for his consideration and after reflection he considered that in the case of files given direct to families only Post Mortem reports of their relative will be included in the future.”

It was made clear that when a family is given files in future, they will include only the post-mortem report for that family’s relative. I ask that the request for that to happen be taken very seriously, and I hope that the Minister will give the issue her full consideration.

I congratulate the right hon. Member for Berwick-upon-Tweed (Mr. Beith) not only on his speech, but on a first-rate report. The Select Committee is doing a great job of scrutinising the draft Bill, and we need more pre-legislative scrutiny. The Committee is to be commended on the thoroughness of its report.

I also welcome the draft Bill, which is way overdue, and I congratulate the Government on introducing it. Unfortunately, I must concur with the Committee’s finding that a golden opportunity has been missed. Although the draft Bill attempts to correct some of the wrongs and the glaring problems with the coroner service, it will not do so if it is passed in its current form.

I want to concentrate on three issues and to refer to a case with which I have been dealing since I was first elected to the House five years ago. The draft Bill seeks to combine the best features of a national structure with the best features of local service delivery, and none of us could disagree with that aspiration, but the draft Bill will not achieve that. Although it stresses the need for local input, which I support, the reality is that most local councils and councillors do not know that they have responsibility for the coroner service. That was summed up in the evidence that the Society of Local Authority Chief Executives and Senior Managers gave to the Committee. The society said:

“There is no real partnership between local authorities and coroners. Neither do local authorities have genuine management responsibilities for coroners.”

I am perhaps one of the few people in the Chamber who has actually appointed a coroner, so let me tell hon. Members of my personal experience. When I was the chairman of the public health committee in Newcastle upon Tyne, it came as a great shock to be told one day by the director of public health that it was my responsibility to appoint a new coroner because the present incumbent was retiring. I inquired how that had come about and what the procedure was, and the chairman dutifully explained it to me. What shocked me was the lack of any need for legal or medical qualifications on the part of those seeking such appointments and the vague nature of the advice about how we went through the process of appointing the coroner. In the end, a sub-committee of the public health committee appointed David Mitford, who is an excellent coroner and who has proved a good and wise choice. Having looked through the applications of those who came forward, however, I must say that there were some very strange individuals. In one case, the applicant’s only connection with the job was that his grandfather had once been a coroner somewhere else in the country, and he obviously thought that it was a family trait.

The main issue has been raised already, and the nub of it is resources. The service is woefully under-resourced, and we cannot continue with the current system. The draft Bill as it is outlined does not and will not square the circle in terms of meeting the need for local accountability and proper resources. The Government must wake up to the fact that a proper, well-funded service will cost money.

I read the draft Bill when it first came out and I was intrigued by the so-called chief coroner’s role of standardising the service. If we leave what we have now largely in place, I am not sure that the chief coroner will have enough powers to direct coroners. If the chief coroner is appointed in the way set out, they may well be able to comment on what people should do at local level, but how, as my hon. Friend the Member for Southampton, Test (Dr. Whitehead) suggested, will they be able to argue with, for example, a local government treasurer who wants to cut the local coroner service’s budget, which is easier to cut than the social services budget or other things in the council’s remit? Although we shall have a figurehead, and we might have a lot of advisory councils and employ consultants to come up with proposals, that will have no purpose. I should like us to have a national coroner. That is important, but we should also have a national coroner service. We need a system under which local coroners are appointed and accountable and can be removed so that standards are uniform across the county.

Another issue that I want to raise has also been touched on. Let us be honest: we are dealing with people who are going through a traumatic time having lost a relative or loved one, but who, in my experience, must then face an over-bureaucratic and occasionally insensitive system. That is not down to unprofessionalism by some coroner’s officers; it is just the system.

The other side of the matter is that if we are to avoid the inconsistencies that have already been mentioned, customer care—the way loved ones are treated—must be thought about. I am not criticising coroner’s officers, because many are very good, but I know of a case from Durham in which a relative who was trying to get a body released for burial was told by the coroner, “This is not your body; it is my body, and I will decide what happens to it.” I am sorry, but that type of language is not acceptable in a modern society. I do not think that standardisation across the country, if we are to have it, can be achieved without some form of national service.

My next point is about clause 5 of the draft Bill, which relates to the duty of coroners when deaths occur outside the United Kingdom. The clause would limit the circumstances in which a coroner would have jurisdiction over those deaths. If I read it correctly, there are four main instances in which an inquest would be possible. One would be that circumstances in this country had contributed to the death—for example, medical treatment might have taken place in this country before the person went abroad. Another would be any case in which broader lessons might be learned from a death, such as a child dying while travelling in a foreign country in a school party. The third would be circumstances in which murder or foul play abroad were suspected, and the fourth would rightly require inquests when members of the armed forces were killed in action. If hon. Members want an example of why the service must be brought into the 21st century, it is the appalling way in which the families of servicemen and women who have died in Iraq or Afghanistan go through another hell waiting for inquests.

My hon. Friend makes some important points. In the short time that I was a Defence Minister I was perhaps more troubled by the problem of the Brize Norton backlog than by any other thing. It is still a justice issue that I hope can be resolved. I know that my right hon. and learned Friend the Minister has done all that she can in providing resources and trying to have the situation rectified, but there is a problem with the system. I hope that the Bill that is eventually passed will ensure that families will never again have to wait as long for post-mortems as those families who are still waiting for post-mortems at Brize Norton.

My hon. Friend speaks from direct experience of dealing with those families. If we are to ask men and women in the armed services to serve abroad, we should ensure that their relatives will be treated with dignity and respect. It is difficult to argue against what my hon. friend said.

A case that I have been dealing with since I was first elected to this House—my first Adjournment debate was about it—concerns the death of Christopher Rochester, one of my constituents. It shows why it is wrong for the Bill to limit the application of coroner’s inquests when deaths occur abroad. Christopher was a young man of 24.

Yes, although it is in the Greek courts.

Christopher was born and bred in Chester-le-Street in my constituency and travelled to the island of Rhodes in June 2000, as many young people do. Unfortunately, on 11 June he fell from a balcony in Faliraki. I have seen where he fell, and how the hell he survived the fall is remarkable, but he did. He was taken to the local Andreas Papandreou hospital where he was allowed, through lack of medical treatment, to bleed to death. When Christopher’s body was returned to the UK the Durham coroner held an inquest. It was only after a post-mortem carried out by a very good doctor, Professor Redmond, that it was discovered that the reason given for his death by the Greek authorities—that he had a slight tear in the vein to his left kidney—was not the case. Professor Redmond’s conclusion was that he had been allowed slowly to bleed to death, and the death would have been preventable if Christopher had been properly treated on admission to hospital.

Christopher’s mother, Pam Cummings, and the family have been tenacious in trying to get justice for him. Their efforts resulted in the conviction of three doctors for manslaughter by medical neglect. The case is going to the High Court on appeal in Athens later this year. There is no way that that case would have been taken seriously by the Greek authorities—I raised it in the House in 2001—or that any of the evidence that came before the court would have emerged without a coroner’s inquest in this country. My fear is that under the draft Bill the injustice that was clearly perpetrated in Greece would have gone unresolved, and the families would have been left asking questions about how Christopher died.

I was present at my hon. Friend’s first Adjournment debate, having also lost someone on Rhodes, necessitating, on the body’s return, an autopsy and coroner’s inquiry. I hope that any Bill that comes before the House will take account of the coroner’s service abroad, so that if that is thought to be inadequate in doing its job, checks and balances in our system can be applied, so that such things never happen again.

I totally agree, but, alas, what is proposed will not achieve that. The attitude of the Durham coroner was such that he would not necessarily have conducted an inquest into my constituent’s case if he had not had to. Christopher’s family—like most families to whom I have spoken after they have lost someone—just want answers. They do not want vengeance. The family have never been concerned with compensation, although they are now pursuing a private compensation order in Greece. They just want answers to questions: what happened and how did the person die? That is the core of what the service should be about: getting answers for the next of kin about how people died, and learning lessons from avoidable accidents. I ask the Government to reconsider the clause.

I must declare an interest in making my final point, as the chair of the all-party group on cardiac risk in the young. It is about consistency of coroners’ findings and the usefulness of pooling the verdicts given by the coroner service. Cardiac Risk in the Young estimates that eight young people die every week of unexplained cardiac arrhythmia. Fit, healthy young men and women die playing sport, drowned or simply in their sleep. More often than not the deaths are put down to drowning, or are left unexplained. How the deaths happened is not examined. Expertise in dealing with such cases varies around the country. The real importance of identifying sudden cardiac death is that it makes the condition treatable for other family members. Not only are answers provided for the families, but it becomes possible to ensure that the young person’s siblings, and other family members, are checked for what is often a hereditary condition. With the best will in the world, with the current pressures on the coroner service—certainly financially—it is difficult to build up the necessary level of expertise. That is why I am pleased that, as a charity, CRY is investing £300,000 in coroners’ referrals to an expert cardiologist to try to build up that expertise and assist the coroner service in identifying why sudden cardiac death occurs.

If we could build up a body of evidence that showed how many people die each week from that disease, it would, as the right hon. Member for Berwick-upon-Tweed said, put pressure on the health service and others to take it seriously. Cardiac Risk in the Young is doing a great job in highlighting that tragic disease, but without the statistics and the force of coroners and medical professionals, I do not think that a great deal will be done about it.

We are part way through the process, we are scrutinising the Bill, and the Government must take seriously the report and today’s debate to reframe it before it becomes an Act. If, as the right hon. Gentleman said, the issue is about limited resources, I am sorry but that is not acceptable in a modern society. If the issue is about money, money must be found to create a system of which we can be proud and which supports coroners. They are very good professionals who do a hell of a hard job in very difficult circumstances.

I am very happy to serve under your chairmanship, Mr. Weir.

I begin with some general thanks, but they are no less well meant because of that. The Minister has taken a particular interest in the issue, and I thank her for that. Her commitment is clear. I do not intend to criticise the Government’s very welcome initiative to try to address what is a muddle of a system and get it into better shape, but it is right that we discuss the issue and subject it to careful all-party scrutiny. Therefore, a very important job is done by the Committee, which my right hon. Friend the Member for Berwick-upon-Tweed (Mr. Beith) chairs and in which other colleagues participate. The fact that there was a difference of view means that it is right for us to be open about the issues and to debate them. We must not be afraid of that, and today’s debate is a helpful part of the process.

There are many excellent coroners to whom we ought to pay tribute. The Minister and I, because we represent the same borough, share the coroner in Southwark. When she and I were first elected, the coroner, who had been a GP in Kennington for many years, was a strong, well known character called Sir Monty Levene. He was known for his handlebar moustache and—I hope that I am not being rude to him—what was clearly a wig, which he wore at all times.

I think Sir Monty was a Yorkshireman—he was certainly a northerner—who came down south. He was a gruff, lovable northerner who presided over his court in a pretty robust and idiosyncratic way, but he was much appreciated by and large, and he was often very gentle in spite of a rather aggressive exterior. I had occasion to attend with families who were constituents and who appeared before him.

Dr. Selena Lynch then became coroner, and she was in the post until recently. There is now a new coroner whom I have not yet met or seen in action. By and large, the court and the coroner’s officers have done a good and competent job, and I thank them for that. Many other coroners have done a good job, too.

I also pay tribute to funeral directors, because they have not been mentioned and they are a very important part of the process. They are the people most likely to handle families with expertise and to advocate on their behalf. In my constituency—indeed, in our borough—we are fortunate to have some very good funeral directors. I pay tribute to one company in particular, and I declare an interest, because the person who runs it is a friend of mine. It is, none the less, good by objective judgment, and not just by local community reputation.

The firm is called F. A. Albin and Sons—a family-run firm that has been established for more than a century—and it is responsible for the contract with the Ministry of Defence. It returns all our service people who are killed overseas to RAF Brize Norton; it provides an absolutely superb personal service to the families, and it continues to look after them throughout all subsequent difficulties. Such a service, as the hon. Member for Llanelli (Nia Griffith) said, is very important to people at those times. For the first time ever, they come into contact with a system that they have been hitherto fortunate enough to avoid.

There are some very important participants in the system, but it has not worked well in many cases, and I shall identify what strike me as failures and what may be the remedies. I do not pretend to have the perfect answers, but I have clear views about where we ought to go.

The first set of issues is about the initial process from death to the start of the inquest, and I alluded to one or two issues when I intervened on my right hon. Friend. I was not aware of this until recently, but more frequently than we might like to think, there is controversy over who is the next of kin. I dealt with a case last year in which a constituent was shot dead in my constituency. He was unmarried but had had a girlfriend by whom he had one child. I think that it was their child, rather than hers by a previous relationship.

There was then effectively a tug of war between the mother and the ex-girlfriend over who had family control. Such issues need careful resolution at the outset, and, possibly, legal advice. The mother did not receive any legal advice, and she was told that she was not the next of kin, which came as a shock to her at what was already a traumatic enough time. She had heard a shot outside her window and had seen her son run in. He died in her arms in the hall of her house.

Secondly, there is an issue about control of the body, which I raised with my right hon. Friend. The presumption is that, once the next of kin has been established, they have the overriding say about the body, unless a court decides to overrule that for some good reason—argued publicly, with the next of kin represented or representing themselves. The Marchioness case was the most horrible one in that circumstance, but it is not unusual for pathologists or people working in that service to require some bodily invasion or surgery to take place as part of the autopsy or post-mortem. We must be very clear: that process should be under the family’s control. Only if one cannot track the family in the time needed to take the action necessary should something else happen.

Thirdly, there clearly needs to be a localness about the process in almost every case. I shall come on to the exceptions, but, as my right hon. Friend said, the presumption should be that, just as there should be a local court in each community, so there ought to be a local coroner’s court and service in each community. It is important that the staff know the community well—its places, geography, layout, hospitals, doctors and so on. People should be able to register the death locally and the inquest should be carried out locally.

There are two final preliminary issues. First, when the death certificate is issued, there ought to be an automatic right to challenge it within a certain time, and that right should be explained to people. During my time as an MP, I have encountered several cases in which there has been a dispute about the cause of death as described on the certificate, and that links in with my second point.

The situation arises most often when there is a death in hospital and the family think that the person—normally old—has been neglected. Although the death certificate may say, for example, “Death from bronchial pneumonia”, the family are absolutely clear that the old person fell out of bed and was neglected, injured and bruised and that the trauma, shock and lack of care led to their death.

It is very important that no one thinks that there is any collusion or a professional mutual support system. That is why my general point is that the Government should ensure that death certification systems are incorporated at the same time as the coroners’ courts review systems in England and Wales—they logically go together. I agree with my right hon. Friend the Member for Berwick-upon-Tweed about that.

I should like to make some points about structure and needs. The more I think about it, the more it is clear to me that coroners’ courts should be part of the judicial process. I have come to hold that view more and more strongly. They should be part of the judicial process, accountable through the Department for Constitutional Affairs, as it now is, or the ministry of justice, as it may become. They are as much a part of that process as local magistrates courts and the other courts.

As all colleagues who have spoken from the perspective of local authorities have confirmed, the local authority role is not something that they assume they should do, expect to do, or even normally know that they do. And it is not logical that they should do it. If we wish to retain a local authority role, the only thing that it might be a good idea to retain is the right of the local authority to nominate a person to be a coroner when there is a vacancy and possibly to confirm or veto any nomination from the local community’s point of view.

I want to make it absolutely clear that the process is judicial. The coroner should be a judicial person who is accountable through a hierarchy, as proposed by the Minister, that has a national coroner service, just as a county court judge or district judge operates in a system with a hierarchy, a discipline, peer group review and accountability. The coroner’s officer and the pathologist should be part of that system; they may be nominated by the Department of Health or whatever, but they should be part of the judicial system. That carries the implication raised by the hon. Member for North Durham (Mr. Jones).

It is clear that the process needs to be better funded and that the Minister and her colleagues need to ensure, during this month and next—perhaps immediately after the Budget is dealt with—that they put the case to the current Chancellor and the Lord Chancellor, who is the head of their Department. They need to persuade both of them that we must get a properly funded DCA—or ministry of justice, if that is what it becomes—in the comprehensive spending review announcement that comes from the Treasury during the summer, or thereabouts, depending on Government changes consequent on the Prime Minister’s resignation.

The DCA must be properly funded to deal with legal aid, court pressures and the coroner service. That would be far better, and we would then be able to ensure a consistency of funding throughout the country that was not subject to the variability that is bound to occur at the moment, which is well evidenced in the report. In some places, there is a one-person operation that is run pretty much on a wing and prayer.

I do not know whether the Government’s suggestion is the answer to the full-time or part-time question. My sense is that it might be better, more cost-efficient and more appropriate to have part-time coroners in some parts of the country, such as rural areas where there is not enough work to justify a full-time coroner. It could be someone perfectly good; there are part-time judges, so it seems to me that we could have part-time coroners, too.

A further point has been suggested to me by coroners: where will future coroners come from? If we are to attract people from, for example, the solicitors’ profession, it might be possible for them to take an appointment as a part-time coroner, gain experience of that role and then decide whether it is the career pattern they want to follow. That would create a source of recruitment for future full-time coroners.

Yes, that is a very good argument, and it supports the case. The likely outcome is one that includes full-time and part-time coroners.

Does the hon. Gentleman agree that it would help when dealing with peaks or major incidents—the hon. Gentleman referred to the Marchioness disaster earlier—to be able to pull in other coroners to assist and speed up the process? Leaving one coroner to deal with huge accidents, such as the Marchioness disaster, is just not practical.

I shall come back to big incidents such as the Marchioness, but I agree with the hon. Gentleman. We always need people who can be deputies or work part-time. In a different context, the Church of England has a system whereby people who have been bishops elsewhere in the world or in England can be nominated as assistant bishops once they return to a particular diocese, and they then help out. Provided that they are willing and able, and still thought to be competent, people who have served as full-time coroners could be part-time or deputy coroners. We certainly need a back-up system; that is very important.

It is clearly nonsense in this day and age—this is a topical point, but I shall not get into the difficulties of the issue—that we have a separate system for the royal household. I think that we all agree that there should be a common system for everybody, no matter where they come from.

I am keen that we should keep a jury system where a set of issues or facts need to be resolved, or where a clear, potential conflict arises. It is difficult to say what triggers the use of a jury system—the point at which a coroner must decide whether something is a matter for a jury and not for them. I shall not pretend to give the answer, but we need a consensus about what triggers the point at which an inquest goes from being heard simply by a coroner to being heard in front of a jury.

My right hon. Friend the Member for Berwick-upon-Tweed alluded to a similar point, which is that we must be clear about what triggers an inquest in the first place. A large number of inquests and post-mortems take place in England and Wales. I am not suggesting that there are too many or that they are inappropriate, but it is not clear to the public, or even to many professionals, how the decision is taken after a death to hold an inquest or an inquest with jurors.

I want to pick up on the point made by the hon. Member for North Durham. We seem to need special arrangements in two or three types of case. The first such cases include that of the Marchioness. That was a huge local, regional and national tragedy, and people from all parts of the country were affected. The boats were owned by different people with companies registered in different places. The sinking actually happened in the middle of the River Thames, which is where the boundary between different local authorities lies. The boat ended up on the north side of the river, so it was dealt with by a coroner on the north side, but the collision probably took place in the middle.

When there is a big case, such as a rail fatality or whatever, someone should be specially appointed for the purpose: a senior, tried-and-tested person who has the ability and experience to deal with it, and who has the confidence of the public. The Marchioness experience, which the Minister followed at one remove, was a terrible, traumatic one, and it was only when Labour came to power and the Deputy Prime Minister ensured that a public inquiry was held that the beginning of the end came to that failure to deal with the inability of people ever to get a say. They felt terribly badly treated by the first coroner, and in the end, they had to spend money to go to court to get that inquest overruled and ensure that a further one was held. We should avoid such situations.

The second type relates to military deaths. It seems an anomaly that the Oxfordshire coroner has been dealing with military deaths that take place abroad, simply because the planes arrive at RAF Brize Norton, which is equipped to deal with families and the receiving of coffins—it does so well—but we need something with a broader base that does not require people to be dealt with there. If people on active service die abroad in the service of the country, we need the right system. We need expertise because coroners need to know about certain circumstances. The person in question needs to have experience, so it might be someone with experience in the services, as well as medical or legal experience.

Thirdly, we need a system that looks after people where deaths occur abroad and the processes may have taken place abroad. I had a constituent called Jeremy Larkin, who died in the terrorist explosion at Sharm el-Sheikh a year and a half ago, when he was there with his girlfriend. His parents were intelligent, bright and committed, but they had a terrible time finding out what their rights were and how to go to Egypt to sort out the procedures and so on. I have raised the issue with Ministers in the Foreign and Commonwealth Office, because it is partly a consular matter. However, we need to think through the system for dealing with British citizens or British residents where deaths occur abroad. We need a much clearer and more user-friendly system that supports people much better.

Does the hon. Gentleman agree that what is proposed in clause 4 of the draft Bill is a mistake? It assumes that the autopsy systems even in European countries are of a high standard. If we make that blanket assumption, there will be more cases like the Christopher Rochester case, where medical malpractice came to light only because the coroner performed an inquest in this country.

The issues in cases that cross a national boundary are difficult. Just as with court judgments that cross national boundaries, we have to assume, to start with, that the sovereignty of the state means that we respect its system. However, we need a mechanism—it would have to be agreed, probably among Council of Europe countries, but perhaps also among European Union countries—for referring cases if there is real cause for concern about the lack of due process.

There is nothing worse than someone feeling that they have been dealt with thousands of miles from home in a way that was dismissive of their rights and interests. We no longer think that genocide in another country is not our business. Nowadays we cannot reasonably say that how countries investigate deaths of their citizens is none of our business. The issue is a diplomatic matter that needs to be sorted.

I want to finish by paying tribute to another organisation that I have dealt with for years and years, namely Inquest, which has done an extremely good job and has obviously taken an interest in the process. Inquest is a small organisation in terms of funding and personnel, but over the years it has desperately fought for the sort of reforms that we have been talking about.

The right hon. and learned Lady rightly suggested in her statement in January that coroners should be able to make recommendations and that they should be seen through. I support that approach. Bluntly, it is no good having a system that discovers that a terrible failure of process has led to deaths—whether people have been electrocuted at home, killed on the roads or whatever else—but that does not allow somebody who has heard the evidence to say, “This should be done”. I support the ability to require something to be done. I appreciate that the issue is difficult, but that would be a way for families to feel that there was some positive news after a tragedy that they could not prevent.

Clearly, there should be a maximum length of time between the death and the inquest. Other countries, including yours, Mr. Weir, have maximum lengths of time in the judicial system for dealing with criminal matters. There must of course be a let-out clause if something unforeseen happens. However, just as with people who are detained, the coroners’ system or the police should have to apply to somebody to get an extension. The families of the military personnel who have been waiting for the Oxfordshire coroner to deal with their case are the obvious example. The situation really is not acceptable.

Sometimes such cases arise because of incompetence—the case was cited earlier where the coroner elsewhere in the country was not up to the job. I pass no judgment on the competence of the people who have been looking after the Oxfordshire service, but I ask Ministers to say that there must be a maximum time limit and that the family must know that a delay will happen. If they agree to that, so much the better.

There must be a right to the transcript of the inquest without having to pay loads of money. At the moment people have to pay, but it is not at all guaranteed that they will receive it easily. I ask Ministers to say that that should be an absolute entitlement. I have been to the coroner’s court in my area with several families in cases where children have been killed. If people are asked questions, they will not necessarily be concentrating on what is being said; rather, they will be trying to get through the process. People must have a right to see what the transcript says at the earliest available date within in a limited number of days, so that they can take advice about it and challenge it if they want to.

If the case requires legal representation—whether through an advocacy service, by people who are competent and knowledgeable, or by people representing themselves—we cannot exclude the legal representation service from inquests. If coroners’ courts are courts—which they are—there is a right to access to justice, and access to justice means that people must be represented.

Does the hon. Gentleman agree that a local complaints system is also needed? If families are not happy about the way in which they have been treated or if they have a complaint about any aspect of the coroner’s service, such a system should be in place. At the moment, people have no way to make a formal complaint—something that is now standard practice in most services that we deliver.

I absolutely agree with that point, which links well with my final point. Again, the right hon. and learned Lady has been assiduous in trying to ensure that our courts have user-friendly services, particularly for people who are the subject of domestic violence. In our borough, the service in Camberwell is a great improvement on what it used to be. Coroners’ courts need to have user-friendly services. People on different sides of the case—the person who drove the car that knocked somebody down who died and the family of the victim, for instance—should not have to sit next to one another in the waiting room of any coroner’s court. Refreshment facilities and facilities so that people can go out for a smoke break or whatever are also needed.

Our court in Southwark has been modified and is much better than it was, but in some places that has not been the case. In those places, people need the ability to complain if something does not work. To end where I began, the reason why I support a national system is that the public pay for coroners’ courts, so there must be somebody who can receive complaints about a court not delivering a service that is comfortable for the public to use and who can say, “I’m sorry, but this person”—this court officer or coroner’s officer—“is not up to the job”.

This is an important debate about an important service. We have taken a long time to get it right. I hope that lots of work will be done in the coming weeks and months, so that we can agree a way forward that will allow a Bill to be introduced in the new Session. However, I am clear that we should have a Government legal service system, not a local authority system, and that it should receive the funding. That will require Ministers to go into bat for the funding from the current Chancellor—and if he moves on, his successor—to ensure that we have the coroner service that we deserve.

I start by declaring an interest. The very first case that I did at the Bar involved attending an inquest on behalf of a family. I attended many other inquests, although unfortunately I did not reach the dizzy heights of taking silk, unlike the Minister and the Under-Secretary of State for Constitutional Affairs, the hon. and learned Member for Redcar (Vera Baird).

I pay tribute to the Minister, because as the hon. Member for North Southwark and Bermondsey (Simon Hughes) pointed out, she has taken a great interest in the subject and has built up a huge amount of respect throughout the country among the people to whom she has spoken. I have had discussions with different organisations and numerous coroners who have all been very appreciative of the time that she has given up. I also pay tribute to the right hon. Member for Berwick-upon-Tweed (Mr. Beith) and his Committee on putting together such an excellent report. A great deal of time went into it, and the Committee can be very proud of the end result.

The case for reform is compelling. The existing system has been described as fragmented, insufficiently professional and characterised by variable standards. All those constructive criticisms are correct. I argue for some local variation, because that can be a strength. However, I am clear that we need a proper national framework with a much more focused national direction and, within that, better training. I agree with the Committee that the fact that the certification and investigation systems are separate from each other is a drawback. The Conservatives also feel that it does not make sense for a coroner to have no jurisdiction to investigate deaths not reported to him. The whole reporting process needs to be considered.

We have heard about changing public expectations. Families are now better informed, much more likely to demand clear answers, and more aware of their rights and of what they can do by way of litigation—claiming compensation, in some cases. The system must reflect the rights and expectations of the bereaved families. However, the right of the bereaved to demand clear answers often conflicts with the overwhelming imperative of proceeding quickly with funeral arrangements.

That is all in the context of an ever-growing terrorist threat. The right hon. Gentleman pointed out the huge challenges that resulted from the terrorist attacks in London a year and a half ago. Tragically, we are seeing many more deaths in prisons, and obviously human rights legislation has an impact. A number of hon. Members, including the hon. Member for North Durham (Mr. Jones) and the former Defence Minister, the hon. Member for West Bromwich, East (Mr. Watson), raised the situation at Brize Norton. The bodies of many tragically killed servicemen and, in one case, a servicewoman, have been returned there at a time when this country is fighting in more theatres than it has since the last war. I fear that that will become ever more of a problem, particularly given that in the past servicemen were often buried in the battlefield where they fell. The vast majority of fallen servicemen and women are now brought back to this country at the request of their relatives. Hon. Members made the case for ensuring that the operation at Brize Norton is given extra resources and perhaps more flexibility. That could come about only through a national framework. Those arguments are very important.

The hon. Members for North Durham and for West Bromwich, East mentioned constituents who died in Rhodes. As a constituency MP, I hear time and again that families want closure. However, they also want something positive to come out of the coroner’s inquiry. They want lessons to be learned and, possibly, preventive measures to be put in place. We think that there is a case for better use of coronial information and for improvements to public health and safety.

There is a compelling case for reform. On the report and the Government’s proposals on death certification and referral to coroners, I believe that the death certification procedure should be standardised, regardless of whether the body is buried or cremated. I support that recommendation of the Select Committee. There is a need for a common certification process with a requirement for two professional opinions. I support the idea of a medical examiner giving that second opinion. I certainly agree with the right hon. Gentleman that the medical examiner should be sited in the coroner’s office.

We also need to consider carefully the £100 raised from the public for the doctor’s cremation certificate. I understand that the Minister is keen to abolish that. Given that she is keen to make the changes cost-effective and cost-neutral, what are the implications of abolishing it? What are the implications if that fee is extended to burials in the event that the requirement for the second professional opinion is put in place? As she has made clear on a number of occasions, her Department wants the changes to be cost-neutral. She will have to consider those two points carefully.

When I started looking again at the whole issue of the coroner service, having previously considered it carefully during my days at the Bar, I was staggered to see the number of deaths referred to the coroner— 45 per cent. in 2005. I do not know whether we have the figure for 2006; if we do, perhaps the Minister will tell us. However, that is far too many cases, and there is a great deal of confusion over whether doctors should refer. I would support a new set of statutory rules that would remove some of the confusion.

There is a need for much clearer legal guidance. I support Dame Janet Smith’s recommendation on that. She made the point very cogently in the Select Committee when she said:

“In my report I drew attention to how very difficult it is for doctors to know when they ought to report a death to the coroner, that the existing statutory rules are opaque, that those rules have been built upon and there are lists in existence which try to elucidate the statutory rules, that local coroners have their own local rules and it is extremely difficult for doctors to form a view.”

That makes the issue very clear: we must aim to reduce the number of referrals so that coroners can concentrate their efforts and resources on those more serious cases and on cases for which referral is required by law. I would add that there is an argument for getting rid of the 14-day rules, as has been done in your country of Scotland, Mr. Weir.

There is an argument for much better training for doctors. An important point was raised by the hon. Member for North Southwark and Bermondsey (Simon Hughes): there needs to be more co-operation between the Department of Health and the Department for Constitutional Affairs. Tom Luce made that clear in his strong recommendation that there should be combined certification of burials and cremations. He also made a strong point about moving the whole certification process into the coroner service, so that there is one seamless process. I would certainly support that.

The Government’s view is that the local service should be within a national framework, and I support them on that. Yes, there are many local variations; some coroners are well supported, while others are less so. The same is true of coroner’s officers. I had a look at the briefing given to the Committee by Her Majesty’s coroner for Essex and Thurrock, Caroline Beasley-Murray; the Committee Chairman also referred to it. She pointed out that when Tom Luce first investigated how her service was going, he

“referred to his shock at discovering when he visited”

Essex that the full-time coroner was working out of her own home

“and held inquests in a room in Shire Hall with a small kitchen as a retiring room.”

She went on to say:

“I currently hold most inquests in the Essex County Council Chamber, but this is not available…when citizenship ceremonies are taking place and it has other drawbacks too. I have campaigned successfully for a purpose-built coroners court”.

She added that, given the support of her MP, my hon. Friend the Member for West Chelmsford (Mr. Burns), there is now a strong possibility that that new build will take place under a public finance initiative, and the coroner’s court would be part of the new magistrates court complex. Obviously, that is good news.

Up and down the country, there are many different levels of support and infrastructure. Personally, I feel strongly that localism is to be encouraged. Each coroner inherits local traditions. When I have talked to coroners, I have been struck by how important that is. I take on board the hon. Member for North Southwark and Bermondsey (Simon Hughes) point that although he supports localism, he feels that the coroner service should be integrated into the judicial system. He argued—as did other hon. Members, in particular the hon. Member for North Durham—that rather than just having a national framework, there should be a national service. I would not go that far. What the Government propose makes sense, because we have the benefits of localism and of local sovereignty and discretion.

The hon. Gentleman says that it is okay to have a national chief coroner and a standard that we expect everybody to abide by, but unless there is some power over the delivery of resources at the local level, how will we get the system that I believe we all want, which is a first-rate coroner service of the same standard up and down the country?

The hon. Gentleman makes a good point—he argued it very well in his speech—but if the service were better funded at the local level, and if there were better facilities and consolidation of the certification process with the coroner service, we could have a national framework. There would be an appeals system—as far as that is concerned, there would have to be a clear, narrow process whereby appeals could go forward—and we could have far more national training as well. We could preserve the best of localism within a national framework. I support what the Government are trying to do in that respect.

Surely, at the very least, we must resolve the argument of who is paying. A situation in which chief constables sometimes provide coroners’ offices, and sometimes pay for them and sometimes do not, involves uncertainty that cannot survive for long.

The right hon. Gentleman makes an important point. It is one that was put to the Select Committee and to me by Her Majesty’s coroner for Essex, Caroline Beasley-Murray. Indeed, every coroner I have spoken to has made the same point, but they have also said that if the service were better funded at the local level, there would be no reason why we could not have a national framework and a chief coroner, and preserve the best of what I describe as localism.

Is not the greatest weakness of the hon. Gentleman’s local funding argument the fact that the local authority and the police authority would have to ask for more money through the council tax? That is the only way that they can get it, but I have never heard his party say that council taxes should go up. No politician wants to say that. There are very few, if any, votes in better funding for the coroner service. It would be far better, surely, if the service were part of a national settlement, negotiated nationally, for which the Government would have to provide funding that followed the service.

We could delve into the hon. Gentleman’s argument at great length, but I shall not do so. The only point that I will make is that if one considers Norfolk, for example, the cost of providing the service in the context of the overall police and county budgets is a fraction—it is a very small amount of money.

We have to be realistic. We must consider the other pressures the Department faces on, for example, the legal aid budget, and the other changes that are taking place in the judicial system. That is why I give guarded support to what the Government are doing, but, obviously, we must look at things in much more detail when they publish the Bill.

I am not yet convinced that there is a need to change boundaries and appoint full-time senior coroners for each coroner area. The new boundaries will have quite an impact, particularly on remote areas, and they are already having an adverse impact on morale. I received a letter the other day from a coroner for an area in the north of the country. I will not mention his name. He said that the Minister

“talks about ‘transparent appointment of a new cadre of legally qualified coroners’. You will be aware that service blight has set in, the morale amongst coroners is very low, there has been no information about transitional arrangements nor indeed about how HMG plans to ensure there is no loss of experience and expertise. There is as good a public satisfaction rate of coroners…as any other public servants—in spite of the blight, resource issues and uncertainty.”

That reveals that there is a great deal of concern at the sharp end.

Another aspect to consider is the solicitors who provide the service. I take on board what the hon. Member for North Durham said about how the old-boy network kicks in, and the colourful point that the hon. Member for North Southwark and Bermondsey made about the coroner he met when he first became the Member for that constituency. Nevertheless, part-time coroners provide a hidden subsidy that is obviously worth a great deal of money. I do not know how much, but figures of up to £30 million have been suggested. That is something worth bearing in mind. The Select Committee report deals with the issue on pages 27 and 28.

There is an argument for keeping much of what is good in the local system, but ensuring that it is funded better. If that hidden local subsidy were removed, central Government would have to provide a great deal of extra resources. Is that realistic in the current climate? I would argue that it probably is not. We must be realistic, and Conservative Members strongly believe that we should not make spending pledges that we know are unrealistic.

On the death investigation, I said that fewer cases should go to inquest, and that has been backed up by all the reports that have been produced. The Government need to consider carefully what has been said on that front. There is a good possibility that the changes could be made on a cost-neutral basis if fewer cases went to inquest. Otherwise, the Government would have to provide a great deal of extra money.

On post-mortems, the hon. Member for Llanelli (Nia Griffith), in what I thought was a moving short contribution, raised a very sad local case. It supports the point that post-mortems should not be automatic. A post-mortem should be ordered only if one is necessary to clarify uncertainty about a death. At present, all the evidence is that far too many post-mortems take place, and not necessarily for the right reasons.

There has been much discussion about the position of the bereaved. I agree with the hon. Member for North Southwark and Bermondsey that Inquest has been active in briefing hon. Members and has been proactive in this debate. I would add the views of Victims Voice, which has been equally proactive and assiduous in ensuring that we are properly briefed.

I very much welcome the draft charter for deceased people. I know that the Minister has been active in promoting its benefits, and I hope that it will eliminate for ever the sort of arrogance and uncaring incidents to which the hon. Member for North Durham referred. I agree that such attitudes are completely unacceptable.

I agree with the hon. Member for North Southwark and Bermondsey about maximum time limits. I am dealing with a case that was referred to me by my hon. Friend the Member for Rutland and Melton (Alan Duncan). I cannot give the name because of the sub judice rule, but it involves a constituent of his who was killed exactly four years ago as a result of an armoured vehicle coming off a low-loader on the motorway. The inquest was opened and adjourned but has not yet started, four years later. There may well be important lessons to learn from a case like that. Such delays have a devastating impact on families, and we have heard that time and again in respect of the families of servicemen and women who have made the ultimate sacrifice.

There is also a debate about whether bereaved families should sometimes get legal aid when a case involves a lengthy, complex hearing and they will be up against a panoply of Ministry of Defence lawyers and QCs in an intimidating environment. The Minister has argued strongly that the essence of inquest procedures is that they should not be too formal or intimidating, but when Departments can appoint top lawyers and QCs and the bereaved family have to pay for their own solicitor, there will certainly be arguments for the chief coroner having flexibility in some cases to award legal aid.

Having said that, I appreciate the pressure that the Government are under on legal aid. The Under-Secretary of State for Constitutional Affairs, the hon. and learned Member for Redcar, and I have had many discussions about it. She told me yesterday that I ought to look to the future, and I take that on board. Far be it from me to make extra pledges on legal aid, but it is something that should be carefully considered.

The hon. Gentleman made a point about delay, citing a constituency case of another of our colleagues. Does he agree that the knot that needs to be sorted out once and for all by the Bill is how we prevent the coincidence of inquests with actual or possible criminal proceedings and public inquiries, which spins out the process for years? Those three processes often follow a death, and they need to be brought together so that decisions can be made and they can all proceed as quickly as possible in an integrated manner.

I agree. The hon. Gentleman has made many sensible points, and that is another. It underlines the need for a national framework, because exactly such issues could be addressed.

The point has been made about how we must learn lessons from inquests. I was impressed by the Committee’s comments about how it learned from the evidence given by the state coroner’s office in Victoria, and how the collection of timely and detailed evidence led to sensible recommendations. The Committee gave many examples of how those recommendations have led to significant improvements in public health and safety. I find that compelling, and it is a great pity that we do not look more carefully at the data and evidence from inquests. If we did, and we had a more co-ordinated method of doing so, we could learn more lessons that could be spread around the country, which would benefit our constituents. That reinforces the argument in favour of a national framework.

In conclusion, there is certainly a need for a Bill. The Government have a golden opportunity to move forward, as they have support from all parties. It is not often that an issue gains so much cross-party support and that they have quite so much good will running in their direction. However, the various reports and the draft Bill have led to enhanced expectations among members of the coroner service, as well as among the public and many bereaved families. Unless the Government get their act together and move quickly, the uncertainty will continue, as will the poor morale in the service, and the good will towards their moving forward and taking action might well dissipate. Will the Minister not only answer the queries that have been raised in this well-natured debate, but use all her skills and her considerable contacts and credibility in the Government to ensure that the draft Bill becomes a reality soon?

We have had an extremely interesting and productive debate. I thank the right hon. Member for Berwick-upon-Tweed (Mr. Beith) for his leadership of the Select Committee and for his attention to the subject. I welcome the Committee’s work, because its focus, which has provided an opportunity for all organisations to consider where we are going and to broaden the debate, enables the Government to acknowledge the subject and to take it forward with the seriousness and importance it deserves.

I welcome the Committee’s work, despite the fact that it described my responses to it as evasive. I do not plan to evade any questions today. There is some disagreement about the practicalities of the structure and the way forward, but there is a lot of agreement about the problems. I shall say a little about what we all think the problems are. There is a lot of agreement about what should be the end result of the processes of change that we want to see. I want to say something about what I am doing in the meantime to try to improve the system, and I shall conclude by saying something about progress on the Bill on death certification.

There is a problem with the system. I think that we all agree that we would not start from here if we had the choice. Although we all recognise that important work is done in the system, it is incredibly variable. My hon. Friend the Member for Southampton, Test(Dr. Whitehead) said that the fact that there are so few complaints—despite the fact that 30,000 inquests a year take place, against the background of a shambolic, antiquated structure—is testimony to the dedication of coroners, coroners’ officers, the voluntary organisations that support them and local authorities and police authorities, all of whom have put their shoulders to the wheel. I agree absolutely and pay tribute to that work. However, I agree, too, with my hon. Friends the Members for North Durham (Mr. Jones) and for Llanelli (Nia Griffith), who have highlighted some real horror stories. Both are true: for the most part some incredibly good work is going on, but some terrible problems occur in the system that no bereaved person should come up against.

Let me identify some of the agreed problems with the system. First, I shall deal with the question of delay. It is unacceptable that it should take years after a death and after the opening of an inquest for the family to able to come to that inquest, sit in the coroner’s court and hear answers about how their relatives died. Many relatives have told me that, if they are trying to fight for answers, they cannot start the grieving process. They have to fight the system, rather than moving on and mourning the person whom they have lost. The idea that the delay can sometimes last years is totally unacceptable. We have started to collect and collate the figures by coroner’s area to find the average length of delay and the oldest case in each area, and it has become clear that the variation is unacceptable.

We must work with our colleagues in the Coroners’ Society of England and Wales and in local government to try to iron out that variation, as some areas have a prompt system, while unacceptable delays are the norm in others. I shall deal separately with the situation in Oxfordshire. People do not want delay, because not only can they not get on with the grieving process, but if lessons are to be learned, it is better that they are learned at the time and not six or seven years later. We have inquests, and they are important, not only for the bereaved relatives but for the public interest, as we learn lessons about how someone has died in order to do things differently in future.

Is the Minister willing to argue that, when there might be criminal case or a public inquiry, the inquest could take precedence? It could start, rather than having to wait for the other two processes. Of course, if further evidence were to come to light in the inquiry or criminal case, the inquest could be reopened at the instigation of the family, but they would not have to wait five years for a public inquiry that might or might not bring anything new.

That is something that a chief coroner could assist with. There will not be one blueprint for dealing with situations when a number of different agencies are involved. As the hon. Gentleman said, two agencies might be involved in the investigation—perhaps the Health and Safety Executive and the Crown Prosecution Service, or the British Transport police and the coroner’s officers. There is no blueprint, but if something is snarled up locally, we need a chief Crown coroner to bring it together and to say, “In this case, I suggest that we do this, this and this, in this order.” That is something that the Director of Public Prosecutions, leading the CPS, often does. The role of chief coroner could be very important.

I am intrigued by that statement. What happens if local resources are the problem—for example, if a police authority or councillors have cut resources, thus causing delays? Could the chief coroner direct a council or police authority to put more money into a service?

I was going to speak later about resources, but as my hon. Friend has raised the subject I shall deal with it now.

If anyone were to ask the Chancellor for more resources, the first thing he or the Chief Secretary to the Treasury would want to know is how much was being spent now, how much was being spent in each area, why was there a variation in the amounts being spent in each area and whether there was any correlation between the amount being spent per inquest and the outcome—in other words, how well the system was running.

As Minister with responsibility for policy concerning coroners—I have no operational responsibility—I want to improve the system. I am drawing together all that information. That is something that chief coroners would do, and I look forward to their being appointed. At the very least, however, we need to understand the present situation, because there is no evidence as yet that the difficulties in various areas are the result of resourcing problems. We do not yet know whether some coroners are doing a good job with relatively modest resources or whether others with adequate resources are not doing as well.

I do not disagree with my hon. Friend the Member for North Durham that resources are a problem, but we have to drill down into the system to see what is being spent area by area. There are no national guidelines on what the level of service should be, so resources are being addressed in the most general way. The answer to the question of how much a coroner needs per inquest is as long as a piece of string. There is no central guidance.

The Minister poses an important question, and she admits that she does not know the answer. It will not do to wait for the chief coroner; the answer is fundamental to deciding whether the scheme that we are setting up will work. She needs to carry on the work—I am glad to hear that she is doing it—of considering what is put in by local authorities and police authorities, and what would have to be replaced if coroners’ private practice offices no longer provided underlying service support for individual coroners. We need that figure in order to know whether what is proposed in the Bill will be workable. We really cannot wait for the chief coroner to be appointed in order to find out.

I assure the Chamber that I am not waiting for anything. I am getting on with addressing the issues, not only so that I can be better informed on what is the right policy solution for the Bill, but so that we can make a difference now by working with coroners and local authorities. I want an open and transparent understanding of how the system varies from area to area, and realistic dialogue and discussion with local authorities about why that is so and how things can be improved.

I move on to another point that concerned all Members—the question of disclosure, which was raised by my hon. Friend the Member for Llanelli. The problem is two fold. The bereaved families whom we met, who suggested how to run inquests into those in the armed forces who lost their lives in Iraq, and those bereaved families who helped us with our pre-legislative scrutiny told us that, at the inquests, they would sometimes see that the coroner had a thick pile papers on his desk and that the counsel for the military had an equally thick pile, while they had only two or three sheets of paper.

I also heard a complaint from someone whose daughter was killed by a speeding police car. The police authority, the chief constable and the Police Federation representative each had great wodges of documents, reports and legal representation—I shall deal with that point in a moment—and the bereaved family, who cared most about that death, had only a small amount of information.

The problem is that information is not being given to relatives in advance. We are analysing the reasons for that, and we intend to issue guidance to coroners on ensuring that information is given to them in advance. We do not want bereaved families to find themselves unable to follow proceedings because they do not have the same documents as everyone else. On the one hand we have inadequate advance disclosure, and on the other we have disclosure to people who are not entitled to it. That points up the problem of not having a national standard. In my daily work as Minister with responsibility for coroners policy, I am trying to assist the process; I want people to recognise what the minimum standards should be in the absence of a national system. I want to move the situation forward. That is something that the chief coroner will be able to help with.

We have an independent judicial system, and I am responsible for policy. However, when I receive complaints or when I hear of problems—for example, in relation to the armed forces deaths in Iraq—it is impossible for me to sit back and say, “Let’s wait until the next Queen’s Speech and see whether we have a Bill.” In the absence of anyone else, I and my officials—I pay tribute to them; they are from the Home Office—are doing what we can without encroaching on the independence of the system. I want to move forward, but I am explaining the situation as it is now.

I think that everyone agrees that, if there is a problem and people have a complaint about how they were dealt with by a coroner’s officer or a coroner, there is nowhere for such complaints to be considered and acted upon or for lessons to be learned. Sometimes, people simply want to complain so that the situation can be recognised and changed. At other times, they want to appeal a finding, or have it reviewed. However, as the Select Committee made clear, the ability to appeal is very restricted.

Hon. Members also spoke about the appointment system. Some parts of the coroners’ system can be seen as our only hereditary system—except, of course, for the monarchy. Sometimes, the job belongs within a solicitor’s firm, so one practice can hold the coronership. If that practice is a family firm, the job will go from father to son, and from son to daughter. None of us think that that is the right way to run the system.

I agree with the hon. Member for North-West Norfolk (Mr. Bellingham), however: not only is ours a non-appointment system, but some people regard it as a part of their local public service. I do not take anything away from those who do so. The hon. Gentleman is right also that many who are called part-time coroners have given up their other jobs and are acting as full-time coroners, but they are paid only as part-timers.

It is no disservice to those who do so to say that it is not acceptable to have a system with no proper appointments—one that can be run by the partners of a coroners’ firm in which the job can go from father to son. If someone can appoint their own deputy coroner, when the local authority comes to make an appointment, the only person qualified for the job has already been appointed; indeed, he will have been working alongside the coroner, perhaps for six years. That is how things work, and we do not think that it is acceptable for appointments to be made in that way.

We are also concerned about the lack of national training standards for coroners’ officers and that there is a postcode lottery. Those are the problems in the system. As previous mentioned, we recently carried out a poll of bereaved relatives to measure their satisfaction rating, because we only tend to see the complaints about those 30,000 inquests. There were some grave and serious complaints, however, in our survey, we also found that bereaved relatives judged their experience of the coroner service to have resulted in a higher level of satisfaction than their experience of the NHS.

Although nothing can overtake the misery of somebody who is badly treated in an inquest, people have an ocean of gratitude for those who go the extra mile and do not just treat the situation as being all in a day’s work but understand that it is an incredibly stressful and difficult time in people’s lives. For example, a woman who had worked in the coroner’s court and pathology system in Sheffield for many years told me that, when dealing with the death of a child, she prepared the child in the mortuary and asked the mother to give her the washing powder and fabric softener that she usually used on the child’s clothes. When the mother came to see her child and be with the body, the child’s clothes smelt not of formaldehyde or horrible chemicals, but like her child. There are stories from all over the country of people who have strained themselves to ensure that the system helps those who are dealing with a sudden, unexplained or violent death.

I will explain what I am currently doing to deal with some of the problems. As I have mentioned, I am trying to get to the bottom of the variation in the amount that is spent in different local authority areas. So far, that does not seem to be related to the number of deaths. I am also examining the variation in time that an inquest takes, as it does not seem to correlate to the amount of money spent. We will shortly introduce the cremation regulations, which will automatically allow relatives to have copies of the cremation certificate so that they can see if there are any problems. That was something that Ann Alexander, who represented the bereaved relatives of the Shipman murders, asked to be done. We will introduce those regulations for consultation in April.

We are also dealing with the situation in Oxfordshire. Hon. Members will understand that, when military fatalities are flown into Brize Norton, that is where the body lies, and once the coroner has opened an inquest, there is no possibility to transfer the body to another coroner’s area because each coroner’s jurisdiction is a law unto itself. Therefore, delays build up because a body cannot subsequently be transferred to the coroner in the jurisdiction where the person was stationed in the UK or where their relatives live. That has caused incredible difficulties for many relatives who have had to travel hundreds of miles at great expense to themselves and been unable to be supported by as many family members and friends as they would have liked because of travelling expenses.

Those military fatalities have led to many deaths from abroad coming into the Oxfordshire coroner’s jurisdiction. Often such deaths have occurred in complex circumstances and it is difficult to obtain the necessary evidence, much of which is very technical. Unacceptable delays have occurred and, because of an absence of transparency in the system, it took a while for us to recognise that there was a delay building-up.

No reporting system is in place to bring such a build up of cases to the relevant person’s attention, and I pay tribute to my ministerial colleagues in the Ministry of Defence, who raised this matter with me. They were particularly concerned about the service families involved. We were able to work with the Oxfordshire coroner and provide the resources for him to appoint extra coroners, so that we could have many inquests running at the same time to ensure that such a terrible delay was brought to an end. In many cases, people had been waiting four, five or six years for inquests.

I pay tribute to Sir Richard Curtis—a retired High Court judge, who as assistant deputy coroner, dealt with one of the most complex technical cases involving a helicopter—and to Selena Lynch, a barrister, who was an assistant deputy coroner, and to Andrew Walker for the work that they are doing to ensure that the relatives of those who have died in Iraq get the answers to their questions.

One of the responsibilities of a chief coroner will be to back up an individual coroner in a particular jurisdiction when they need evidence from abroad or some other agency. If a coroner felt that they were not getting the information that they needed, a chief coroner at a level similar to that of the Lord Chief Justice will be able to contact the authority involved and say, “My coroner is not getting the information that they need from you”. In the absence of a chief coroner, that role is, to some extent, falling to me. I have taken it upon myself to see the American ambassador and ask him to give the relevant information to the Oxfordshire coroner, so that he can conduct a proper inquest into the deaths of those military personnel in Iraq.

I am glad that the Minister has paid tribute to the members of the judiciary who have been helping out with the backlog in Oxfordshire. Under the new system that she envisages, would it be possible for a national coroner—or chief coroner—to move the bodies in such cases to other areas, such as the garrison town where the serviceman was based or to the area where the family live?

That will be possible under the system that we envisage because the statutory boundaries that make each jurisdiction entirely independent and hermetically sealed will change. It will be easy for the coroner to make that happen of their own volition without the intervention of a chief coroner.

The Oxfordshire case highlights the problems relating to resources and has demonstrated the need for more of them. What authority would the chief coroner have to transfer a case to another jurisdiction and force taxpayers in that area to take on that burden?

They would not have that authority. I will come on to resources in a moment, but the coroner concerned would to able to see the coroner in the home town of the family and if the family wanted the inquest to be near where they live, or if it made more sense for the inquest to be near where the person was stationed, the legislative changes envisaged will mean that the inquest can be moved. The coroner cannot do that at the moment.

I will not be able to answer satisfactorily all the points that my hon. Friend the Member for North Durham and other hon. Members made about resources, but I will try to explain what I am doing now and what the Bill will change.

Every bit of the logic of the last section of the Minister’s speech—much of which is welcome—suggests that the coroner service should become part of the judicial system. Unless that happens, there cannot be rules to require evidence to be given equally to everybody, so that there is disclosure. That would be perfectly possible in the judicial system and the Minister could lay regulations to deal with that. Will she reconsider the fundamental question of whether the coroner service should remain a local authority service as opposed to a judicial service, and will she examine her power—the Government power—to introduce regulations to allow for disclosure, transfer and all the other things that could follow, which would result in a much better service?

I have two observations to make on that. A system placed on a proper statutory footing, with a charter for bereaved relatives, with a system of inspection and monitoring, with performance standards and with a chief coroner, provides a huge amount more than we have at the moment. We do not want to make the best the enemy of the good. From my vantage point as a Minister, dealing with some of the problems, I can say that if we already had the measures in the Bill, we would not have nine out of 10 of the problems that we are discussing—I could tick them off because they would not be occurring.

We need national standards with local delivery. I know that there is disagreement on that. The high point of my support is a guarded welcome from the official Opposition, and I might have to be very grateful for that, but we are aiming for national standards, with local delivery. What might have to build on what we are suggesting, but it will be a million miles better than what we have at the moment. The difficulty is that if everybody argues that what we are doing is not enough, it makes the Bill seem unpopular and people think, “Well, then, let’s not do it at all.” I do not want to give too many insights into how the Government’s legislative programme is constructed, but I will say that I would appreciate a bit of warm support for the proposals. I want us to get on with them and not carry on with the current system. When we were consulting on the Bill, one coroner said, to the approval of many others at the conference, that all this business about standards for bereaved relatives and reducing delay was none of our business, and that:

“Coroners are accountable only to God and the Court of Appeal and that is how it should stay. ”

From that point of view, this modest Bill looks like a great leap forward.

We have listened very carefully to what coroners have said. We have listened to the voluntary organisations, such as Inquest. We have listened to, among others, the very important organisations that are analogous to the Victim Support witness service. The people in those organisations are volunteers who meet people and help to explain the system, and I pay tribute to them. We have listened carefully to the views of bereavement organisations, which are mostly self-help groups comprising those who have been bereaved in particular circumstances. I will take the points made by hon. Members as part of the consultation as we develop the Bill’s substance.

When we get to the substance, we want national standards, delivered locally. We want the system to be prompt, sensitive and contestable. That is where complaints and appeals are so important. With a system that is neither inspected nor has any proper appeal system, it is not possible to ensure the right quality of decision making. That would be dealt with in the Bill. We want the system to be professional. When I talk about whole-time coroners, it is so that we do not have a situation in which the local coroner, who is part of a solicitors’ practice and is also the coroner investigating deaths, feels pulled and pushed between his responsibilities to his firm and his responsibilities to his public office. That is not acceptable.

I am not saying that there cannot be part-time coroners, but they must be whole-time coroners—I am sorry to be confusing about this. They must not be doing another job as a solicitor. There could be part-time coroners, but they could not be part-time coroners and part-time people in a solicitors’ firm. One problem with that is that conflicts of interest arise. Somebody might be sitting as a coroner in relation to a hotly disputed inquest at which one branch of the family has been represented by the coroner’s solicitors’ firm. If somebody from a local firm of solicitors is the local coroner, conflicts of interest can arise.

There is an enormous amount of warmth for the thrust of the measures that my right hon. and learned Friend proposes, and a wish to get on with them. Perhaps the issue about local government funding is that a number of local authorities have now discovered that they are funding coroners’ courts and therefore the genie will not go back in the bottle in terms of the rather hazy arrangements that there were before. The question of national standards with local delivery will perhaps be considered in terms of local authorities saying, “We now have even less control over what we are providing, because of that national framework,” and questioning how that system works. At the very least, an understanding of how it operates—an understanding of, for example, what real money is being spent, including money that is below the counter, as it were, as well as above the counter—could inform that debate in the future.

I very much appreciate what my hon. Friend says. What he describes might well be the next step, but the Bill sets out the important first steps. That is the best I can say at this point.

We want the system to be prompt, sensitive, contestable and professional. We want its proposals and findings to be acted on. That is all in the Bill. We have listened to what people have said about deaths abroad. We will not restrict coroners’ inquests in relation to deaths abroad in the way that was in the draft Bill. We are changing our mind on that. We are making a U-turn, because of what people have said. We are making a U-turn on juries for deaths at work as well. We have put proposals in the draft Bill. People came forward with views, such as the one about the case of the young man, Christopher Rochester, who died on Rhodes. We thought about whether our Bill would be all right in those circumstances. It did not look as though it would be. Therefore, we have changed our position.

Resources were mentioned. I have to say to the hon. Member for North-West Norfolk that the new service would not be cost-neutral; it would cost an additional £6 million a year and implementation or start-up costs would be £15 million.

Death certification is mostly the area of my colleagues in the Department of Health, but hon. Members have complained about where we differ from what has been proposed by Dame Janet Smith and Tom Luce, and they have asked about death certification. We have been working across the Government to identify ways in which the system can be improved.

In responding on behalf of the Government to the Shipman report, my right hon. Friend the Secretary of State for Health said in the House on 21 February that her Department would produce proposals to improve the death certification system. That is likely to involve an independent check on all certificates, carried out by a medical professional employed in a clinical governance capacity and attached to a hospital or primary care trust. There is no blueprint for that medical capacity, but there is a determination that it should be available. The individual would scrutinise the first doctor’s death certificate and investigate as necessary—for example, by looking at the medical history and interviewing the certifying doctor or the family. If there were concerns, the death would be referred to the coroner in the usual way.

Our Bill would provide an opportunity for families to make a referral to the coroner. One of the problems is that if families are suspicious, they do not necessarily have the ability to make a referral directly to the coroner. The Bill would make that possible.

That is where cross-Government work is not working. The Minister relied heavily on her brief from the Department of Health to address that point, although I do not criticise her for that. The system could lead to a three-stage medical examination, because the coroner’s medical adviser will have to check, on behalf of relatives, what the medical examiner who was employed by the trust has done. Will the Minister look into that on the public’s behalf to ensure that the medical examiner of death certificates is sited in the coroner’s office? That is logical and would fit naturally into her Bill. Her Department has to start asserting itself.

I hope that we combine the right degree of assertiveness and co-operation when working with colleagues in other Departments. Primary care trusts have to be concerned about ensuring that patterns of malpractice in general practice are identified and about spotting the early warning signs of bad practice or criminality. I am working closely with my colleagues in the Department of Health to ensure that we propose the right solution.

I pay tribute to the work of my hon. Friend the Member for Blackpool, North and Fleetwood (Mrs. Humble), who is the chair of the all-party group on Army deaths, which does important work. I hope that she, the Secretary of State for Defence and I will meet to take matters forward.

I also pay tribute to the all-party group on funerals and bereavement, which deals with the burial industry and graveyards, which my hon. Friend the Member for Nuneaton (Mr. Olner) chairs. Such matters are not glamorous, but they are incredibly important to our constituents. As my hon. Friend the Member for Llanelli said, these issues will not hit the front pages of newspapers day in, day out, and nobody particularly thanks Members of Parliament who take up the cases of constituents who have a problem with an inquest.

Nobody particularly fights to have ministerial responsibility for graveyards and coroners, but, as my hon. Friend made absolutely clear, that is incredibly important, and not just in terms of learning lessons and making changes. The system should treat people who have had terrible bereavements properly; it should help to answer their questions and not make matters worse. That is what we are trying to do with the Bill.

I thank my colleagues on the Committee and other hon. Members for their contributions, including the hon. Members for Southampton, Test (Dr. Whitehead), for Llanelli (Nia Griffith) and for North Durham (Mr. Jones), my hon. Friend the Member for North Southwark and Bermondsey (Simon Hughes), and the hon. Member for North-West Norfolk (Mr. Bellingham). They all made valuable contributions.

I also thank the Minister for her response. I hope that she will write to me about one or two of the points that she was unable to cover, such as post-mortems and religious objections to them, which I believe the Government are still considering. We all want to help her to get the Bill on the statute book, because we are conscious of how urgent the need for legislation is, but we cannot ignore the fundamental problems that we have identified. There can be few present who do not still feel uncertainty as to whether the chief coroner and the national structure can deliver very much if the complex resource and power problems that will remain in the system are not sorted out.

Several of us who looked into this matter remain very dissatisfied with the idea of medical examiners being sited in the employing trust of the institution at which criticism may be directed at the inquest or in subsequent negligence proceedings. The right place for those medical examiners is in the coroner’s office. I genuinely believe that the Department of Health needs to sit down with the Department for Constitutional Affairs and work through this issue. The proposals are very good in many ways and will fill the gap that we were worried about, but they retain a fundamental weakness. I do not intend to leave the Minister alone on this; I shall continue to pester her, because I know that that will make her continue to pester her officials and Department of Health officials. We have to get this right and we have to get it right soon.

Question put and agreed to.

Adjourned accordingly at four minutes past Five o’clock.