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West London Coroner’s Court

Volume 603: debated on Wednesday 16 December 2015

Before I call Mr Berry to move the next motion, I want to make it plain that it is neither my intention nor my desire to curtail debate. However, I have to advise colleagues that inquests, which are the subject of the House’s sub judice resolution, may not be referred to directly in this or, indeed, any other debate. Investigations that are under way by the Judicial Conduct Investigations Office are not subject to the sub judice resolution, but I ask Members to exercise good sense in referring to such investigations. I will be as tolerant as I can, but I may have to draw the line. Looking at the number of Members present, I would be grateful if speakers apart from the opening speaker would curtail their remarks to no more than about three to four minutes.

I beg to move,

That this House has considered standards of service at West London Coroner’s Court.

It is a pleasure to serve under your chairmanship, Sir Roger, and to see so many colleagues here who have been so vocal on this important issue for their constituents and mine. Two years ago tomorrow, my father died unexpectedly. It was a devastating experience for my family, as death is for every family, but the seamless service from the local council and the coroner made the whole experience just that bit more bearable. Although the registration process itself was clinical, because it was efficient it did not compound our distress as a family. Sadly, the same cannot be said for the experiences of many bereaved relatives of those living in Kingston, Richmond, Hounslow, Ealing, Hillingdon, and Hammersmith and Fulham, which are the boroughs that comprise the jurisdiction of West London coroner’s court.

Since I was elected in May, I have received numerous complaints about the standards of service at West London coroner’s court and about the senior coroner there. Those complaints come not only from bereaved constituents, but from the council itself and, indeed, from our local newspaper, the Surrey Comet. The complaints include: long delays in issuing death certificates; inordinate delays in bringing on inquests; a telephone service that is never answered when relatives call for advice; crass errors on death certificates, such as getting the age or sex of the deceased wrong; and general rudeness to boot.

It is important to note at the outset—I note your guidance, Sir Roger—that I do not intend to criticise the senior coroner personally, because I know that there is a complaint against him by a number of councils, and that that is under investigation. I would not want to impede that investigation, but there are three issues that I would like to consider in some detail: delays, burials for certain faiths, and deprivation of liberty safeguards.

West London coroner’s court has one of the worst records for delays in the country. It takes almost double the national average time to process inquests. The delays are a shocking abrogation of the state’s responsibility to bereaved families, including those in my constituency. The estimated average time taken to process an inquest in England in 2014 was 28 weeks—a figure that has been effectively stable over the past five years. However, in west London and in inner south London, the average time taken to process an inquest is 50 to 53 weeks. The figure of 53 weeks is the worst in the country. In West London coroner’s court, the figure is 50 weeks—the second worst in the country.

In my borough, Kingston upon Thames, the target for registering a death is five days from the date of death, or seven days in a case where a post mortem is required. In 2013-14—the period during which the coroner was appointed, as he was appointed in November 2013—Kingston was meeting that target in 70% of cases. In this year, 2015-16, if we continue on the current trajectory, Kingston Council will meet its target in only 11% of cases, and that is because of delays at West London coroner’s court.

In terms of post mortems, prior to the appointment of the current senior coroner in November 2013, the waiting time in Kingston from a death to a post mortem was two to five days, yet between June and September 2015, the average waiting time was four to six weeks. I understand that the situation has since improved somewhat. Those statistics speak for themselves and do not need labouring, so I will return to the bereaved families who are at the heart of the debate.

For most people, an inquest is a new and somewhat unsettling experience at a very vulnerable time in their life. In most cases, bereaved relatives simply want to bury their dead as soon as possible. In a small number of cases, they want answers or an inquest is required by law, but in all cases, they want to have the system explained to them, and to be kept informed of the reason for and the length of any delays.

Ronke Phillips from “ITV News London” has done a lot of work exposing the problems at West London coroner’s court. In October, ITV London brought a number of families affected by services at West London coroner’s court to Parliament to speak to their MPs, a number of whom are here today. The accounts those families gave of the distress they had been caused were quite moving. There were unexplained delays, no updates, and a telephone service that was never answered and turned out not to be manned at all.

I am sorry to interrupt my hon. Friend’s flow, but I do not want to take up the House’s time by making a speech. He highlights some of the issues very well. My constituent, Mrs Doreen Garcia, had what was essentially a completely straightforward issue in relation to her husband’s death. She needed to get a death certificate because it was essential for the administration of the estate, yet she had to wait more than a year for an inquest that, in the end, was a hearing on the papers because of the complete inefficiency of West London coroner’s court.

That experience is by no means unique. In terms of the telephone service, when I called up on behalf of a constituent very early on in my role as a new MP, I had to wait on the telephone for more than 45 minutes, and then it became clear that the call was never going to be answered. Frankly, that plumbs the depth of poor service for bereaved families. As I understand it, the senior coroner’s position is that he inherited a backlog from his predecessor in 2013. Be that as it may, he has not cleared that backlog since November 2013, and has compounded the situation with an ill-conceived staff reorganisation and shocking failures to communicate with bereaved families.

On the point about the attitude towards bereaved families, I would like to put on the record that twice I have had people in tears in my constituency surgery over inaccuracies on post mortem certificates, as my hon. Friend the Member for Kingston and Surbiton (James Berry) described. It is extremely distressing for MPs not to be able to improve the situation. I absolutely agree with everything he said.

Finally on the delays at West London coroner’s court, it would be easy to blame the situation on cuts, but they are not to blame. I wrote to the chief executive of Hammersmith and Fulham Council, which is responsible for funding the coroner service in west London. He made it clear that although the council has had to make cuts to various areas, the coroner service has been protected from those cuts. The responsibility for sorting out this shambles lays squarely with the senior coroner for west London. He needs to get his house in order for the sake of bereaved families living across the boroughs represented here.

I am grateful for the comment that the hon. Gentleman just made. I have been copied into the letter that he received from the chief executive of Hammersmith and Fulham Council, dated yesterday, which points that out. I am sure it was done in good faith, but on the hon. Gentleman’s website, he has said that the situation could be the council’s fault. I hope that he will correct that. One of the issues that we will deal with is putting blame for this matter where it lies.

I do not intend to go into the technicalities of the Coroners and Justice Act 2009, but it is a matter of interpretation as to whether the local council or the police are responsible for providing administrative staff. However, the council is quite clear that there have been no cuts to the funding that it believes it ought to be providing.

Moving on to the subject of religious burials, Jewish and Muslim families have to bury their dead in a matter of days, and the pressure on those doing so is compounded by the situation at West London coroner’s court. I need not say any more about that, because I can simply welcome the Minister’s recent announcement of a review into the interaction that some faiths have with the coroner service across the whole country. I simply observe that in diverse communities, such as those served by the West London coroner’s court and by MPs here, a reliable out-of-hours process for death certificates that are required over the weekend would seem to be the most sensible way forward.

The third point I would like to make is on the matter of national application—the requirement to hold an inquest when someone dies while subject to deprivation of liberty safeguards. Section 1 of the Coroners and Justice Act 2009 requires that a coroner holds an inquest in certain defined circumstances such as a death in state detention, or a violent or unnatural death. In other cases, the coroner has discretion as to whether to open an inquest, depending on the facts.

Since the Mental Capacity Act 2005 came into force, the definition of whether someone is detained or deprived of their liberty has been tested in the courts on numerous times. In March 2014, the Court of Appeal considered the cases of P v. Cheshire West and Cheshire Council, and P and Q v. Surrey County Council. In those cases, the Court of Appeal gave a very broad definition of deprivation of liberty. The result of that decision has been that authorisations now have to be sought for deprivation of liberty in many more cases than they used to. That includes most cases where a person suffering from dementia lives in a care home and would be prevented from leaving if they attempted to. An inquest must be held in each of those cases because the individual is deemed to be in state detention. In my constituency, we have a nursing home in which 90% of the residents are subject to the deprivation of liberty safeguards. On the current interpretation of the law, there would have to be an inquest into each and every one of those individuals’ death, even if they died entirely predictably in their sleep.

I am not saying that there should be no inquests at all into deaths where the deceased is subject to the deprivation of liberty safeguards—far from it. I am arguing that inquests should be opened at the coroner’s discretion; they should not be mandatory. It was certainly not the intention of this House in passing the Coroners and Justice Act or the Mental Capacity Act to mandate an inquest in every case in which the deprivation of liberty safeguards apply, nor was it the Court of Appeal’s intention in the P and Q cases, so far as I can work out; the issue was not canvassed before the Court at all because the case did not concern inquests.

In support of my point, the Chief Coroner of England and Wales highlighted the problem in his 2014 annual report to the Government, and highlighted the massive increase in the number of deprivation of liberty safeguards from 11,300 in 2013-14 to some 83,000 in the first three quarters of 2014-15, which will inevitably lead to a huge number of additional inquests. I ask the Minister to find legislative time, as a matter of real priority, to exempt people who die while they are subject to deprivation of liberty safeguards from the mandatory requirement to hold an inquest. That change would reduce the pressure that is building on coroners across the country. It would help, but by no means resolve, the problems at the West London coroner’s court, to which I return in closing. It is clear that something must be done to improve the terrible standards of service in that coroner’s court.

I congratulate my hon. Friend on securing this debate and on what he is saying. In the few months that I have been back in this House, I have received an amazing volume of complaints about the West London coroner’s court. Can the issues regarding the role of the West London coroner be properly remedied by the Chief Coroner, or should there be a formal investigation by the Ministry of Justice? We need to get to the bottom of what is going on.

That encapsulates the sentiment of many MPs on this subject. I am pleased to have received reports that the telephone service at West London coroner’s court has improved—that has been confirmed by the leader of Hammersmith and Fulham Council—but the inordinate delays in issuing interim and final death certificates and in bringing on inquests must be addressed now. If that means sitting at the weekend, as judges did after the riots, or if it means appointing additional assistant coroners to help clear the backlog, so be it. By whatever means, the senior coroner, for the sake of bereaved families in our constituencies, must get a grip of the situation now.

I will be brief, not least because this matter, although it is not sub judice, is potentially subject to an investigation by the Judicial Conduct Investigations Office, which is the appropriate body to deal with it. Indeed, in answer to my parliamentary question on 9 November, the Minister confirmed that that is the case. The chief executive of Hammersmith and Fulham Council sent a letter to the hon. Member for Kingston and Surbiton (James Berry), whom I congratulate on securing this debate on a subject of great concern to all MPs in the six boroughs, stating that the council expects to hear back from the JCIO in the second week of January on whether it will launch a full investigation, but clearly that is already under consideration.

Like everyone here, I have had complaints about the West London coroner’s court, and this week I have corresponded with my constituent Angelita Rodriguez about the sad death of James Rodriguez, her late brother, which exhibits many of the problems that the hon. Gentleman identified. It is not necessarily appropriate to go into the individual details of these cases today, but it is not sufficient to blame others for what is going wrong in the coroner’s office. Whatever is going wrong and causing the problems we have heard about, it ultimately falls at the coroner’s door to resolve. I am not impressed by the fact that, at different times, the local authority, administrative staff, the coroner’s officer, the Metropolitan police and even the previous coroner have been passed the buck. I declare an interest, because I chaired the panel that appointed the previous coroner, Alice Thompson, some 15 years ago—I was then the leader of Hammersmith and Fulham Council. She had more than a decade of distinguished service and conducted some of the most difficult and complex inquests.

This is a matter that concerns literally millions of people across west London, because the six boroughs have a population in excess of 1.5 million people. The coroner’s court deals with people at a time of great stress and in extremis. It is often considered a bit of a Cinderella service. I am very glad that we managed to persuade the coalition Government not to abolish the post of Chief Coroner before it was introduced, and Peter Thornton is doing a very good job. Coroner services can and do go wrong from time to time, but they are an essential and ancient part of our judicial system. It is vital that those services work well, so I hope we will see a full investigation in the new year. I am pleased to hear that there has been some improvement, and I know that the borough council, which is the providing authority for these purposes, is taking the matter seriously in respect of its responsibilities, and I am sure the Metropolitan police are doing the same. In the end, the buck does have to stop with the West London coroner.

I echo the feelings of everyone here today in thanking the hon. Member for Kingston and Surbiton (James Berry), and I express our sympathy for his personal loss. He understands, as do many of us, but perhaps not to the same degree, how much pain can be caused by even casual incompetence. Just under 18 months ago, a very talented and beautiful 14-year-old girl in my constituency, a neighbour of mine, died. I will not refer to the case directly, but we now know that the case papers were left on a train—I can scarcely imagine the pain and agony caused to that family, who suffered again.

Like all Members here, I have a catalogue of complaints about the operation of the coroner’s office, and they tend to fall into two categories. One is the most basic administrative errors. A constituent of mine, Roniel Mulchan, died on 28 November last year. His mother had some very basic and simple questions to ask of the coroner. We wrote in February 2015, in March and in June—no answers did we receive.

I hear from the hon. Gentleman that the telephone system has improved, and I would like to say that to my constituent Sally McMahon, whose mother died very recently, God rest her soul. My constituent tried to ring the coroner’s office and was told that it shut at 4 o’clock —this was at 3.20 pm. I rang on 10 December and received the same message at 3 o’clock in the afternoon saying, “We are only open until 4 o’clock.” That is casual incompetence of a degree that piles Pelion on Ossa when it comes to the suffering of individuals.

In another particularly unpleasant case, the absence of information was so awful that I wrote to the Judicial Conduct Investigations Office in July 2015 on behalf of Dr Batten, whose relative, a constituent of mine, had died. The complaint started with the typical waiting for 45 minutes, rudeness and that sort of stuff, which could almost be discounted. However, as part of the response I received from the Judicial Conduct Investigations Office—my hon. Friend the Member for Hammersmith (Andy Slaughter) is familiar with this, as I am sure the Minister is, but I had previously been unaware—I learned:

“The Coroner’s Office is not run directly by the Coroner, staff and resources are provided by the Local Authority for the area and the Police service. Therefore, if you wish to further your complaint about your experience with the Coroner’s Office…you may wish to contact the Police Service and the Local Authority”.

Sir Roger, you are a distinguished Member of Parliament and you have probably dealt with more casework than anybody else in the room. When you receive a letter such as that, I am sure your reaction is precisely the same as mine, which is, “How on earth can we operate a system where the buck is passed with such dizzying speed that it is more like an ice hockey puck, and it cannot be slowed down in court?”

However, in many ways the most unpleasant, the most egregious and the most disturbing case that I know of relates to the daughter—the child daughter—of my constituent, Mr Seefat Sadat. His daughter died on 17 April 2013. After six months, he came to see me to ask why the inquest had not yet taken place, and I wrote, and I wrote, and I rang, and I wrote, and I wrote again. I then contacted the then Minister, the right hon. Simon Hughes, and received a response from the right hon. Member for Epsom and Ewell (Chris Grayling) in April 2015. Two years after this child’s death, the inquest had not taken place, and we were told that there were various reasons for that. The right hon. Gentleman—I place no blame whatever at his step—said that the West London senior coroner, who has been referred to obliquely today, telephoned my constituent, as he says,

“on or around 1 April”—

he cannot be sure—

“explaining the problems within his area that have caused this long delay and that he now expects the inquest to take place in June”,

And saying that the coroner was going to reallocate the case on Morwa Sadat’s death. The right hon. Gentleman then went on to point out some structural difficulties and problems within the system.

That simply is not good enough—it is not good enough. We are talking about people who are in agony, who are grieving and who are in pain, and they are hanging on the telephone. They are being fed nonsense, and a child’s death remains unexamined for two years—two years—and I have to bring in Ministers in the coalition Government and even Ministers in the present Government. Fortunately, thanks be to God, it has now been resolved.

How on earth can we say to our constituents, “Trust the system, trust the coroner’s office”, when we have this constant, almost ceaseless, list or catalogue of incompetence? Even when the incompetence is almost casual incompetence, the reverberations it causes throughout a family are so awful.

I have had experience of very similar situations, and what is distressing for us as MPs is that people’s grieving process is unnecessarily extended and made worse, so there are not just administrative consequences.

The hon. Lady speaks from a privileged position, because in her profession before she entered this place she obviously had closer dealings with the coroner’s office than many of us do. The fact that she says that certainly adds weight to the point, and I am even more concerned given that she makes those comments.

The case that I cited was unusual, because, as the hon. Gentleman will appreciate, my constituency does not fall within the area of the coroner in question. I was therefore particularly startled to receive the information from my constituent about the difficulties she was having with that coroner’s court, because it is so completely at variance with my experience of the other coroner’s courts that I have had to deal with. I would be most interested to know what is so particular about west London as to cause these immense problems, if indeed they are outside the coroner’s hands.

The right hon. and learned Gentleman also speaks from a position of great authority. It is not for me to say; I hope that the Minister, when she responds to the debate, will indicate some way in which we can ventilate these issues further. I do not believe that west London is unique; I do not believe that it has more problems than, for example, east London. What I think we are talking about here is a structural failure. There is a failure of leadership, without a doubt. The problem is that we have a failing structure, and the leadership required to take the matter forward is absent.

I am conscious of your strictures, Sir Roger, and I want to allow other people to speak. I will simply close by again congratulating the hon. Member for Kingston and Surbiton on securing this debate and expressing my sympathy to him. I add that the finest tribute in remembrance of his father will be if we, today and in this place, can improve the situation not only for individuals here today but for all our constituents now and in the future. Quite frankly, anything else would be wholly and utterly unacceptable.

I am a new MP. I have only been here since May, but even from that short time, the vivid stories that Members from all parties have described are depressingly familiar to me from doing surgeries once a week for two hours.

I completely understand that it is not helpful to bring up individuals and hang people out to dry, and it is not my intention to do that today. However, I will highlight a couple of cases to see whether lessons can be drawn from them whether we can find ways forward.

I received an email in the summer from Sharon Hennelly and her sister, about their brother. They said:

“We have been contacting the coroner’s office for a year trying to find out when we will get an inquest. We have phoned on numerous occasions and been kept in a queue for up to 2 hours. Our emails now go unanswered. We have no information about the circumstances of my brother’s death. He was hit by a train at Barons Court tube…It is now 19 months later and we are completely at a loss”.

Their brother died in 2014, so we are approaching the two-year mark since it happened, since when they have been dealing with the case.

There appear to be common problems, including the length of time it takes for cases to appear in the coroner’s court in question. A report from 2015 in the Kingston Guardian says that at another inquest in April, the coroner himself confessed that he was “deeply embarrassed” by the length of time it took for cases to appear in his court, and that cases should not be taking 18 months to appear in court. He said:

“In future they will not.”

However, it seems that things have continued since then.

Communication problems seem to be common, including the speed at which communications are made. My hon. Friend the Member for Ealing North (Stephen Pound) described such problems. We have all heard stories about people being made to wait for hours on the phone and then, when that draws a blank, physically turning up in person, only to receive rather brusque treatment. The appropriateness of the communications is a problem in what are obviously sensitive situations. The hon. Member for Twickenham (Dr Mathias) is a medical professional. People talk about “bedside manner” in the medical profession, but the bedside manner of the coroner has been found wanting on many occasions.

My hon. Friend the Member for Hammersmith (Andy Slaughter) mentioned that the interpretation of what constitutes west London seems to be quite generous. There are six boroughs. My borough alone, Ealing, has 350,000 people, and the population of the six boroughs put together is getting on for a couple of million people, so maybe we should examine that unmanageable area. In one of his communications with me, the coroner referred to the time when the coroner’s court in Uxbridge was in operation. I do not know what happened there, but perhaps such a wide geographical area is unmanageable for one coroner.

There are several cases that I could cite. Theresa from east Acton was administering funeral arrangements for a 97-year-old deceased friend who had no relatives. She waited for four months, and it was only when the funeral director, W Sherry & Sons of Acton, intervened that it was found that the case did not require a post-mortem. There was no need for a coroner, so that sped up the process and the burial could take place. However, we hear horror stories of bodies waiting in fridges and people being left in limbo.

I must say that the communications that I myself have had from the coroner’s office have been completely defensive and displayed a complete inability to accept any kind of criticism, even though constructive criticism could be helpful as we move forward. One of the emails I received said:

“This office, under pressure, attempts to deliver a standard of service that befits all the deceased”

and that is “faith-neutral”. The hon. Member for Kingston and Surbiton mentioned that Muslim burials in particular are meant to be expedited quite soon after the death. Perhaps sensitivity could be shown in such situations, and if the coroner’s office is under pressure, perhaps there are things we can do to help.

As my hon. Friend the Member for Ealing North mentioned, the notoriety of some of the cases in question has spread beyond west London and they have become cases of national interest. Leaving an important case file containing sensitive information on a train is not good practice; I believe that case has now been transferred to Westminster coroner’s court. As far as I understand it, it is a rare occurrence to have a case completely transferred.

I will chop my speech because we have limited time. This coroner has said in his communications to me:

“The Coroners Court is a court of law. It is the oldest Court in the country. A judge can only make determinations based on evidence.”

The evidence seems to be that standards at this coroner’s court are falling short of what people in west London, across six boroughs, expect. We need to improve that experience.

People never know when they will need a coroner’s services. As Members have said, it will be at a moment when people are raw, grieving and going through a healing process, so heavy-handedness is not what is needed. Most people have a positive experience. I have been an Ealing resident for 43 years. My father passed last year. It was not a controversial death, so there was no cause to contest anything, but for those who do have problems, we need to make the experience better.

It is a pleasure to serve under your chairmanship, Sir Roger. I thank the hon. Member for Kingston and Surbiton (James Berry) for securing the debate and speaking at a time that may not have been easy for him. I concur with what other Members have said about the memory of his father and about seeing whether there is anything we can do to help the many people—our constituents and their families—who are going through such pain. I also thank him for doing the research on comparative examples to let us know that what we are experiencing is not normal.

Delays in death certificates cause huge disruption and pain to those coping with the death of a loved one. We must not underestimate the problems that the delays at the West London coroner’s court have caused, especially for those planning religious burials, as has been mentioned. I want to share two examples from casework in my constituency, which illustrate two different aspects of the administrative problems being experienced.

First, a constituent of mine sadly passed away at his home in Chiswick in April this year at the age of 85. He had not seen two doctors in the preceding months, so his body was taken to the mortuary and referred for an autopsy. In order to make arrangements for the funeral, the family rang the coroner’s office to establish timings for the release of his body. They were held in a queue for more than 50 minutes without reply and directed to send an email. Two weeks later, the family were still waiting. They had not received an acknowledgement of the email and no phone calls were answered or returned. They did eventually get an answer, but for 16 days, the family had no idea whether the remains would be subject to autopsy or when the body would be released back to the family. That is a common situation.

Secondly, Cheryl Hounslow is the ex-wife of Raymond, who died and an inquest was needed. Although estranged, she was the next of kin. He died in April 2014, and she waited 15 months for an inquest that only went ahead, so far as I understand, after my intervention. It turned out that the person handling the case had all the files ready to present to the coroner within two months, but for some reason they were not passed on. I understand that the staff member may have left, but the case could have been passed on for inquest in June 2014. Every organisation should have a procedure for what happens when staff leave, and files should not disappear when someone leaves an organisation. Cheryl could not get through on the phone and got no response to five emails. It was only when my staff got involved that the case was looked at again. In fairness, when the coroner found out that the paperwork had not been passed on, he expedited the hearing and allowed Cheryl to choose the date of the inquest. He blamed the local authority and the Met police for the poor customer service. With that inquest being brought forward quickly, it will have meant someone else waiting longer.

In any organisation, someone somewhere must be responsible for performance standards. I spent 25 years in local government, and we had systems, processes and accountability. That seems not to be the case in this example. The coroner is a public service that people need when they are at their most vulnerable. I hope that the Minister can respond with a plan of action for us and our constituents.

It is a pleasure to serve under your chairmanship, Sir Roger. I am astounded by the humanity, sensitivity and care with which Members have presented cases on behalf of their constituents. I cannot think of anything more distressing for someone who has lost someone dear to them than having to deal with such poor administration as some constituents have had to endure. I congratulate the hon. Member for Kingston and Surbiton (James Berry) on securing the debate and on the incredibly sensitive manner with which he presented his argument. I was also struck by my hon. Friend the Member for Ealing North (Stephen Pound), who normally speaks with great humour and characteristically puts a lot of anecdote into his speeches. There was not one shred of humour today, such is the seriousness of the case he was arguing.

We seem to be having three different problems with West London coroner’s court: errors on certificates; delays; and, rudeness, lack of care and poor communication with families. I will not go into specific cases in detail, but some of the comments that the families have made are useful in illustrating the problems. One said:

“After months of emailing I finally got a reply but my complaints were not acknowledged. In July this year I finally got the post mortem report riddled with mistakes. Talking about my daughter and referring to my mum as ‘miss’. It was harrowing enough reading but the mistakes made me feel that my mum was just another body.”

Another family said about a very young child:

“My granddaughter’s baby boy died on the 3rd of January this year. And she still has not had a death certificate or told why he died. He was 11 weeks old and she is still devastated.”

Another said:

“This was after they had put my late father’s place of birth as my mother’s home address. We still haven’t been getting full responses to emails and it’s only been 4 1/2 months since my father died, so I expect they won’t have the inquest in the next year, let alone get a full death certificate. They are an utter disgrace.”

Some people know more about this issue than MPs: funeral directors. I cannot imagine the frustration that funeral directors must be experiencing. One said that

“my heart sinks when we have to call them. To stand a chance of getting a reply we call at 7am and they answer around 3pm! It’s awful when other calls come in and all people can hear in the background is ‘your call is number ** in the queue’!”

It is maladministration, it is bad practice, and it is insensitive. It is not good enough and it should not be happening in this country in 2015.

As my hon. Friend the Member for Ealing North said, we are looking at a structural failure and a failure of leadership. It is surprising to families when they discover that it is difficult to know where to complain. There are many organisations with a hand in the issue, such as the council and the Metropolitan police. It is unfortunate that the hon. Member for Uxbridge and South Ruislip (Boris Johnson) has had to leave, because I would have been interested to hear an intervention from him.

The hon. Member for Kingston and Surbiton (James Berry) referred to the ITV News investigation. One of the emails I have from the coroner says that

“this complaint is fuelled by the recent unbalanced ITN news items.”

That is what I mean by the inability to take criticism—someone who is grieving has been pooh-poohed by the coroner saying that it is media manipulation.

I was not aware of that as I am from the north-east and I do not watch the local news when I am down here. What my hon. Friend says gives a good indication of the lack of care and sensitivity that has been experienced by families who have to access the service at such a devastating time. It seems odd to me that councils and the Met provide admin staff support, but do not have responsibility for the overall service. That confuses families at a time when they should not be expected to find their way through some web of the civil service.

I will not speak for too much longer, because I want to give the Minister as much time as possible to explain what she intends to do to put that right. As my hon. Friend the Member for Hammersmith (Andy Slaughter) has indicated, the council has called for the JCIO to investigate.

I want to put something seriously on the record, bearing in mind what my hon. Friend has just said, before the Minister responds. The debate is more in sorrow than in anger. It is not an attack on the Government in any way, shape or form. We are absolutely united here. The tone struck by my hon. Friend is exactly the right one. We are not seeking to blame the Government, but we are looking for some hope from the Government on how this situation can be resolved with the greatest expediency.

That is exactly right. I know the Minister will care deeply about this and will want to respond and put this matter right as quickly as she possibly can.

The JCIO will let us know in January whether it intends to conduct a full investigation into matters in west London. I sincerely hope that it agrees to do that, and I hope that it is done in a timely fashion so that families who are currently experiencing delays can have their cases heard as quickly as possible, and so that the wider community can have confidence in the service. That is something the Minister will care deeply about and want to put right. I will stop now so that she has as much time as possible to let us know exactly what she intends to do.

It is a delight to serve under your chairmanship, Sir Roger. I congratulate my hon. Friend the Member for Kingston and Surbiton (James Berry) not only on securing this important debate, but on the incredibly diligent work that he has done. I took on this role earlier in the year and already I am aware from my own postbag of all the issues that he has raised, namely the standard of service at West London coroner’s court, the provision of coroners’ out-of-hours service to facilitate religious burials, and the need for inquests into those who died while under a deprivation of liberty safeguard. All those matters are of concern to many people.

My hon. Friend wrote to me in September to bring my attention to the case of his constituent who had to wait nearly two weeks for a death certificate from the West London coroner’s office after her husband died. Other hon. Members have today raised issues of their own—disturbing and heart-breaking stories in many cases. I am grateful to them for doing so, as I am sure their constituents will be.

The West London coroner is not here to defend himself, so I will cite the case of James Rodriguez that I mentioned earlier. The post mortem was carried out on 30 April. By the coroner’s own admission, five months later they had not chased up the results, and he says now to the bereaved relatives, who have no death certificate at this stage, nine months later,

“I will not guess at this stage”

when that will happen. That is not in dispute, and that is the level of service we are dealing with.

I am grateful to the hon. Gentleman for bringing that to my attention. I am absolutely clear that the needs of bereaved people should be at the very centre of all coroners’ services. That was supposed to be the main aim of the coroner reforms that we implemented in July 2013.

The West London coroner’s office in Fulham is very busy. It covers a large geographical area, as we know. In 2014 the office received 3,437 reports of deaths and 383 inquests were held. However, that is no excuse for poor, inefficient, rude and insensitive services, or, in some cases, a lack of communication, particularly at such a difficult time when people are grieving. My hon. Friend the Member for Kingston and Surbiton is not the only Member whose constituents have been unhappy with the level of service they have received from the West London coroner’s office, particularly with regard to the responsiveness of the office. Several Members have written to me detailing individual cases of constituents who have encountered delays, lack of engagement and rudeness from the coroner’s office, and other Members have raised that today.

My officials and the Chief Coroner’s office have also been alerted to problems. These include bereaved families not being able to access death certificates in a timely manner; delays in holding inquests, which is particularly stressful for bereaved families when they are already going through a very upsetting time; and not having staff at the end of the phone to deal with queries and concerns when they are needed. I understand that a number of complaints have also been lodged with the London Borough of Hammersmith and Fulham and that my hon. Friend the Member for Kingston and Surbiton has written to the council’s chief executive on this matter as well.

Earlier this year, the Chief Coroner went to Fulham to visit the senior coroner and his staff. Along with him were representatives from the local authority, which provides the funding and infrastructure for the local coroner service, and also representatives from the Metropolitan police, which provide the coroner’s officers, who are the front-line staff who deal with bereaved people. The senior coroner, the local authority and the police all have a role to play in improving the service. They discussed the issues together and looked at ways to resolve them, and an action plan was agreed. I am pleased to note that, as a result, we are beginning to see signs of a more positive picture emerging from west London. The office has reached its full complement of administrative and investigative staff, including a coroner’s officer manager and six new coroner’s officers. There is now a new way of managing the telephone system so that administrative officers deal with all phone calls in the first instance to relieve the burden on the coroner’s officers, thereby allowing them to focus on progressing cases. However, I take on board the recent instances that the hon. Member for Ealing North has raised about his own experiences with the telephone service. I have made a note of them and my officials will certainly deal with that, because that is not acceptable.

Members will be pleased to hear that west London has now reduced the backlog that it inherited. The senior coroner inherited 400 outstanding inquests when he took up post. That has now been reduced to 70 cases and it is anticipated that these final historic cases will be cleared by the end of February, which will allow staff to focus fully on new cases. The senior coroner has attempted to clear the backlog by making sure there are two courts running in parallel with his assistant coroners hearing cases alongside him.

As the Minister with the coroners portfolio, I share the wish of all Members in the Chamber to resolve matters as quickly as possible. As they have already articulated, the process is not straightforward. The Ministry of Justice has overall responsibility for coroner policy and law, but the responsibility for the delivery and funding of coroner services is a local matter for the appropriate local authority, in this case the London Borough of Hammersmith and Fulham. It is for it to decide how to run and fund the coroner services.

The Minister has outlined where the funding lies and where responsibility for the overall policy and strategy lie. Where does overall responsibility for the monitoring and reporting of performance of coroners’ courts lie?

That would lie with the coroners themselves and with the Chief Coroner, whose post was created in 2012. We now have a Chief Coroner who is responsible for overseeing all such matters, but where there are cases that need to be investigated, it is up to the Judicial Conduct Investigations Office. It is currently investigating the conduct of the West London senior coroner, including the case that the hon. Member for Ealing North referred to earlier. That case has been transferred to the inner west London coroner, Dr Fiona Wilcox, who will now be dealing with it. In cases where performance has not been as expected, it is up to the JCIO to carry out investigations.

The Minister referred to standards. Is there a set of standards for how coroners have to deal with cases? What are the measures against which we know that delivery is getting better or worse, or is adequate, satisfactory or inadequate?

That was all included in the coroner reforms. If the hon. Lady gives me just a little time, I am about to talk about them.

As I said earlier, bereaved people must be at the heart of the coroner service, and that was the key aim of the reforms in the Coroners and Justice Act 2009. The coalition Government implemented those reforms, including the rules and regulations that underpin the Act. The provisions came into force in July 2013 and introduced the role of the Chief Coroner. In September 2012, his honour Judge Peter Thornton QC was appointed as the first Chief Coroner. He has already played a central role in providing guidance for coroners on the new national standards for coroners set out in the legislation. Coroners are now required, for example, to conclude an inquest within six months of a death being reported to them, or as soon as practicable afterwards. They are also required to report coroner investigations that last more than 12 months to the Chief Coroner, who is in turn required to report on that to the Lord Chancellor and to Parliament in his annual report.

For bereaved people and families, the most significant development under the 2009 Act was perhaps the “Guide to Coroner Services” booklet, a document published by the Ministry of Justice that sets out the standards of service that people can expect from coroners’ offices and what they can do if they feel that those standards are not being met. It is vital not only that coroners know what the standards are, but that bereaved people understand how a coroner’s investigation is likely to proceed. The guide is accompanied by a shorter leaflet that sets out the key aspects of an investigation. We have sent hard copies of the guide and the leaflet to every coroner’s office in England and Wales so that they can be given to every bereaved person or family. The guide is also available on the website.

What the Minister is saying is very interesting, but we are talking about a service that has failed. It has been failing, persistently, for some time. It has been flagged to any authority that anyone can think of, yet we have seen the failure continue. What does she think she might need to do to ensure that we do not have this kind of delay in taking action should such a situation arise again in future?

A lot of the reforms that were part of the changes over the past two or three years will begin to take effect soon. There are obviously a number of issues at play here. We are dealing with a situation where someone is already under investigation. That may well continue, so there are a number of things to consider.

I shall make some progress because I want to address in full the concerns raised by my hon. Friend the Member for Kingston and Surbiton about the provision of out-of-hours coroner services. I am aware that faith communities, particularly the Jewish and Muslim communities, are concerned about the lack of an out-of-hours service because that can delay the timely burial of their loved ones required by their faith. As part of our commitment to improve coroner services, we have recently completed a post-implementation review of the coroner reforms that we implemented in 2013, seeking views on, among other things, the availability of out-of-hours services. We have now received all the responses, which are being analysed, and I hope to come back to the House with a report in spring next year.

While the review was ongoing, we also worked with London local authorities and the Metropolitan and City of London police to develop a pan-London out-of-hours service. The police and local authorities are now also planning to commission a more general review of coroner services in London to see how resources can be better shared and managed to streamline and improve both in-hours and out-of-hours services in the hope that that will also address some of the issues raised by Members today.

On deprivation of liberty safeguards, my hon. Friend the Member for Kingston and Surbiton raised concerns about additional distress caused to families and the pressure put on coroners’ workloads by their having to conduct inquests into the deaths of those who were under a deprivation of liberty safeguard when they died. The safeguards frequently occur in care homes or in long-term hospital care, even when someone quite plainly dies of natural causes. That is because of a Supreme Court decision last year that held that such individuals are effectively in custody when they die, which is a category of case that coroners are under a statutory duty to investigate. With that in mind, I have been speaking to the Minister for Community and Social Care. We agree that we need to do what we can to solve the problem as a matter of urgency. My officials, together with their counterparts from the Department of Health, are looking at how we can remove the burden while maintaining the protections put in place for those who truly are in state custody.

I am grateful to my hon. Friend the Member for Kingston and Surbiton for all the matters he raised today and to all those who have raised concerns about the West London coroner’s court, out-of-hours services and the deprivation of liberty safeguards. I have welcomed the chance to hear more details about such concerns. I have set out measures that will lead to improvements across the country, but we will continue to monitor and will be grateful for feedback as we move forward.

Question put and agreed to.


That this House has considered standards of service at West London Coroner’s Court.

Sitting adjourned.