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Suicide: Coroners’ Courts

Volume 646: debated on Wednesday 5 September 2018

[Sir David Amess in the Chair]

It is a pleasure to be here under your chairmanship, Sir David, for this short debate on the standard of proof for a conclusion of suicide in the coroners’ courts. To say that any suicide is a tragedy is to state the obvious. It is a tragedy for the person concerned, who could see no way out other than to take their own life; it is a tragedy for their family and friends, left with an intolerable burden to carry; but it is also a tragedy for us as a society, because we have failed to offer them another way out and failed to support them through their illness.

Suicide is an increasing problem for us. The rates are now highest among middle-aged men and have gone up by 40% in 10 years. It is also the biggest killer of young people between 15 and 34. It is a real public health emergency, yet we are often prevented from openly discussing suicide by the stigma that surrounds it. Nowhere is that stigma more obvious than in a coroner’s court. Suicide ceased to be a crime in 1961, yet until very recently the courts held consistently that the standard of proof for a conclusion of suicide had to be the criminal one of “beyond all reasonable doubt”. In effect, the state, having decided that suicide is not a crime, still treats people in a coroner’s court as if it were. That is something we should alter.

It is settled in English law that there are two standards of proof—the civil and the criminal—but a coroner’s court is not a criminal trial. It is not even litigation. It is, as Lord Chief Justice Lane said,

“a fact finding exercise and not a method of apportioning guilt.”

A coroner’s duty is to investigate someone’s death and to find out and record the facts in the public interest. That public interest duty is important, and I will return to it later.

An inquest can find that someone died in a number of ways or it can record an open verdict, but its decision is not conclusive in any subsequent litigation. The rules of procedure prohibit a coroner’s court from any finding of fact that may seem to determine criminal liability. The coroner’s court no longer has a connection with a criminal court. It used to have, and could name a person who was thought responsible for a homicide, which committed them to trial, but that power was abolished in 1977. Why, when suicide is no longer a crime and when the courts no longer have that power, do we still stick to the criminal standard of proof?

The Minister will probably be relieved to hear that I do not have time today to go through all the cases that have led us to the current position, but it is important to note that it has come about through case law; it is not in statute or in the coroner’s rules of procedure. Many of those cases were decided some time ago, when attitudes to suicide were very different from what they are today. Many of them resulted from people challenging a coroner’s verdict on suicide. That was understandable prior to 1961, when suicide was a crime and when a conclusion, or verdict as it was then, of suicide could have significant financial implications for those left behind. For instance, insurance companies often did not pay out when there was a suicide verdict. That is no longer the case, yet we continue on that road.

The situation was probably set out most clearly in the case of R v. Her Majesty’s Coroner for Dyfed, ex parte Evans, where Lord Justice Watkins held that a coroner’s jury could not return a verdict of suicide based on the balance of probabilities; it is only permissible for a coroner’s jury to return a verdict of suicide if they find, upon evidence proved to their satisfaction, that the deceased intended to, and in fact did, take their own life. That is a very high threshold to meet.

Other cases that have contributed were not in fact about suicide, but about unlawful killing. In the famous one, ex parte Gray, Lord Justice Watkins, again, referred to an earlier case, ex parte Barber, which he said had held that a verdict of suicide was only permissible if proved beyond all reasonable doubt. Other cases established that the presumption ought always to be against a conclusion of suicide, and that intent was crucial. That was understandable when suicide was a crime—every first year law student knows that to prove a crime, both the mens rea and the actus reas must be proven—but it is not understandable when it is not a crime, and many of the key cases on intent were decided many years ago, when attitudes were very different and suicide was a criminal office—for instance, the case of Southall v. Cheshire County News Company Ltd was decided in 1912, and that of ex parte Lockley was decided in 1944. None the less, they still haunt us today.

This is a real problem that still has an impact on many cases. In the case I referred to earlier, ex parte Evans, and in a similar one, R (Jenkins) v. Her Majesty’s Coroner for Bridgend and Glamorgan Valleys, the challenges to the coroner were all based on intent. Family and friends gave evidence that the deceased were in a positive frame of mind prior to their deaths. That puts us in a position where we are returning conclusions that go against the facts. What we know about suicide now is that when someone has decided to take their own life, they often seem in a calmer and better frame of mind because of that decision. In those two cases, where people tragically threw themselves in front of trains, the facts of the case were very clear—those individuals intended to end their own life. We end up with conclusions that go against the known facts.

It seems to me that the current position is also legally unsupportable. We are basing our approach on cases decided a long time ago, when suicide was a criminal offence, and on some cases that did not even involve suicide at all. Other cases in the coroner’s court are decided on the balance of probabilities. In civil litigation, a court can decide based on the balance of probabilities, even when criminal facts are involved—for instance where someone seeks compensation for a fraud, or where people sue for compensation, perhaps following a rape or the murder of a family member, we decide on the civil balance of probabilities measure.

Given this situation, it is not surprising that there are other common law jurisdictions that have refused to follow these precedents. In Canada, for example, where the coroners’ court system is closely modelled on our system, the Supreme Court decided that suicide should be decided in the coroner’s court on the balance of probabilities. Until recently, we have had all these decisions in English courts that have gone the other way. That only changed recently, in a case, R (Maughan) vs. Her Majesty’s Senior Coroner for Oxfordshire, that is now subject to appeal—I have therefore had to take advice from our omniscient and helpful Clerks about what I might say about it—concerning a narrative verdict and the instructions to a coroner’s jury. The judges held in that case—subject, of course, to appeal—that it is no longer tenable to use the criminal standard of proof given that there was no connection with the criminal courts, and that cases, whether they involve a narrative or a short-form verdict, should be decided on the balance of probabilities.

It remains to be seen what happens in that appeal. The judgment may, of course, be overturned, but I believe it is time for the Government to end this situation and legislate to make clear that the civil standard of proof should be used in a coroner’s court for cases involving suicide. I believe that for a number of reasons. First, by continuing to use the criminal standard of proof, we are in fact maintaining the stigma around suicide, which prevents us from discussing it openly and dealing with it effectively. In the past, Ministers have argued that that is not the case, but Professor Louis Appleby, who knows something about this issue, told the Health Committee during its inquiry in the previous Parliament:

“There is a principle here, which is that that standard of proof is a reflection of a system that is full of prejudice and stigma, which we ought to dismantle.”

The second reason is that, in the current system, we may be hugely underestimating the number of suicides we are dealing with. Academics who have looked at this matter, such as Professor Pritchard at Bournemouth, have concluded that we may be underestimating by between 30% and 50%. The first step in dealing with the problem is to know how widespread it is. Currently, we do not know that properly. In the past, some Ministers have been concerned about making changes that may offend faith groups. As a born and bred believing Catholic, I say gently to the Minister that that is not the duty of the state. The duty of the state is to find out the facts, as was said in the recent case, without fear or favour. The view that any faith group takes of suicide is a matter for them, not for the Government.

The third, and understandable, reason is that coroners are often reluctant to reach a conclusion of suicide because they fear the upset it would cause to the family. I understand that. I have nothing but sympathy for families left to deal with the after-effects of a suicide. In fact, I think we should offer them more support than we currently do, but again that is not the courts’ role. The public interest in knowing how many suicides we are dealing with and how they are occurring overrides that concern. In the end, if we are not able to discuss suicide openly and if people are prevented from being honest about their suicidal thoughts and seeking help because of the stigma that attaches to it, we cannot design services effectively and we may lose the chance to save lives. That, to me, is far more important.

This is not a party political matter—the current position has prevailed under Ministers of different political parties—but it is time to get hold of the anomaly and deal with it. If the Minister did that, he would have widespread support from the National Suicide Prevention Alliance, from PAPYRUS, which works to prevent young suicide and is based in Warrington—it gave me a great deal of help in preparing for this debate—and from the Health Committee, which recommended this change in its report on suicide prevention in the previous Parliament. He would also have the support of the former Chief Coroner, Peter Thornton, who wrote to the chair of PAPYRUS in 2013:

“I am supportive of the change which would reduce the standard of proof for suicide to the civil standard and have expressed that view to the Ministry of Justice.”

He would also have support across the House.

In the end, this matter is too important to leave to the lawyers and the courts. It is a major public health issue, which we need to tackle. Unless we get it right, we will not be tackling it effectively. We will lose the chance to prevent more deaths in the future, and we will be culpable for that. Some things in politics are not easy, but they are nevertheless right. I strongly urge the Minister, who has seen coroners’ courts operating and is concerned about this issue, to do the right thing and make this change for the benefit of many individuals and their families in the future.

I congratulate the hon. Member for Warrington North (Helen Jones) on securing this debate on such an important, complex and sensitive issue. I am grateful for her passionate and thoughtful views. Her erudite speech highlighted, if my recollection is correct, not only her distinguished time as a parliamentarian but her previous career as a distinguished solicitor, as was evident from her careful and clever deployment of her legal knowledge.

Coroners’ courts are the oldest part of the judicial system in England and Wales, but they have not stood still; they have continued to evolve their processes. The Coroners and Justice Act 2009 set out a comprehensive suite of reforms to coroner law and practice, which was implemented in July 2013. The dedication and commitment of the Chief Coroner, His Honour Judge Mark Lucraft QC, and that of his predecessor, whom the hon. Lady mentioned, both in working towards continued improvement and in providing leadership, guidance and support to coroners, is second to none, and I am grateful to them both for their service.

In 2017, almost 230,000 registered deaths in England and Wales were reported to coroners—43% of the total number of deaths—and inquests were opened into 31,500 deaths by the 88 coroners’ areas across England and Wales. As the hon. Lady said, by definition bereaved families engage with coroners at an extremely difficult and stressful time in their lives. I believe that the coroner service does a wonderful job of working to ensure that its engagement is as respectful and caring as possible.

As the hon. Lady alluded to, I had first-hand experience of that when I recently had the privilege of visiting the Westminster coroner’s court to open a garden of remembrance—a personal initiative taken forward by the excellent Inner West London senior coroner, Dr Fiona Wilcox. I was also able to observe an inquest into a suicide, and I saw for myself how deftly and sensitively Dr Wilcox handled the legal process, alongside sensitively handling a bereaved family and their feelings. I pay tribute to her and all her coroner colleagues for their dedication and professionalism, often in very difficult circumstances. It is a service of which we can be proud.

As the hon. Lady said, put simply an inquest is a court hearing held by the coroner to establish who died and how, and when and where the death occurred, but it differs from other types of court hearing because it is inquisitorial, rather than adversarial, and does not establish criminal or civil responsibility, as she said, deploying her legal knowledge. At the end of the inquest the coroner—or jury, where there is one—reaches a conclusion. Historically, the standard of proof for a conclusion of suicide has been established by case law, as the hon. Lady said. Although suicide was decriminalised in 1961, case law continued to apply the criminal standard—that is, beyond reasonable doubt—as opposed to the lower civil standard.

To go to the crux of the debate, as the hon. Lady said, there have been calls for the Government to address that situation, not least by campaigning organisations such as PAPYRUS, which she mentioned and which campaigns energetically not only on this issue but on the broader one of preventing suicide among young people. As she said, the Health Committee recommended lowering the standard of proof for suicide in the reports of its suicide prevention inquiry, published in December 2016 and March 2017. The Government made it clear in their July 2017 response that they had been considering whether to make such a change. Recently, however, the matter has moved on as a result of evolving case law, with the judgment handed down by the High Court on 26 July in the case of R (Maughan) v. Her Majesty’s Senior Coroner for Oxfordshire. Before continuing, I put on record my sincere condolences to the family of James Maughan on the sad loss of their loved one in difficult circumstances.

In brief, the case, which has been alluded to, was a judicial review of the jury inquest held into Mr Maughan’s death. The senior coroner invited the jury to record a narrative conclusion, rather than a short-form conclusion of suicide, which he directed should be determined on the civil standard of proof. The judicial review claim was made by the bereaved family on the basis that the jury’s conclusion was unlawful because it amounted to a conclusion of suicide reached on the balance of probabilities, rather than on the criminal test of beyond reasonable doubt.

That judicial review claim was dismissed by the High Court on the basis that previous case law applying the criminal standard of proof was incorrect and that the correct position in the opinion of the court was the application of the civil standard. However, the High Court gave the bereaved family leave to appeal the judgment, which they have now done. A date has not yet been confirmed for the Court of Appeal hearing of the case. Pending that hearing, I hope that the House understands that it would not be appropriate for me to discuss the judgment of the High Court, other than the factual account that I have just put on the record, the forthcoming appeal, or any issues relating to or arising directly from either one, because that might impact on the case.

I realise that the Minister cannot comment on the case, but may I ask whether he has had discussions with his colleagues in the Department of Health and Social Care about the impact of the existing situation on any assessment of the number of suicides and the design of services to meet them?

Such issues of suicide prevention are discussed regularly with the Department of Health and Social Care. I am about to come on to suicide prevention and the broader point that the hon. Lady made, in particular about understanding the scale of the issue. If she allows me one more paragraph, I shall come on to exactly that.

I appreciate that the point I made about being slightly limited in what I can say given the legal context will disappoint the hon. Lady. I hasten to add that my intention is never to disappoint her—

I hope not by me—yet. I can only assure the hon. Lady that I have of course noted the points that she and other hon. Members have made today and in the past. I will consider them very seriously, along with the Court of Appeal ruling when judgment is handed down in that case. I shall respond as appropriate at that point. Clearly, however, while the case is being heard I shall stray no further.

To come on to the hon. Lady’s wider point, I shall touch on the broader issues underlying the debate: the importance of preventing suicide, tackling potential contributing factors and understanding what it is that drives suicide in some cases. As she said, a verdict of suicide in a coroner’s court of course means that a tragedy has already occurred, and every death by suicide is a tragedy with a devastating effect on families and communities. That is why the Government updated the national suicide prevention strategy last year—to strengthen the delivery of its key areas for action, such as expanding the strategy’s scope to include addressing self-harm as an issue in its own right.

I am encouraged that data published by the Office for National Statistics this week show that in 2017 the suicide rate in England reduced for the third consecutive year. The rate is now at its lowest for seven years, which brings us closer to achieving the national ambition to reduce suicide by 10% by 2020.

As the Minister knows, evidence given to the Health Committee stated that apparent reductions in suicide are often linked to changes of practice in the coroners’ courts. Will he therefore look seriously at what the Health Committee recommended on coroners being given more training in how to construct their narrative verdicts, and on giving the Chief Coroner more resources to ensure similar practice across all the courts?

I am happy to look into both those matters. My understanding is that the suicide registration statistics, which are used to calculate the suicide rate, already include deaths by undetermined intent, where a suicide conclusion was not reached but where it is likely that the death was caused by suicide. There is a slight difference in the calculation of the rate, but I shall look into the points that the hon. Lady made.

I am encouraged that the suicide rate among men—the highest-risk group, as the hon. Lady said—reduced for the fourth consecutive year. That is of course a reason to do even more, because every suicide is a tragedy, and we must seek to do everything we can to prevent any suicide if at all possible.

To address suicide prevention in mental health settings, this year, the previous Health and Social Care Secretary launched a zero-suicide ambition across the NHS, starting with mental health in-patients but seeking to include all mental health patients. My opposite number in Health, the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Thurrock (Jackie Doyle-Price), has a personal commitment to that agenda. She is working extremely hard to ensure that the record levels of spending on mental health by the Government continue to drive improvement.

Clearly, suicide prevention must be a key Government priority. The hon. Member for Warrington North is absolutely right to highlight the fact that the issue is not a partisan or party political one; it is about doing what is right and improving the situation for everyone. I thank her for securing the opportunity to focus on such an important issue in the specific context of the operation of the coroners’ courts and system.

The recent High Court judgment has thrown a spotlight on a particular aspect of the national debate around the complex and sensitive network of issues involving suicide. I may not have been able to go into the level of detail that the hon. Lady might have wished, but I hope that I can offer some reassurance with my commitment: we await the decision by the Court of Appeal with keen interest, we will consider it carefully, and we will continue to reflect on the particular issue that she has highlighted so eloquently. Furthermore, should she so wish, I am happy to meet her to discuss it further.

Question put and agreed to.