asked Her Majesty’s Government what action they propose to take in view of the absence of a coroners Bill in the legislative programme.

The noble Baroness said: I was sorry to see no coroners Bill in the gracious Speech, hence I have instigated this debate. A complete overhaul of coroners’ services in terms of both infrastructure and legislation is long overdue.

I start with the subject of death certification. Reform of death certification has been recommended by a succession of reports, including the Brodrick report in 1971, the Luce report in 2003 and, most recently, Dame Janet Smith’s report on Harold Shipman.

The cremation certificate system, which requires families to pay a fee, has proven inadequate in detecting patterns of criminal practice and I believe does not detect poor clinical performance or systematic errors in death certification. A better system of scrutiny of all deaths—not just those involving cremation—with built-in statistical analysis is required and is now easily within the competency of an IT programme. It should analyse deaths and certification by doctor, by location of healthcare delivery and by cause—similar to the data from the Prescription Pricing Authority. For example, hospice doctors will of course certify more deaths than GPs but high numbers from one service, wherever that service is in healthcare, that lie outside the normative curve could at least be spotted.

As for determining the cause of death, it seems that the coroner should be able to pursue a diagnosis beyond an immediate “mode” of death and to obtain a precise diagnosis by further pathological investigation for the benefit of a family and also for the benefit of the healthcare system.

There is a need for authoritative guidance to coroners and pathologists on exactly what a coroner’s post-mortem should achieve. To exclude unnatural causes of death is far too simplistic. Fewer and fewer non-coroners’ post-mortems are being done, so verification of the precise medical cause of death is happening less and less, yet it is essential for an audit of clinical services to improve patient safety. Furthermore, it is unclear what level of investigation is justified—and lawful—once unnatural causes have been excluded. Perhaps I may give an example. A patient with mesothelioma dies at home. Because the illness is related to asbestos, this results in a police interrogation of the bereaved family, even though the diagnosis has been clearly established. That is an unnecessary and hurtful consequence of current regulations. If we had a chief coroner, that could be completely avoided.

Another example is that, currently, if a patient dies with a dementia syndrome, a coroner is not motivated to establish the cause of the dementia—an expensive procedure costing around £600—even though the family may wish it. Therefore, if it happens at all, a research programme might pick it up as a by-product of the family agreeing to donate the brain for further research. However, dementia represents an increasing cost to the public purse, so the underlying causes need to be known if we are even to plan spending in the future.

Sometimes information might prevent a premature death. I was recently told of a case of sudden adult cardiac death where the strong suspicion was of an inherited cardiomyopathy. A coroner’s post-mortem was done but, despite having the consent of the relatives, the coroner refused to pay for appropriate specialist investigation of the heart, with genetic testing, because it was clear that the death was due to natural causes. The coroner had neither remit nor resources to undertake investigations for the benefit of the relatives. The NHS then also refused to pay because the test would be for the benefit of the relatives, not the deceased, and the deceased came from a different primary care trust from the relatives. Yet such investigations would have clarified future management of the close relatives and could have lowered their risk of sudden death.

Why is complex, controversial and expensive legislative change to medical revalidation being pushed with greater vigour than legislation to permit improvements in the investigation of death? A draft Coroners Bill was announced for this Session, published, then dropped. That is unjustifiable.

I shall move on to the provision of medical advice. The draft Bill, as previously published, emphasised legal aspects, but the medical aspects of ascertaining a cause of death are key to accuracy and require expertise. Surely it is the medically qualified specialist pathologist who should have the ability to pursue the appropriate investigations and dictate how to examine the body, rather than the coroner, who often is not medically qualified at all.

Nowhere is that more important than in the vexed issue of sudden and unexpected death in infants. The report by the noble Baroness, Lady Kennedy, into that subject recommended that tissue blocks and slides should be retained in perpetuity after a post-mortem examination in a case of sudden infant death syndrome, in case future developments justified re-examination of those samples. When we debated the Human Tissue Bill, I stressed the need to be able to revisit the specimens but the Government did not accept that. Now retention is illegal without “appropriate consent” once the work of the coroner has been completed. If the parent had been culpable, of course they would want to ensure that all tissue was cremated and all evidence destroyed. If not, then in the horrible and unthinkable event of a second cot death, the tissues could be re-examined.

The situation in Scotland is exactly the opposite to that in England and Wales because, under the Human Tissue (Scotland) Act, the blocks and slides become part of the deceased’s medical record and the pathologist is specifically prohibited from disposing of them or returning them to the parents. That polar difference between Scottish and English law is contrary to the stated intention that the tissue legislation between the two jurisdictions should have broadly the same effect.

The noble Baroness, Lady Kennedy, also recommended that certain time-sensitive samples, such as blood, cerebrospinal fluid and nasal swabs for microbiological investigation, should be taken as soon as possible after the death of the child has been confirmed to maximise the chances of ascertaining fully and reliably the cause of death. She clearly anticipated that this testing would take place in accident and emergency departments before transfer to a mortuary. However, the Human Tissue Act 2004 has made such sampling illegal, except where the A&E department has a Human Tissue Authority licence to undertake such sampling—but there is cost and complexity to obtaining such a licence. The Royal College of Pathologists believes that this was an oversight and that this consequence of the Human Tissue Act was not recognised prior to Royal Assent. A coroners Bill could easily correct that anomaly.

Why do we need a chief coroner? We need a national structure to ensure consistency of standards and to ensure that the investigation of deaths is carried out to a gold standard nationally. I have already mentioned the problem of mesothelioma, which could be easily solved if we had a chief coroner. The current law has to be ignored when it comes to setting a gold standard. We have a shortage of highly specialised paediatric pathologists, so the bodies of dead children are being transported great distances for post-mortem examination. This is a serious issue because the law as it stands states that a body can be transported only to the adjoining coronial area of jurisdiction. When a family has to deal with the sudden death of a child, they must know that a satisfactory post-mortem has been carried out—and carried out within the law. The Ministry of Justice is aware of the problem, but everyone turns a blind eye to the benefit of the bereaved.

It is time that the needs of the bereaved, particularly their need for information, were properly addressed. Pathologists undertaking coroners’ post-mortems must know the wishes of the relatives before the post-mortem starts in order to be able to respect them, not simply consult them later. Relatives need information. I should like to see them have a copy of the pathologist’s report interpreted for them as a routine, with a copy to the GP so that they can ask questions later.

After Alder Hey, the University Hospital of Wales established a group, similar to the groups established in hospitals up and down the country, to take inquiries about tissue samples and retained tissues. When the family were not satisfied with the first-line response team, a few of us gave one-hour appointments for relatives to ask questions and tried to allay their concerns. The overriding factor was that they wanted answers. One woman said to me that she had waited 15 years to understand why her daughter had died. In that hour, I finally gave her the answers.

That situation cannot be allowed to continue. The charter for the bereaved lays out important guidance. I hope that it will not be abandoned now that the responsible ministry has changed. The legislative changes must be underpinned by organisational changes and clarification of funding. The “who pays” issues are now working increasingly against good practice. The Department of Health consultation on death certification in pandemic flu mentions reforms, but when are they coming? Until we modernise the coronial system we risk denying justice to our dead and their bereaved families.

I declare an interest as vice-president of the War Widows Association and I thank the noble Baroness, Lady Finlay of Llandaff, for introducing the debate.

We, too, were disappointed that the coroners Bill was not in the Queen’s Speech. We had hoped that it would be because there were a number of issues that we needed to bring forward. We now have a situation where service personnel are being killed in operations—that is not new, but the numbers are new in our times—and members of the dead personnel’s families are having to wait a long time for the inquests to take place and may have to travel long distances to attend when they do. There are also a number of other issues.

We had a meeting with the Minister at the Ministry of Defence. I know that this subject does not strictly come under its remit but, nevertheless, understandably the Armed Forces look to the MoD to assist them with their issues and problems. We hoped we were going to carry on and discuss the coroners Bill. That is no longer there for us to discuss but we cannot leave matters as they are. I know that there has been additional funding and that in the past year the backlog has reduced, but there is still a substantial backlog of inquests to be heard. Can the Minister give an indication of what the Government are going to do in this area?

There are a number of problems. It seems obvious that the inquest should take place in the area where the deceased’s family live—it would be better for them and more convenient—but that may not always be the right way of doing it because of a shortage of expertise. Local coroners may deal with a military death only once in their whole career and there needs to be some expertise. We believe that, for the different reasons that have been mentioned, that expertise could be gathered and made available under a chief coroner.

Multiple-death cases will still be heard in Oxfordshire because the aeroplanes bringing the bodies back go into Lyneham, with Swindon and Wiltshire also involved. There have been cases where a deceased’s home is in Scotland and the family has had to travel from there. That cannot be the best thing. On the other hand, if people with the relevant expertise are not available to go to Scotland to carry out the inquest, it may be the only answer. We would welcome a debate on the delay and where the inquest is to be carried out.

There is also the issue of legal representation at the inquest for the families. These personnel have been killed on Her Majesty’s business and we believe that the state has a responsibility to assist their families.

In my view, looking at the backlog, at what has happened and at reports in the press, one of the most heart-rending aspects is the lack of transparency and lack of information. Families are told that there is a delay or that the inquest will not be heard yet. Also, families do not have the detail to which, in our view, they are entitled. Transparency and information are absolutely key. If we had had a Bill, that would probably have formed the basis of an amendment.

Costs are a problem for families. These families do not have huge incomes and, at a time of huge trauma and stress for them, they then have to find travel costs. I know that they can apply for travel costs, but the system needs to be much more upfront and proactive in the way that the families are looked after. It is possible to do that because the Armed Forces’ welfare services are very good and very well developed, but perhaps we could ensure that their concerns for families in the services extend also to those who are faced with a member of the family who has paid the ultimate price in performing their duty to their country. That would certainly be of great assistance.

A whole range of issues could have been aired in a very healthy and straightforward way had we had a Bill. I confess that I am not absolutely sure where we take these issues now. I am not making a special pleading to the Minister, but I ask the Government for a joined-up approach, with the Ministry of Justice and the MoD coming together. We would certainly welcome meetings about this because we feel that we have made a little progress. The additional legal resource put in has helped to reduce some of the backlog but it is by no means anywhere near enough. I am sure that neither the Government nor we want this issue to continue to make headlines in the press, as it does from time to time. We would welcome an indication from the Minister that the Government are prepared to take this forward, even if we do not have a Bill, to see what can be done to improve the situation for families who have lost their loved ones. They have paid the ultimate price in serving their country.

I remind the Committee of my interest: I am a serving TA officer. Like the noble Baroness, Lady Dean, I too am disappointed that there was no coroners Bill for very similar reasons: military inquests and delay.

I served in headquarters, 1 (UK) Armoured Division, between March and May 2003. We recorded several fatalities arising from operations, and I know the details very well. Of course, there is no need to go into those details or to draw the Committee’s attention to them—particularly the problems of the current system. However, it was not until three years after the events that inquests were held, which had a very serious effect on the families. Clearly, there was no way the widows could restart their social lives prior to the conclusion of the inquests, so they could not achieve closure on the disaster in their lives for years. Of course, that was no doubt to the delight of the solicitors’ profession.

In my opinion, there are other serious problems related to inquests arising from military operations. The noble Baroness, Lady Dean, talked about transparency and the noble Baroness, Lady Finlay, in her submission on different issues, talked about the need for the families to have transparency and to understand what went wrong. I think she was talking about a situation in which the family found out what went wrong 15 years later. The MoD is very poor at telling families what happened in a frank manner. It is very difficult to do but it is poor at that.

In the past, repatriation, especially from operations, was rare because it was impractical. We can do it now, but we did not in the past. I think that it was a court case in the 1980s, some time after the Falklands campaign, which determined the need for inquests. During the Cold War, there were very few operational casualties. If World War 3 had occurred, the need for inquests would have been the least of our problems.

I do not know the answer to these problems but I know that they are very sensitive. I urge the Minister to give inquests arising from military operations urgent and careful attention.

I, too, express thanks to the noble Baroness, Lady Finlay, for introducing this important topic and raising these issues of concern. In my early years as a solicitor, the head of my firm, Mr Maurice Evans, was Her Majesty’s Coroner for Denbighshire. In that capacity, he presided in 1938 over the inquest into the Gresford colliery disaster of 1934, when 264 miners lost their lives. The mine was sealed and none of the bodies was recovered. At that inquest, the miners’ union was represented by Sir Stafford Cripps QC and the coal owners by Sir Hartley Shawcross QC. Your Lordships will appreciate that, with lawyers of that standing, very serious consideration was given to the issues. All that happened was that the mine manager was prosecuted for destroying the records of the condition of the mine prior to the explosion. “The Ballad of the Gresford Disaster” recalls:

“The fireman’s reports all are missing

The records of 42 days

The colliery manager had them destroyed to cover his criminal ways.

Down there in the dark they are lying

They died for nine shillings a day

They worked out their shift and now they must lie

In the darkness until judgement day”.

My noble friend Lord Hooson tells me that he went with my late father-in-law down the shaft and was shown where the miners had been bricked in.

In my day, the part-time coroner, my partner, was on his own. His staff consisted of his secretary, and there was no other support. Inquests were held in any convenient court room. I am not sure how his fees were paid—I think that it was probably by the local authority. Funding varied, and still varies, all over the country.

Nothing has changed. The terms of reference and the procedure remain the same. I recall the frustrations of appearing for grieving families but being denied, under the procedure, any right to address the coroner or his jury on the verdict. My role was confined simply to cross-examining the witnesses, and, of course, there was no legal aid. I shall be interested to see whether my colleague, Mr Michael Mansfield, is able to address Lord Justice Baker at the termination of the inquest into the death of the Princess of Wales and what he will say if he is not allowed to do so. So far as I am aware, the system has not changed over these years.

It was Dame Janet Smith, in her inquiry into the Shipman murders to which the noble Baroness, Lady Finlay, referred, who pointed out how archaic and ramshackle the system of coroners had become in this country. To be fair, I say that the Government took up the cause, admitting that the current inquests system was failing. Harriet Harman told Members of Parliament back in February 2006 that the system was archaic and said:

“Under the current coroner service, families frequently get overlooked during the inquest process. There is nowhere for them to turn when they think that something is going wrong; there is no complaints system. The system is fragmented, with no national leadership”.—[Official Report, Commons, 6/2/06; col. 607.]

She said that the changes that she was proposing would give families the right to contribute to coroners’ investigations. Those were very fine words but, although a draft Bill followed, there has not been a great deal of action since.

Since that statement was made, we have seen problems, to which previous speakers have referred, with inordinate delays in inquests into the deaths of servicemen in Iraq and Afghanistan. The coroners for Oxfordshire and Wiltshire were unable to cope with the numbers and others had to be drafted in.

Another area of equal concern is the deaths of vulnerable people in custody. In some of those cases, there have been delays of up to three years. Again, so far as I am aware, the same limitations on legal aid and representation persist.

The proposals that the Government put forward in their draft Bill for a service of full-time coroners were heavily criticised in the report of the Constitutional Affairs Committee published on 1 August 2006. Crucially, the committee found, first, that the limitations of the local structure of the current system gave rise to an uneven distribution of resources, and under the draft Bill that would remain. It also called on the Government to address the problems of under-resourcing in the existing system in order to create solid foundations on which reforms could be built. It asked the Government to reform the structure of the coronial system by creating a national service with centralised and adequate funding so that all coroners would be able to work to the same high standards.

Another recommendation of the Constitutional Affairs Committee, to which the noble Baroness, Lady Finlay, referred, was a charter for bereaved people. However, the Constitutional Affairs Committee noted that the,

“raised expectations of the bereaved may lead to severe disappointment in circumstances where serious under-resourcing and, therefore, variable standards in service are likely to persist as a result of inadequate funding for reform of the coronial system”.

Its final point was about public health and safety. It recommended that the Government took a,

“bolder approach to reform of the coronial system, embodying in legislation an enhanced role in relation to public health and safety”.

It is a matter of significant concern that there should be proper funds to carry out the recommendations that a coroner makes at the conclusion of an inquest.

The matter was discussed when the coroners Bill was dropped from the Queen’s Speech. Your Lordships will recall that it had been mentioned in the series of measures announced in the mini-Queen’s Speech in July. Then, the coroners Bill was promised but that promise was simply not fulfilled. In the debate on the Queen’s Speech, my noble friend Lord Dholakia expressed his anger that the coroners Bill was not included, and he referred to the problems that I have already mentioned. He stressed:

“We need the introduction of a system for monitoring inquest verdicts and statutory obligations on public bodies to respond to the findings of an inquest”.—[Official Report, 12/11/07; col. 273.]

One problem is that a coroner makes recommendations but, unfortunately, they do not carry sufficient weight to be carried out by the public bodies to which the recommendations are addressed.

The problems in relation to families were very well summarised by the noble Baroness, Lady Howe, who in that same debate said that, by delaying the introduction of the Bill,

“the Government are acting directly against those whose cause they claim to champion; namely, victims, and in this case their own victims—the relatives of those who have died in custody”.—[Official Report, 12/11/07; col. 316.]

As the noble Earl, Lord Attlee, and the noble Baroness, Lady Dean, have pointed out today, it is a scandal that families are left for such a long time before they learn about the circumstances in which their loved ones died in combat.

I am glad that it is the noble Lord, Lord Hunt, who is to respond because he assured the House in that debate that the Government remained committed to reform and that the Bill had been deferred rather than abandoned. He said:

“We will look to see what can be done in the mean time to strengthen the coroner process”.—[Official Report, 12/11/07; col. 336.]

I am not aware that any steps have been taken to strengthen the coroner process since we debated the matter last November, but I shall be interested to hear whether there are any plans in hand.

We are anxious that this archaic system, which does not comply with so many modern standards of justice, should be thoroughly and properly reformed, that adequate resources are put into it, and in particular that the recommendations of coroners should be followed through as they were in relation to the inquest held in 1938 into the Gresford colliery disaster.

I, too, want to thank the noble Baroness for introducing this matter for debate. We owe her a considerable debt. My enthusiasm for legislation on coroners is tempered by the contents of the Government’s draft Bill, published in June 2006; and I hope that when at last the Government do introduce this matter into the Queen’s Speech, they will have thought again about aligning the legislation with their March 2004 position paper.

As a number of noble Lords have said, the issue of coroners’ reform has been with us for a long time, ever since the Brodrick report. It is true that the Government have taken a number of initiatives in the last seven or eight years. In 2000, there was a Home Office review of death certification, and the then Home Secretary, Mr Blunkett, set up a fundamental and independent review of coroners’ services under Mr Tom Luce, who found that the system was not fit for purpose. In July 2003, we had the third report of the Shipman inquiry, which also recommended serious reform; the Government position paper with proposals for reform was published in March 2004.

I must say that I am really astonished that the draft Bill of 2006 does not deal with the most important issue of all, which is that of aligning death certification with the coronial system. It will always be hard to forget the appalling evil of Dr Shipman. The consequences of that were very well put by Dame Janet Smith in her foreword to the third report. She said:

“In the First Report of the Shipman Inquiry I disclosed my finding that Shipman had killed at least 215 of his patients over a period of 24 years. It was clear that the current arrangements for death registration, cremation certification and coronial investigation in England and Wales had failed both to deter Shipman from killing his patients and to detect his crimes after they had been committed. The failure of the existing system prompted Parliament to set up the Shipman Inquiry”.

Later she goes on to say:

“If there is a risk that a doctor might kill in the future and if, as is now clear, the present system would neither deter nor detect such conduct, surely the system must be changed”.

A year later, in March 2004, the Government brought forward their position paper with proposals for reform. That paper quite rightly sought to integrate the death certification system with the coronial system. In the future, every time a death occurred, what followed from that death would immediately be within the purview of the coronial system and proper checks would be made on the doctor’s certification of death. It is amazing to think that of the more than 200 people who died under Dr Shipman’s care, not a single one of those was double-checked by a medical practitioner. It is also the case that the 2004 position paper proposed not just a centralised system for reform of the structure of the coronial service, but also a centralised system for financing it.

But the draft Bill contains neither of these things. Given what Dame Janet Smith said, how can the Government possibly justify not integrating the death certification system with the coronial system? It bewilders me because Dame Janet Smith has put us on notice that unless there is that integration, then another Shipman could strike, or even more than just one. I therefore ask the Minister: what is the justification for this? What happened between March 2004 and June 2006 that made the Government change their mind on this issue—in flagrant breach of what Dame Janet Smith said? She looked at this issue in depth over a long period of time, is better informed than anyone else in the country, and thus in a much better position to make a judgment. The Government initially accepted what she said, but then subsequently spurned it.

I share in the views of those who have spoken before me, and I would particularly like to underline the contributions of the noble Baroness, Lady Dean, and my noble friend Lord Attlee. This is a terrible human problem, but it is one that would be so easy to resolve through legislation.

I hope the Government have taken that on board. Although I want to see legislation on this matter as quickly as possible, I do not want to see just any old legislation. I want to see legislation which confronts the human problems as well as confronting the real dangers to our society. It seems that this draft Bill does not meet either test, and I hope that when the Government do legislation, they will have thought again about these issues.

First, I thank the noble Baroness for allowing us to debate what is clearly a very important matter. I can assure noble Lords that in responding to the points that have been made, our debate will be invaluable in assisting the Government in thinking through the further changes that will be necessary. I can give an assurance that we will pay close attention to the substantive points that have been raised. I thought that the noble Lord, Lord Thomas, illustrated graphically the importance of the inquest and the coronial process, and I agree strongly with him about that.

On the question of legislation, as I said in our debate on the Queen’s Speech, I deeply regret that we have not been able to find legislative time, but I want to confirm again that the Government remain committed to legislation in this area. Naturally, I cannot go further than that in terms of exactly when, but I want to reassure noble Lords that we see this as a very important measure. Obviously, we are looking at ways of bringing it forward at the earliest possible stage.

Although imperfections have been identified in the current system, Dame Janet’s report, the Tom Luce report, other reports, the Select Committee and, very importantly, families have raised issues of concern, I want to place on record the Government’s thanks to all those in the current system for the work that they do. Of course we can do better.

The legislative reform to which the noble Lord, Lord Kingsland, in particular, referred attempts to do a number of things: first, to put families at the heart of the inquest process; secondly, to have a chief coroner to set national standards, to hear appeals, to improve training arrangements and to oversee the operation of a statutory charter for the bereaved. It aims to give flexibility in the system to transfer cases easily from one area to another, if it is in the interest of families to do so; to begin the process towards the formation of a predominantly full-time group of coroners, completely focused on coronial duties, rather than the large part-time group that we have at the moment; to improve medical expertise available to the service with a new national medical adviser to work with the chief coroner and to provide better advice available locally. In a moment, I will describe to the Committee what can be done in the absence of legislation.

On the question of the inter-relationship and links between the coronial system and death certification, that is of course vital. We are working with other government departments, not least the Department of Health as it develops parallel proposals on reform of the death certification system. I assure the noble Lord, Lord Kingsland, that, although there has been a development of ideas since Dame Janet's report, we want to ensure that the respective work in my department and that of the Department of Health closely inter-relates.

On medical certification, I make a number of comments. First, the noble Lord, Lord Kingsland, referred to the proposal that all deaths should be reported to the coronial service. We are not taking that forward. We believe that to have all deaths reported to the coronial service would not be an effective response in targeting resource where the risk is greatest. I want to respond later to the specific question of delays. We also think that such a system could bring unnecessary delay to families wishing to proceed quickly with funeral arrangements. The focus under the proposals and the changes that the Department of Health has made on control of drugs—it is also consulting on the better regulation of doctors—will, we believe, reduce the likelihood of a Shipman operating undetected in future.

More generally, the single system of effective medical scrutiny applicable to all deaths will be of great assistance there. The work of the Department of Health on certification will bring obvious benefits, including better quality and accuracy in the certifying of deaths and improved local public health monitoring more generally. The proposals will also tackle the lack of independent scrutiny in the system, which was so ruthlessly exploited by Harold Shipman. I assure noble Lords that we are working very closely with the Department of Health in this matter.

Since I was responsible for this area in the Department of Health last year, and gave evidence to the Select Committee, I should say that we are working very hard together to make sure that we match the work of both departments and that there is integration of approach.

What are the non-legislative changes that we can introduce in advance of legislation? First, subject to the agreement of the Lord Chief Justice, there are some changes we can make to the current coroners’ rules, which we are already working on. I refer particularly to the comments of the noble Lord, Lord Thomas of Gresford, concerning the coroner’s duty to report to an organisation to take action to prevent future deaths. We want to improve that system. He has identified some of the current weaknesses in it. We want to make the process much more transparent.

Organisations will for the first time have a requirement to respond. In the absence of a chief coroner, my right honourable friend the Lord Chancellor will oversee the reports made and responses to them. He will bring them to the attention of ministerial colleagues and, when appropriate, to Parliament. I say to the noble Lord that as a Minister at the Department of Health, I received such reports from time to time and we responded to them. I felt that, while it was not always right to respond immediately to the recommendations made by individual coroners, that could be an extremely useful part of the process in terms of reassuring families that lessons are being learnt and taken account of by public organisations, as well as demonstrating ways in which government departments may need to look at weaknesses in systems that have been identified in individual inquests.

We are also planning to introduce a new rule to ensure that coroners and local safeguarding children boards have the correct framework to work together effectively with their respective responsibilities to investigate child deaths, again making sure that there is close collaboration and that some of the current loopholes and gaps are identified and dealt with. I also assure noble Lords that we will work closely with coroners to consider any other changes to the rules that will enable them to carry out more effective investigations and inquests, or that would lead otherwise to better services for families.

The Department of Health is piloting its plans for medical examiners. As part of those pilots we can see whether the list of deaths we have drawn up to guide doctors in their referrals is effective and helpful. Modifications can be made in the light of experience. We believe that too many cases are referred to coroners that they ought not to receive, while they do not receive some that they should. This is the first time that the definitive list of deaths has been drawn up for national dissemination, and it is intended that it will eventually become statutory guidance on the implementation of the Bill.

We are working with the Press Complaints Commission to review its code of conduct in the reporting of inquests. Clearly, we do not intend to prevent inquests being reported; however, we want all steps to be taken to ensure that they are reported sensitively. Some inquests provide very good copy to editors, but we want to encourage editors to give some more thought to the impact that will have on the lives of surviving family members, not least any children concerned.

A number of noble Lords have mentioned the charter for the bereaved. We will be issuing that for further consultation. It will contain the minimum services that families are likely to receive in the future, and we will be working with coroners and their officers to establish what service improvements they can offer to the bereaved within the existing system—particularly when it comes to the timely provision of information; I take the point that was made about that.

I thought that the noble Baroness, Lady Finlay, made some very important points, particularly on post mortems. As, by necessity, post mortems have to be carried out as soon after death as is practical, it is important that procedures are in place to ensure that the next of kin of the deceased person can be properly informed and consulted. In addition, there will be in legislation appeal rights to the chief coroner if a coroner chooses not to order a post-mortem or a particular type of specialist examination. We think that that will provide a safeguard for families who want to know whether the death of a loved one has been caused by a genetic defect that can be treated in other family members if the problem is diagnosed sufficiently early.

We are also working with the Royal College of Pathologists and the Department of Health to ensure the most effective post-mortem system. I accept the noble Baroness’s point that this presents some considerable challenges. I was the Minister concerned with Alder Hey some years ago. I shall never forget that time and, in particular, meeting the families who suffered so grievously from the way in which the organs were retained. As the noble Baroness knows, some families went through the trauma of at least three burials when new body parts were discovered. That, of course, led to the Redfern report and then legislation in the form of the Human Tissue Act 2004.

The noble Baroness referred to a number of issues that were raised in that Act, particularly in relation to keeping material in perpetuity. At the time, we took the view that the compulsory retention of tissue could not be justified in circumstances where the coroner had fulfilled the coroner’s function. I am sure that it will be a disappointment to the noble Baroness when I say that we have not moved from that position. She mentioned Scotland, but clearly that is a matter for Scotland. We feel that the view that we took with the Human Tissue Act was the right one and it was endorsed by Parliament.

I shall need to come on to the question of military inquests but perhaps I may respond quickly to a very important question raised by the noble Baroness on post-mortems on children, and babies in particular. I well understand the problem of the shortage in particular specialties, and the Department of Health is working very hard with the royal college to see what can be done. It remains a challenge and I would never seek to deny that.

I very much agree with all the comments that noble Lords have made about information given to families. In taking through reform of the system, we will emphasise the critical importance of information being made available to families as early as possible.

I thank my noble friend Lady Dean, who raised, on behalf of the War Widows Association, very important matters in relation to military inquests. The noble Earl, Lord Attlee, for whom we have enormous respect, also has much knowledge of these matters. I assure noble Lords that my department works, and liaises closely, with the Ministry of Defence to ensure that inquests into the deaths of our courageous service personnel are held as promptly as possible. I am well aware of the trauma that the delays have caused to their families. A total of 144 inquests have been held since the conflicts began in Iraq and Afghanistan.

I shall come on to funding generally in a moment, but we have made additional funding available to both the Oxfordshire and Wiltshire coroners. I believe that good progress has been made, although I accept that there are still a number of issues concerning the transfer of single deaths to coroners closer to the next of kin. Of course, we want to ensure that that happens wherever possible.

I understand the cost implications for families. The Government will pay overnight expenses to enable two family members to attend any pre-inquest hearings which may take place, as well as the inquest itself. On the more general point of support to families, I agree with my noble friend about the teams. We have established a dedicated team within the Ministry of Defence to improve liaison between boards of inquiry investigators and coroners.

On the question of legal aid, the noble Lord, Lord Thomas of Gresford, will understand that because the procedures are inquisitorial, legal aid is not provided as of right, but families may be provided with legal aid for those inquests if they meet the necessary criteria. Several families have been assisted. The Legal Services Commission considers these matters, and if it believes exceptional funding should be made, it comes to me as the Minister concerned at the Ministry of Justice. I assure the noble Lord that I take this matter very seriously and give it careful consideration.

Some of the reasons for the delays in military inquests are because of the military boards of inquiry. Special investigations have to take place in the field; they also have to be listed on dates that suit the families. All that aside, though, I well understand the need for us to do everything we can to help the coronial service keep those delays to a minimum. My officials are in weekly contact with the coroners who are handling these inquests to check progress in this matter and to give what assistance we can. My right honourable friend Harriet Harman, who had the responsibility for this, has taken part in a number of meetings with families in this area, and I hope that that will continue.

On the question of specialist coroners or a centre of excellence for military inquests, which my noble friend raised, we do not support that idea. We think it might even create a backlog of inquests and increase the time—and, indeed, the distress to bereaved families—by requiring more families to travel further to their inquest. We have to ensure that all coroners, wherever they are in the country, are able to handle those inquests. As my noble friend will know, a number of inquests have been held outwith both Oxfordshire and Wiltshire and we believe they have been handled effectively and quickly. However, I will keep a close eye on that matter.

I shall finish with a comment about resources. This is a local service. We think there is sufficient resource within local authorities’ budgets, but the Select Committee thought there should be a mechanism for auditing the expenditure and it is our intention that the chief coroner will indeed look at comparisons of expenditure. We are not moving to a national service, however, so it must be a matter of local discretion. I defend that; it is perfectly possible to maintain a local service but with the benefit of a chief coroner to ensure that there is auditing in order to establish that every coroner is carrying out their responsibility effectively. It is better to have that kind of national leadership but local provision.

I have taken a lot of time because this is an important matter. I hope that at the very least I have assured your Lordships that we are keen to proceed with legislation. I cannot guarantee when that will be, but I give a guarantee that we will look at all the other issues that noble Lords have raised.

I thank my noble friend the Minister for that comprehensive response, but he did not respond to my request for his department and the MoD to meet representatives of the war widows for a discussion.

The answer, of course, is yes.

[The Sitting was suspended from 3.58 to 4.00pm.]