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Coroners and Justice Bill

Volume 711: debated on Tuesday 9 June 2009

Committee (1st Day)

Clause 1 : Duty to investigate certain deaths

Amendment 1

Moved by

1: Clause 1, page 1, line 9, at end insert “notwithstanding the location where the death occurred”

As your Lordships will see, the amendment seeks clarification from the Government that the jurisdiction of the coroner is determined by the location of the body; in other words, the location of the death is irrelevant. If a body comes to rest in a particular coronial jurisdiction, no matter where the death occurs, that coroner is seized of his responsibilities. I believe I need say no more than that. I beg to move.

Amendment 2 stands in this group and is in my name and that of my noble friend Lady Finlay of Llandaff. I strongly support the point on clarification that the noble Lord, Lord Kingsland, has just made. I look forward to hearing the Minister’s response. Amendment 2 would add to the Bill,

“or when the coroner has reason to believe that the circumstances of the death were such that, in the public interest, the death should be investigated”.

At the beginning of 2008, following the delays in implementing many of the recommendations that arose from the murder of patients by Dr Harold Shipman and the subsequent murder in 2002 of patients at Leeds General Infirmary by the nurse Colin Norris, I tabled a series of Questions to the Government. The Shipman murders had led to an inquiry, which published six reports and 228 recommendations at a cost to the public purse of some £21 million. Weaknesses were discovered in the death certification process; the requirement for one doctor alone to certify a death and decide on referral to a coroner; and the failure to cross-reference notified deaths and look for trends and patterns. Among the 228 recommendations were many other proposals to strengthen the system of public protection.

After Shipman’s trial, the inquiry, chaired by Dame Janet Smith, decided that there was enough evidence to suggest that Shipman had probably killed around 250 people, of whom 218 could be identified. About 80 per cent of his victims were women. In the case of Nurse Colin Norris, on 8 March 2008, he was convicted of murdering four elderly patients and attempting to murder another. Mr Justice Griffith told Norris, in sentencing:

“You are, I have absolutely no doubt, a thoroughly evil and dangerous man. You are an arrogant and manipulative man with a real dislike of elderly patients. The most telling evidence was that observation of one of your female patients, Bridget Tarpey, who said, ‘He didn’t like us old women’”.

On 25 March 2008, the noble Lord, Lord Darzi, in responding to my Written Questions about these events, stated:

“I understand that the Yorkshire and Humberside Strategic Health Authority is arranging for an independent investigation of the events at Leeds General Infirmary and it would therefore be inappropriate to comment further at this stage”.—[Official Report, 25/3/08; col. WA81.]

Later, on 21 May 2008, the noble Lord replied to my Written Questions about the Shipman recommendations, stating:

“Clauses implementing these important reforms will be included in the coroners and death certification Bill announced as part of the Government’s draft legislative programmes for 2008-09”.

He also stated:

“The Government believe that these proposals represent a transparent, proportionate, consistent and affordable response to the weaknesses identified by the Shipman inquiry that will provide greater protection for the public and improve the quality and accuracy of death certification”.—[Official Report, 21/5/08; col. WA196.]

I recognise, as I told the noble Lord, Lord Bach, at Second Reading, that this Bill goes a long way in trying to prevent a repetition of these appalling crimes that took place in the north of England. However, there are still anomalies in the law that could allow cases such as those that I have described to slip through. At Second Reading, I asked the Minister how many of the 228 recommendations of the Shipman inquiry had been incorporated into this legislation, and what further measures would be needed to deal with the failings identified by the Norris inquiry. Last week I called the Minister’s office to indicate that I would pursue the question today. I hope that it will now be possible to answer that inquiry. For the sake of clarity, I inform the Committee that I met Dame Janet Smith with my noble friend Lady Finlay of Llandaff. We discussed the amendments that I have tabled to the first part of the Bill. They have been tabled in consultation with Dame Janet Smith and try to close the gap that still exists in the legislation. Out of courtesy, I copied details of the amendments in advance to the noble Lord, Lord Kingsland, and the noble Lords who represent the Liberal Democrat Front Bench. I believe that the incorporation of the amendments standing in my name would improve this legislation and go a long way to answering Dame Janet’s concerns.

In particular, I take the Committee to page 54 of the Ministry of Justice document published on 21 May 2008 entitled, Statutory Duty for Doctors and Other Public Service Personnel to Report Deaths to the Coroner, (CP(R) 12/07). Paragraph 6 states:

“Coroners have a broad duty to investigate unnatural deaths, as well as all deaths which occur in custody or other state detention or during the course of police operations. There was a general consensus that the right categories of deaths were included in the consultation paper flowing from this general definition. Many helpful suggestions were put forward to help clarify the detail. Following the consultation process, we believe that the following categories of cases that should be referred to the coroner will provide the basis for further work and consultation”.

I shall give the Committee details of what appears in that list. I know that the Government have an inbred dislike of including lists in legislation so I am not inviting them to include the entire list but these were the conclusions that were registered by the Government themselves in answer to the consultation paper. My amendment seeks to take the list and in a generic way provide a trigger mechanism for investigating any deaths that might fall into these categories.

The list in the document refers to:

“death resulting from self harm and neglect (excluding deaths from alcohol or nicotine abuse where the death would not be investigated but for those reasons); death resulting from neglect or abuse where there is an established duty of care by a public authority, other organisations and individuals; death occurring during or shortly after a period of detention; death caused or contributed to by the conduct of the police or any other state authority or public organisation; death relating to past or present employment; death resulting from lack of care or appropriate treatment, defective treatment and adverse reaction to prescribed medicine; death of a child where it is unexpected; death where a violent crime is suspected; sudden and accidental death, and deaths resulting from traffic incidents; where a death has not been certified as the doctor is unable to identify with any confidence the cause of death; death where there is reason to believe it may have been caused or contributed by a disease or condition that has been specified as being reportable to the coroner because of regional social history, for example lung disease caused through working in the coal industry; and death associated with pregnancy and childbirth”.

Let us take that last category alone,

“death associated with pregnancy and childbirth”,

or deaths in hospitals through, say, the outbreak of MRSA, or a disease such as sepsis where bereaved families might well believe that a loved one has died through negligence and yet the cause of death might not appear to be unnatural. I refer the Minister to page 18 of the response to the consultation document and the specific request of Dame Janet Smith and Her Honour Mrs Justice Swift, who specifically asked that some of the categories to which I have just referred should be incorporated in the legislation as a way for people who feel that the system has not responded to their concerns to be assured that the matter will be addressed.

This amendment is designed to provide a catch-all for all those categories in the list I mentioned which are not spelt out in the Bill. It would remedy the disconnect between what the doctor has to report and what may warrant an investigation in the public interest. I have with me a copy of the final death certificate issued by Harold Shipman. It was given to me by Dame Janet and details the death of Mrs Kathleen Grundy. She died at the age of 81 on 25 June 1998. The day before her death this elderly but sprightly and healthy lady had provided hospitality for her elderly friends at a club she attended. Her death certificate simply records that “old age” was the,

“disease or condition directly leading to her death”.

We owe it to the memory of victims of Shipman such as Mrs Grundy to get this right. We also owe it to Dame Janet and her outstanding colleagues who have provided such a remarkable public service in their meticulous and comprehensive inquiry. I hope that the Minister will feel able to respond positively to the amendment that I have laid before your Lordships’ House.

I would like to speak to Amendment 3 in my name. This stems from the work of the Joint Committee on Human Rights of which I am a member. Before I get to the heart of the amendment, I congratulate the Government on requiring coroners to investigate deaths that have occurred in state detention. This is a positive human-rights move. The purpose of the amendment is to make it clear what state detention is. All we have is the phrase,

“in custody or otherwise in state detention”.

That is a good move but it would be better if we could have clarity in the Bill about what state detention means.

We have the Explanatory Notes to the Bill, which are very useful and come in a thick tome. They explain the Government’s view that the extension enhances the state’s ability to meet its obligations under Article 2 of the European Convention on Human Rights in relation to a number of cases where the liberty of the subject may have been constrained—for example, where people have died while being detained in a variety of contexts, such as in prisons, by the police, in court cells, in young offender institutions, in secure training centres, in secure accommodation and under mental health or immigration and asylum legislation. Of course, that is welcome in general terms but I think that it would be much better if, rather than the key details being in the Explanatory Notes, they were in the Bill.

I am not saying that the amendment includes all the possible instances of where a coroner’s investigation might be necessary. Indeed, the amendment says that the list would “include” the following. Therefore, the list is not comprehensive but it would certainly add clarity to the Bill and I hope that the Government will agree that, rather than hiding this in the Explanatory Notes, it is better to have it in the Bill so that everyone knows exactly what we mean. Having said that, I repeat my welcome for the inclusion of the provision by the Government but I just think that they should go one step further in making it clearer.

I have added my name to the amendment that has already been discussed by my noble friend Lord Alton, and I should like to add a little more to the points that he made.

We have been told that the role of the medical examiners will be to feed into the governance processes and to detect failings in care and drive up standards of care within the jurisdiction of a PCT area. However, one problem is how to define a natural death and how to decide whether the death is natural but has been brought forward in time or whether it has occurred because of clinical non-responsiveness—I shall not say “negligence”, as that is too strong a word, but I am referring to whether something could have been done to avoid the death. A classic example is death in childbirth. Medical science now means that very few women, but still too many, die in childbirth in this country, but of course in many other parts of the world a catastrophically large number of women still die in that way. When these deaths are investigated, some of them are, sadly, found to be due to medical negligence. Examples are where, for whatever reason, a woman has not been oxygenated during a caesarean section under anaesthesia, where the response to something such as a catastrophic haemorrhage has been too slow or where the management of labour has led to some complication which, although rare, does occur, such as a ruptured uterus and the catastrophic events that follow that. These are so-called natural deaths but certainly they are totally unexpected and potentially avoidable. I can of course understand why you cannot define “natural” or “unnatural” clearly in the Bill; it is understood in the way that you speak about things.

The other reason for having a public interest test is that deaths which are due to, for example, infection or environmental issues gradually come to light as a clustering of deaths occurs. As these deaths unroll, the investigation focuses not so much on one individual but on a group of individuals. We have recently heard about swine flu in Mexico, where the mortality rate has been particularly high. It seems that that may be due to the high arsenic levels in the groundwater. That has meant that there is a degree of subliminal arsenic poisoning in the population which inhibits people’s immune system and makes them more vulnerable to the severe effects of swine flu. Therefore, they have died whereas others who have not been so exposed have come through the infection fine, with no adverse sequelae.

Where there is a clustering of deaths, the coroner has to be able to investigate them, not so much for the individual but because of the public interest. With time, we may well find that something such as environmental toxins causes a clustering of deaths, because we do not know what lies ahead.

I am sure the Minister will say that there is great sense in not putting lists in legislation. If you make a list, there is always the problem of what is to be left out. I would simply commend to him the concept of public interest. It would underline the governance role that has been emphasised in some of the reforms of the coronial system.

I shall speak to Amendments 2 and 3. In beginning his speech, the noble Lord, Lord Alton, referred us back to the Shipman inquiry and the dreadful events leading up to it. As I pointed out on Second Reading, the Government rightly moved very quickly to deal with some of the medical aspects, but it has taken more time to deal with the coroners aspects. It seems to me that the important point in the comments just made by the noble Lord, Lord Alton, and the noble Baroness, Lady Finlay, is that sufficient attention had not been paid to the clustering of deaths. If proper attention had been paid, it would have been clear that there was an emerging problem. Indeed, as I understand it, the first observation of the problem ultimately came not from the coroners but from others. As we go through the Bill we will find a number of circumstances that bring us back to that dreadful experience, because part of the business of the Bill is to address and redress that experience. One of the ways of doing that is to give the coroners the responsibility to look a little more widely than they have traditionally done. That is very important.

As the noble Lord, Lord Dubs, said when speaking to his amendment, which we support, we all welcome the new extended duty to investigate deaths in state detention; we very much welcome the human rights-enhancing components of this measure. As he said, however, it is a little disappointing that we find this only in the Explanatory Notes. There does not seem to be any reason why it should not be spelt out and explained in the Bill. “State detention” has different meanings to different people. It is important to spell it out and to make it clear, as he has done in his amendment. If another, more precise amendment is proposed, so be it, but we think that it is important to spell it out. That is not to say that we take the view that coroners should restrict themselves to investigating whether we are all compliant with the human rights convention. We will come to that a little later.

Perhaps I may point out one specific way in which even the excellent amendment from the noble Lord, Lord Dubs, seems not to go quite far enough. He refers in paragraph (b) to those detained under mental health legislation. What we usually think about is how important it is to ensure that people are not inappropriately detained under any legislation, including mental health legislation. However, one way in which a death can not infrequently occur is not in relation to the implementation of the mental health legislation but precisely at the point where the person is no longer detained. They are detained because it is felt that they are suicidal and a danger to themselves. So they are detained in an appropriate place and given an assessment and treatment. At that point they will probably, we hope, be in somewhat less danger. They then present themselves in a reasonable fashion for a time—I have seen this happen myself. So the detention is stopped and they are no longer detained by the state. Often that is precisely the point at which they are at much greater danger of doing harm to themselves and coming into the purview of the coroner.

So even if we were to adopt the amendment of the noble Lord, Lord Dubs—as I say, we very much support adopting it—one incredibly important group of people would not be addressed, precisely because they had moved out of state detention at the very point when they came to harm. That is why not only the noble Lord’s amendment but the prior amendment tabled by the noble Lord, Lord Alton, and the noble Baroness, Lady Finlay, are very important. I think that we will also come to other amendments that will help expand this a little further. At this point, however, we find these amendments extremely helpful. We look forward to the Minister’s comments.

I thank all noble Lords who have spoken on this group of amendments. The noble Lord, Lord Kingsland, asked for clarification on Amendment 1. We argue that Clause 1 makes it clear that the coroner’s duty to investigate a death is triggered by virtue of being made aware of the body of the deceased person being located within his or her area. Where the death actually occurred is largely irrelevant to the triggering of that duty, although if the body were moved after death from one area to another, the duty would apply only to the first coroner to whom the report was made. That also applies to deaths that occur overseas—a matter that I know is of concern to many noble Lords—but where the body is repatriated to England and Wales. In such cases, the duty to investigate the death lies with the coroner within whose jurisdiction the body is returned. I hope that in those few words I have satisfactorily clarified the Government’s position on Clause 1.

Turning to Amendment 2, I refer noble Lords to regulations under Clause 18, which will prescribe cases and circumstances in which a death should be reported to a coroner, which will provide more detail as to the types of case which will trigger a coroner's duty to investigate. We shall be consulting further on the content of those regulations as part of the secondary legislation process. The noble Lord, Lord Alton, and other noble Lords mentioned the tragic, awful case of those who were murdered by Dr Shipman. I thank the noble Lord for saying that we have gone a long way in attempting to deal with the issues that that ghastly case threw up. His point is that the deaths that occurred at the hands of Dr Shipman appeared at first glance to be wholly natural and non-suspicious but, with the benefit of hindsight, it would have been in the public interest to investigate them.

We believe that the new death certification procedures contained later in the Bill will succeed much more readily in detecting such deaths and bringing them to the attention of the coroner, so that the duty to investigate will be triggered where necessary. I stress that the coroner's duty to investigate is a continuing duty. If fresh evidence regarding a death comes to light later—evidence that quite clearly brings the death in question within the scope of Clause 1(2)—an investigation must be held even if a period of some months or even years has passed since the death in question.

The noble Lord wrote to me, and just this morning I signed off the letter back to him, which will be copied to all those who spoke on Second Reading. In advance of his receiving my letter, perhaps I may tell him what I had to say about his request for figures regarding the exact number of recommendations. On the Shipman inquiry, it states:

“The … Bill incorporates legislation responding to the Shipman Inquiry’s Third Report. As you know, whilst accepting the findings of the inquiry, the Government has decided to adopt a different approach to reforming the coroner service than that recommended by Dame Janet Smith. For this reason, [it] is not possible to provide a figure regarding the exact number of recommendations responded to by legislation incorporated in the Bill. More generally, you will wish to be aware that the Coroners and Justice Bill is the last piece of primary legislation required to implement the Government’s wide ranging programme of action in response to the recommendations of the Shipman Inquiry”.

I also wrote to the noble Lord about the case of Colin Norris, which he referred to today.

So we are not convinced of the necessity for Amendment 2. On Amendment 3, the last in this group, we have no difficulty with my noble friend’s comments about accepting the accuracy of the list of circumstances that the amendment contains and which are to be regarded as constituting either custody or state detention for the purposes of triggering an automatic coroner’s investigation under Clause 1. They effectively replicate, as he said, the list contained in the Explanatory Notes. However, we do not think that it is necessary to include such a list in the Bill. I refer my noble friend and the Committee to Clause 39(2), which we think has an adequate definition of what constitutes state detention. It states:

“A person is in state detention if he or she is compulsorily detained by a public authority within the meaning of section 6 of the Human Rights Act 1998”.

In addition, the Explanatory Notes that will accompany this Act, if and when it becomes such, will contain a list similar to that which appears in the Explanatory Notes to the Bill. I would anticipate with some confidence that the Chief Coroner will also include a similar list in any guidance that he or she may publish. I hope that that reassures my noble friend about our intentions, and I thank him for the compliments that he paid to the Government on introducing the concept of state detention within the categories mentioned. I also hope that he agrees that it is not necessary to have such a list in primary legislation and that, in the light of my attempted explanation, noble Lords will agree not to press their amendments.

I am most grateful to the Minister for his response, both to my amendment and to the other amendments in this group. I should perhaps make it clear that the Opposition are, broadly speaking, sympathetic to both Amendments 2 and 3.

In fact, when listening to the Minister’s response to Amendment 2, I was struck by the recollection that on many occasions in legislation Secretaries of State are given specific powers, rounded off by a more general one to act in the public interest. I wondered whether one reason why the Minister was hesitant to grant this more general power to the coroner was because it might be felt that the coroner was less attuned to assessing the public interest. Was that why the Minister said what he said? On my amendment, however, I am content with the noble Lord’s clarification, which I found extremely helpful.

Before we leave this group of amendments, I thank the noble Lord, Lord Kingsland, for his support in principle for the point being made in Amendment 2. I thank the Minister for his response although, like the noble Lord, Lord Kingsland, I have some anxiety about merely recording these concerns in regulation. Between now and Report stage, we shall of course look carefully at the Minister’s suggestions.

I come back to the recommendations made by the Shipman inquiry itself, of which there were 228. Without asking him to go through them in detail today, or even in response to my letter, it is reasonable to inquire now which of those have not been included in the recommendations contained in the Bill. Although the Government have decided not to pursue the route recommended to them by Dame Janet Smith, it would nevertheless be helpful to the Committee to know that. As the noble Lord said, so much of this legislation is based on that experience of the Shipman inquiry and the recommendations that were made.

My noble friend Lady Finlay of Llandaff made a very good point about the issue of childbirth and when babies die in natural or unnatural circumstances, how those are recorded and whether there would be a public interest requirement in triggering an inquiry. That specific point was made by Lady Justice Smith and Mrs Justice Swift when they responded to the Government’s original consultation; that is recorded on page 18 of the consultation document. As we consider this matter further between now and Report, I hope that the Minister will accept that there may be a need to persist with the amendment. However, it would be better if we could reach consensus.

I am grateful for the support from the noble Lords, Lord Kingsland and Lord Alderdice, for Amendment 3. I take the latter’s point about people leaving mental health detention when they can be particularly vulnerable. I understand that; it was not something that the Joint Committee on Human Rights looked into, but I am sympathetic to the noble Lord’s point. My noble friend explained why the Explanatory Notes and the advice to coroners would be sufficient. I would have preferred it in the Bill, but he explained the Government’s position and I do not want to move my amendment.

Amendment 1 withdrawn.

Amendments 2 and 3 not moved.

Clause 1 agreed.

Clause 2 : Request for other coroner to conduct investigation

Amendment 4

Moved by

4: Clause 2, page 2, line 31, at end insert—

“( ) A senior coroner shall inform the Chief Coroner if completion of an investigation is likely to take more than 12 months from the time that the coroner was notified of the death.

( ) The Chief Coroner shall maintain a register of prolonged investigations.”

The amendments in this group concern the time limits of inquests. At the moment, an inquest can be opened but because there is no requirement to keep the family informed and no time limit is set, some families have had an inquest opened but proceedings have not occurred, sometimes for years. The problem for a bereaved family is that they often look to the inquest for closure and for some unanswered questions to be answered. Sometimes they have unrealistic expectations of what an inquest will provide for them.

At the time, however, an inquest is also traumatic for a bereaved family because it reactivates their grief. They relive the events, and with doing that they relive the emotions, raising a whole lot of “if only” questions. Sometimes those had been dormant; sometimes new questions emerge. No one, then, should underestimate the role which an inquest can have in people’s bereavement: to take them back in time and almost to relive the shock of the original event, of hearing the news and all that went with it. The problem is that it can increase distress if new light is shone on what happened or a new slant emerges from something with which they had begun to come to terms.

I have tabled Amendment 6 because if an inquest case is referred to another coroner, it is important that both the first and second coroners are subject to the same requirement. The amendment does not set targets but requires some sort of monitoring process for delays. It is particularly important not to set targets, as it may be that a slow and thoughtful inquest is exactly what is needed thoroughly to investigate a death. The problem is much greater where a coroner has a high workload and one case falls to the bottom of the pile or the back of the queue, lingering on either because it is not a major case or something else very major comes along and bounces it down that queue of cases to be heard.

My view is that the Chief Coroner needs to know if one coroner has an undue workload or is failing to keep up with the workload for whatever reason. It is human nature for people, when they are somewhat snowed under, to take some time to call for help. Monitoring delays could give a good early warning sign that problems may be emerging in one jurisdiction. It may be that a coroner is severely under-resourced, and that would emerge as well. This might be a way to audit the processes.

The other area in which timeliness becomes particularly important is where deaths occur abroad. It is difficult for coroners to get information from other countries about a death. Despite repeated inquiries, sometimes they simply receive a note saying “heart stopped” or words to that effect, which sheds no light on what happened when in this country such a death would be extensively investigated. In the case of an accident or where the remains are dispersed or difficult to find, or they are returned to this country very late, it is extremely difficult to ascertain what really happened. The inquest can be unsatisfactory because currently coroners have no power in this area, and I do not see anything in the Bill that would give them a power to request information. I want to ask the Minister whether there have been moves in the European Union to empower coroners to request information from other countries within the EU and whether there are routes for coroners to get information from countries outside the EU. After talking to coroners, it is the case that information is more readily available from countries outside the EU, so it is not that the EU standard is higher than that of the rest of the world. In fact, sometimes it is quite the reverse.

An inquest can be opened and proceedings delayed because a prosecution is pending, and if the prosecution does not then proceed, so be it. Everyone understands that, and again that is why I would not want to see a 12-month time limit to be viewed in any way as a judgment on an individual coroner.

Quite apart from the difficulties for the bereaved, there may be delays in remedial action being taken if it is evident that it is needed following a death. It may be that another death occurs during the delay, which is a tragedy if it happens because somewhere there was a degree of negligence.

I think that everyone in this House welcomes the provision for one coroner to be able to transfer their workload to another coroner for a multitude of reasons. I hope that it will be possible within that framework to ensure that as a coroner develops expertise in a certain area or in a type of death, the Chief Coroner would be able to steer that coroner towards investigating deaths in their area of expertise. As we know, there are groups of deaths. At Second Reading I talked about the deaths in Bridgend. The coroners in South Wales are aware of the problem of suicide in young people, particularly those related to use of the internet. A pool of expertise has been built up which makes those coroners appropriate to conduct inquests into such tragic deaths.

The background to the amendments is to set a standard of timeliness and I hope that the Government will see the sense in trying to do that. I beg to move.

Amendment 13 is grouped with Amendments 4 and 6. The noble Baroness, Lady Finlay, made several important points about the stress put on bereaved families when they have to wait for three, four or five years for an inquest, and she rightly described how they have to relive the difficulties, memories and traumas invoked by the death. She also mentioned the issue of lessons learnt, which is extremely important in terms of remedial action. The third reason to avoid delay is that it is also difficult for witnesses at an inquest to remember accurately. Memories can fade even after a few months, while after four or five years it is hard for anyone to remember events accurately.

I have tabled an amendment that would simply insert the word “timely”. The noble Baroness is right to say that we should not try to define what “timely” is, but when delay results because authorities have not got their act together, being inefficient and not prioritising the work that needs to be done—I refer to the police, local authorities, the Crown Prosecution Service and so on—it is clear that it is not the coroner who is delaying the proceedings. However, I would accept that a lack of resources may be a problem for coroners, and I recognise that the Government are trying to solve it in this Bill by enabling certain geographical changes.

Inquests are delayed for many reasons. An organisation known as INQUEST has furnished me and, I am sure, many other noble Lords with a lot of examples of young people who have died in custody and the inquest has been delayed for four or five years. That is really unacceptable. There seems to be no good reason except that perhaps these deaths are not regarded as being worthy of being given the same priority as the Government now recognise needs to be given to deaths in the Armed Forces. We should not have a two-tier system of investigations into citizens’ deaths, whether they fought for this country or died in prison. People have families and lessons need to be learnt.

I have kept my amendment simple because it can then be taken that an inquest was not held in a timely manner and a hook is available to go to judicial review. So far as I can see, if the process is unfair on a family and an inquest is not held, there is no means of going to judicial review. Although I accept that there may be other ways of doing this—and certainly the solution proposed by the noble Baroness, Lady Finlay, is elegant because at the least a record should be kept and coroners should notify each other about delays—it may be best to go back to first principles. The Bill ought to recognise that an inquest should be timely.

I support these amendments. In this part of the Bill we are concentrating on the substance of coroners’ inquiries, the skill and experience of coroners, and so on. However, it is right that we should be attentive to the timeliness of inquests. If we are going to have a Chief Coroner, it seems appropriate that he should have the role of monitoring cases that go on for a considerable amount of time. I regularly read the local press and I always look at the regional news. It is quite remarkable how often families are concerned about the time taken for an inquest to be held. In London we may not feel it so much, but when delays arise you realise how badly this affects families because they cannot see any closure. It is quite traumatic for them. A system of monitoring is right. I will not ask exactly how it is to be handled in relation to the text, but I hope that the Minister will satisfy himself that the question of reasonable speed and timeliness of action is given attention during our consideration of the Bill because it has more importance for many citizens than perhaps we realise here in London.

I support these amendments. There is nothing unusual in monitoring the progress of cases. The Heads of Division in the High Court each have a responsibility to see that cases are dealt with in a timely fashion. For instance, certainly when I left, civil cases were supposed to be complete within three months. Family cases should be dealt with within one month; that is, judgments had to come out in that length of time. I can remember spending a considerable amount of time with Ministers discussing the delays in the family courts, particularly delays concerning children, which were monitored very carefully. There is nothing unusual in monitoring. But now that we are to have a new and better system of dealing with coroners, and a Chief Coroner, it would be very important that the Chief Coroner knows, from the moment that the inquest is in its incipient state, when monitoring is likely to be done.

There are all sorts of reasons why cases take a long time. When I sat briefly as an assistant deputy coroner, I was engaged in probably one of the longest of all cases, even before I left it, and other cases have to take a considerable time. It is extremely important that there should be both the requirement of the Chief Coroner to keep an eye on the progress of cases, that individual senior coroners should keep an eye on the cases within their areas, and that the Chief Coroner should know of their progress. Having “timely” in the legislation would be a useful provision for the Chief Coroner, rather than having a judicial review. The effect of judicial review is to slow down a case, rather than to increase its speed. “Timely” would be a useful provision for both the Chief Coroner and for the senior coroner of the area when saying to an assistant coroner, “Perhaps you can let me know how you are getting on, because that is what the legislation requires”.

I support these amendments. In another context, Gladstone famously said that justice delayed is justice denied. Any of us who have had any kind of encounter with people who have been waiting for the outcome of coroners’ inquiries know that that is very much a feeling that is in their own hearts and minds when they have been bereaved, especially when the circumstances have been tragic. During my time in another place, I was heavily involved with victims of the Hillsborough disaster, and with families whose children’s body parts had been used at the Alder Hey children’s hospital. Noble Lords will recall the trauma that both of those events caused to many of the families involved, and those traumas continue to this day. Delays in dealing with these kinds of tragedies are simply unacceptable, so it seems completely reasonable of my noble friend Lady Finlay to suggest that we should put into the system some requirement to keep a check on where we are in the process.

The noble Baroness, Lady Miller of Chilthorne Domer, also made a very good point about the effects of the passage of time. The memories of witnesses and people involved in these events sometimes become clouded, and their evidence is sometimes not so reliable, simply of because of the period that has elapsed since they occurred. So we are putting in place reasonable checks and balances, first, as regards the passage of time and, secondly, to provide for closure. Perhaps, given the suggestion in the second subsection of Amendment 4, that:

“The Chief Coroner should maintain a register of prolonged investigations”,

it would be helpful to the Committee if the Minister, when he replies to this brief debate, could tell us how long it usually takes. What is the average length of such an inquiry? That would give us some indication of whether there are long delays, and could he tell us not just the average but what are the longest outstanding inquiries currently before coroners?

I support these amendments. The Minister wrote to me stating that the overriding aim of the reforms of Part 1 of the Bill is to improve the service that bereaved people, whether service families or otherwise, receive from the coroner system. I am sure that that is the right aim, but at the moment the Bill is missing this important point of timeliness, or some way of ensuring that the bereaved have an awareness of when the coroner inquest will be heard. At the moment, they are left very often with no firm indication of when the inquest will be heard. This is not satisfactory from their point of view.

I thank noble Lords for this interesting debate on the timely hearings of inquests. I start by stating the obvious. No one would disagree with the principle that inquests should be held as soon as possible, as soon as all the relevant information is to hand, and when all related investigations or proceedings have been completed. The average time to complete an inquest is 26 weeks, and the vast majority, 90 per cent, are completed within 12 months of the death. That is an acceptable timescale for the completion of an inquest. It ensures that the families have the opportunity to go through the main challenges of the grieving process and to consider what questions they would like an inquest to answer, before necessarily being confronted by the public nature of those proceedings. We want to ensure that the remaining 10 per cent of inquests are held within a similar timescale wherever possible, provided that the coroner has the appropriate information before him or her.

As the noble Baroness, Lady Finlay, said, there are delays for a variety of reasons, very few of which are the responsibility of the coroner. For example, in many cases the coroner may be waiting to hear reports from authorities with a statutory or other duty to investigate the particular death. This might be the Health and Safety Executive, the Prisons and Probation Ombudsman, the Independent Police Complaints Commission, the transport accident investigation branch, to name a few. Alternatively, the coroner may be awaiting the outcome of criminal proceedings, which generally take precedence.

We have already taken some steps to reduce delays, particularly with regard to inquests into the deaths of military personnel, which we will discuss later. This Bill will bring forward further ways of dealing with backlogs of work and reducing delays. For example, the flexible new appointments process will mean that a local authority can recruit and deploy a pool of assistant coroners to expedite caseloads or to tackle particular peaks of work. This is in addition to the Chief Coroner’s power to transfer cases, which noble Lords have already praised, and the power for coroners to transfer cases between themselves by agreement as a way of tackling backlogs. Coroners will also no longer be restricted to holding inquests within their own areas, if they and their local authority are unable to locate suitable accommodation for the needs of a particular inquest. Clause 24 of the Bill places a statutory duty on local authorities to provide sufficient officers, staff, accommodation and facilities to enable coroners to carry out their functions.

I emphasise that the Bill will not require coroners to do more work per se with the same or fewer resources. The reverse is the case. The introduction of medical examiners will remove a considerable volume of work from coroners, enabling them to focus their resources on the cases for which they have jurisdiction. We estimate that once the role of medical examiner beds down, some 130,000 to 150,000 deaths per year will be referred to coroners, rather than the approximately 235,000 cases per year which are reported to them under the present arrangements. The reduction in that caseload will, we think, lead to significant savings which can be redirected to improving the efficiency and effectiveness of the service. So we are confident that the overall effect of this package of measures will ensure that inquests are carried out in both a timely and thorough manner, with quality and the appropriate speed.

On Amendments 4 and 6, tabled by the noble Baroness, Lady Finlay, I can assure her that it is the intention that the Chief Coroner will carry out the functions that she talked about so persuasively. Clause 35(3)(e) sets out that regulations may make provisions giving the Lord Chancellor and the Chief Coroner powers to require information to be provided to them by senior coroners. This will include an annual statistical return, which coroners are required to provide to the Lord Chancellor currently. Within this statistical information is a requirement to report on coroners’ oldest cases. We can be confident that the Chief Coroner is likely to want to make inquiries as to the reasons why cases have been apparently delayed, although, as I have pointed out, the responsibility may well be beyond the control of the coroner. I hope that that assists noble Lords in at least appreciating that we see this as a real issue that needs to be sorted out, which we believe that the Bill, as drafted, will do.

I was asked for figures by the noble Lord, Lord Alton. I can give him the average figure—the one figure that he asked me not to give—on inquest timelines in 2008. It will probably be helpful if I do so in percentage terms. Completed within one month, 9 per cent; completed within one to three months, 20 per cent; completed within three to six months, 35 per cent; completed within six to 12 months, 27 per cent; and completed over 12 months, 9 per cent. So, as I say, it is a 90-plus per cent figure within a 12-month period.

I was asked about outstanding cases, some of which go back a long way. That must be because they are exceptional cases. The oldest that I can find relates to Wolverhampton, from June 1998. There are also, from October 1998, North Yorkshire eastern district; Avon, the former county of, December of that year; West Yorkshire western district, May 1999; Surrey, March 2000; Manchester City, July 2000; north-west Wales, January 2001; west London, February 2001; and south London, March 2001. It is possible that some districts, such as north and west Cumbria, have inquests older than March 2001, but only the oldest case is shown in the figures that I have given. I hope that they are helpful to the Committee. We believe that the Bill deals with this problem.

The noble Baroness, Lady Finlay, referred to delays with regard to deaths abroad. It is an important function of the Chief Coroner to co-ordinate requests for information from overseas authorities; it is one of his or her functions. He or she will establish positive relationships, we trust, with overseas authorities—some of which have no knowledge of the roles of coroners—to ensure that there is more likelihood of co-operation. Part of the duty of the Chief Coroner will be to ensure that the service is run effectively and in a timely fashion and that there are no outstanding inquests for which there is no excuse.

The noble Baronesses, Lady Miller and Lady Finlay, have made good points but we do not think that the Bill needs to be amended.

I did not hear the Minister give a reason why we could not include the amendments in the Bill. Although I appreciate that some of the examples that he has quoted, and that I could quote, where there have been delays of five, six, seven, eight or nine years, fall into that 9 per cent, which is a small percentage—I accept what the noble and learned Baroness, Lady Butler-Sloss said, that perhaps judicial review is not a good move because it produces delay—surely there is a case for setting an aspiration in the Bill to deal with these cases. It may be only 10 per cent, but it is a very traumatic 10 per cent.

I am not sure that that would really add anything to the Bill given what we intend to do. If a phrase—even one as delightful as “as short as is timely”—does not add anything to the Bill, we are not convinced that it should be in it.

I thank all noble Lords who have spoken in support of the amendments. In particular, I thank the noble Baroness, Lady Miller of Chilthorne Domer, for the points that she made in relation to my amendments and others. I also thank the Minister for his comprehensive and reassuring response. I was particularly taken by his stress on the effectiveness of the coroners service, when it comes into being, and how that will incorporate concepts of timeliness.

I was trying to do the sums quickly as he read the figures out and it seems to me that we have nine, possibly 10, inquests that have been opened and outstanding for eight years or more. That is an incredibly long time for a bereaved family. I have a concern that, if only the oldest cases are collected when we collect statistics from coroners, one will miss the shape of the curve and the average may not represent the whole spread. Comparisons need to be drawn between different coroners.

I should like to record my gratitude to Mary Hassell, who is the coroner in Cardiff. She has set herself a general target of clearing inquests within six months, when possible. She has inspired confidence in the medical profession in Cardiff in a way that her predecessors were unable to do. She has engaged in open dialogue and is seen to be very effective. It is interesting that the average for other people is six months; she has set that as her upper limit. It can be done, even in a resource-tight environment.

When listening to the Minister, I wondered whether something along the lines of “including information on the effectiveness of the service” could be added to Clause 35(3)(e). Perhaps we should think about coming back to that. In the mean time, I am most grateful for the Minister’s full and comprehensive reply and I beg leave to withdraw the amendment.

Amendment 4 withdrawn.

Clause 2 agreed.

Clause 3 : Direction for other coroner to conduct investigation

Amendment 5

Moved by

5: Clause 3, page 2, line 39, at end insert—

“( ) Before giving a direction under this section, the Chief Coroner must take into consideration the resources available to coroner A.”

The amendment would insert a sixth subsection in Clause 3 between subsections (1) and (2). As your Lordships can see from the text of the Bill, Clause 3(1) reads as follows:

“The Chief Coroner may direct a senior coroner (coroner A) to conduct an investigation under this Part into a person’s death even though, apart from the direction, a different senior coroner (coroner B) would be under a duty to conduct it”.

Our amendment would place, in a separate subsection under that, the words,

“the Chief Coroner must take into consideration the resources available to coroner A”.

There are circumstances—your Lordships, I am sure, have come across them more than once—when, for various reasons, there is intense pressure on one coronial area. There might, for example, have been a disaster, such as the one that occurred on the London Underground, in which a large number of people have been killed instantaneously and the task of dealing with the inquests proves intensely onerous. There might, for no apparent reason, be a large number of deaths in a particular area. Alternatively, a separate situation might arise whereby the witnesses in a particular inquest, or, indeed, the family, live a long way away from a particular coronial area and it is appropriate to see whether a better way forward would be to give the responsibilities to another coroner.

Of course, we have absolutely no quarrel with this, subject to one caveat, and that is that we believe it is critical for the Chief Coroner, before he makes his direction to coroner A, to ensure that the resources at coroner A’s disposal are sufficient for the task that he is about to be given. We see nothing about that in the Bill. That is the background to our amendment, which I beg to move.

I support the amendment. I am somewhat concerned, reading the Bill, that the responsibility for coroners of the individual area remains with the local authority and there is not a national coroner set-up, as I know was suggested by Mr Luce and, I think, by Dame Janet Smith. The result is that each individual coroner will be paid for by the area in which he or she will be carrying out his or her duties. Some areas are richer than others. If an area is in financial difficulties or has particular burdens on it—particularly some of the London areas with huge immigration problems—but faces the request that its coroner try a particular case, for some reason, and that case is likely to be long, arduous and expensive, it might well be extremely difficult for that area to deal with the case with the finances available to it. I think that the amendment is extremely sensible in that the practical movement of cases from one area to another should be determined with an eye to whether the area designated as the area in which the coroner tries a case will have the financial resources to do it.

I have two amendments in this group, which concern the resources available to coroners. First, I should like to address the resource of the premises available for a coroner to hold an inquest. The coroner is dependent on the local authority for allocating premises that can be used but, sadly, some of the premises are really not fit for purpose. Coroners have to have premises, ideally, where privacy can be observed and where the bereaved are not sitting in a room facing the person whom they believe to be the perpetrator of the death. Coroners need to have facilities where people in wheelchairs can be accommodated and can be heard if they are giving evidence. At the moment, some of the premises are such that somebody is shouting from a wheelchair in the middle of the floor. There are some premises where, by the time you have the interested parties and the press in, one wonders whether it is unsafe. Indeed, sometimes complaints have been made when the coroner, in the name of safety and fire regulations, has called a halt to the number of people who could even come into the room.

If there is a jury present, the premises should allow privacy—not only a room to withdraw in, but privacy to go to the toilet. Some premises have only one male and one female toilet and it is inappropriate for a juror potentially to encounter somebody else when they have to go. During the course of a day, jurors are just like anybody else and they will need to go. Some premises do not have appropriate disabled toilets. Another problem can arise when the premises are adjacent to somewhere where there is a noisy activity going on—a dancing class, or whatever. It can be particularly difficult for someone who is deaf to hear proceedings adequately and such noise disturbs the thought processes. These are such serious matters that one feels that they should be heard with a degree of solemnity appropriate to the occasion in an appropriate environment.

The other problem is that the relatives may be elderly, they may be distressed or they may have children in school. If a child knows that the inquest is happening that day into the death of their mum or dad, they deserve to be able to be collected from school, if at all possible, by the parent who is still alive, not farmed out to neighbours, other parents from school, or whatever. For that child, just knowing what is going on that day brings back all their grief. The difficulty is that some premises are difficult to get to by public transport and families without a car can face long travelling times with very sparse bus services if they are travelling from one area to another. We know that, for most of Britain, you can get in and out of London pretty quickly, but getting across country can be more difficult. It can be a similar situation within a coronial jurisdiction. My interest is the south Wales valleys—you can get up and down them very fast, but you certainly cannot get across them with any great ease. I am glad to see the Minister nodding in agreement from his own experience.

The other difficulty, to which the noble and learned Baroness, Lady Butler-Sloss alluded, is that the allocation of resources is dependent on the local authority and on the number of deaths. I understand that, if more than 3,000 deaths are referred to a coroner, you get more resources—higher levels of pay—and, below that number, there is a sliding scale. The difficulty is, of course, that in some areas you may get a lot of deaths reported. In one area, a lot of elderly people may die within 24 hours of being admitted to hospital, but those deaths do not require investigation, whereas in another area, where there is a younger population, you may get horrendous crimes, deaths through stabbings, accidents and so on that require investigation, so that the numbers reported to the coroner may be lower but the resources required by those coroners is much higher than in an area with an elderly population.

I should like the coroner to be empowered in the event of there not being appropriate premises. It would be useful if the senior coroner was able to make representation to the relevant authority. My amendment at Clause 24(4) is, indeed, to strengthen those resources. As for benchmarking, which is a word in the amendments, there is a concern that you would benchmark against too low a standard, rather than benchmark against the highest standard, but the idea behind these amendments—I fully accept that the wording of them is not right—is to establish some kind of standard around the resources of all sorts that are available to a coroner so that they can conduct their inquiries appropriately and so that the needs of the bereaved can be genuinely catered for, as was the express intention of the Government when this Bill was introduced.

I shall speak to Amendment 79, which is in this group and stands in my name. The noble Baroness has vividly and rather horrifyingly described some of the inadequacies of the accommodation for inquests. I share her grave concern.

My amendment relates to Clause 24, on the provision of staff and accommodation. The clause says:

“The relevant authority for a coroner area … must secure”,

the provision of staff and so forth as well as the provision of,

“accommodation that is appropriate to the needs of those coroners in carrying out their functions”.

I hope, therefore, that in future we shall not have inadequate accommodation. I notice, though, that the clause refers only to the needs of the coroners in carrying out their functions. My amendment would add,

“and of the families attending the inquest”.

We have already heard about the understandable traumas suffered by families attending an inquest. The last thing that one wants is to see that trauma exaggerated and exacerbated by inadequate accommodation. It is important that there should be recognition in the Bill that families, or members of the public with a special interest in this, should be catered for as well. That is not there at the moment; the Bill relates only to the coroner’s requirements. One hopes that the coroner might take the view that family accommodation is part of his duties, but it is not clear that that is the case. Will the Minister state categorically that families will be catered for in the accommodation?

I support the noble Baroness, Lady Fookes. My name is on this amendment. What has been said makes it clear that the interests of the bereaved’s next of kin who wish to attend an inquest must be catered for. If we are out to improve the coronial arrangements, which the Bill is directed at achieving, this is one area where that can be done, perhaps by regulations setting some sort of minimum standards for any coroner’s inquest accommodation arrangements.

I support the amendments. Schedule 2 sets out the Government’s policy that the coroner areas should be,

“the area of a local authority or the combined areas of two or more local authorities”,

while the responsibilities of providing staff, accommodation and courts are set out in Clause 24, to which the noble Baroness, Lady Fookes, has just spoken. Have the Government carried out any survey of the accommodation that is currently provided? I have experience of an old coroner’s court, local authority accommodation, magistrates’ courts and Crown Courts, but I am sure that inquests are held in places that are much less suitable than court buildings. The Government have deliberately, and as a matter of policy, decided not to include coroners within the Courts Service. If there is a survey, can we have some idea what its findings were regarding the provision of accommodation and the necessary adjuncts to it? If that information is not already available, no doubt the Minister can provide it to us by Report.

I am grateful to all noble Lords who have spoken to this group of amendments, which relate to the question of resources for this important service. I shall seek to establish how we intend to make obligations to get resources up to standard and the responsibility that the Chief Coroner will carry with regard to this matter, although the responsibility for actual provision rests locally.

I do not have a national survey to hand, the noble Lord, Lord Thomas, may note; I am not sure that there is one, but if there is I will make sure that it is available for later stages of the Bill. It is clear, though, that resources vary between different localities. The burden of the remarks made by all noble Lords who have contributed to the debate is that resources should be available to make the service as effective as possible. I emphasise the point with which I am utterly in agreement: we need to place the interests of the bereaved at the centre of these concerns.

Amendment 5, tabled by the noble Lord, Lord Kingsland, seeks to place an obligation on the Chief Coroner to consider the resources available to the coroner who will receive a transferred case before deciding whether to give a direction requesting that coroner to conduct an investigation into a person’s death. I must emphasise the obvious fact that the issue of funding inquests that have been transferred in the manner mentioned in the amendment will be covered in underpinning regulations. I do not have those regulations to hand at present, but the general principle within them will be that with regard to deaths that occur in England and Wales, the relevant authority for the area in which the coroner would be under a duty to conduct the investigation will continue to be responsible for meeting the costs associated with the case, even if it has to be transferred to a coroner in another area to investigate. For deaths that occur overseas, the local authority for the coroner who is directed by the Chief Coroner to conduct the investigation will be responsible for the costs.

These are general principles only and do not meet the points of detail that have been identified in the amendment. I will go on to those in due course. There may indeed be scenarios where a case is transferred within England and Wales and it is appropriate for the authority of the receiving coroner to meet the costs or for the costs to be shared between the two authorities. These are matters that we will need to work through, given the issues that noble Lords have identified in this debate about the necessity of ensuring that facilities are adequate for the inquest to be held properly.

These principles provide a fair and appropriate way to fund such investigations. With regard to the obvious aspect of inquests into Armed Forces personnel who die on active service overseas, not only will the procedure that we envisage enable cases to be transferred to jurisdictions nearer the home of the bereaved family, thereby meeting the principal point that was adumbrated by several noble Lords in this short debate, but it will relieve some of the funding pressures that jurisdictions such as Oxfordshire or Wiltshire and Swindon have faced in the past while carrying out in such an admirable way—we all applaud and recognise the service that has been provided—the vast majority of inquests that have arisen from the death of service personnel in Iraq and Afghanistan, which have fallen under their jurisdiction. We are looking to share this burden on the basis that the inquests will be conducted nearer to the homes of those who are bereaved, which bears somewhat on the point made by the noble Baroness, Lady Finlay, about the problems of travel for the bereaved. I shall come on to that in more detail in a moment.

Amendment 23 and Amendment 79 seek to place an obligation on coroners and the local authorities that fund them to consider the needs of the bereaved when deciding on the location of an inquest. I hope it will be appreciated that this is an important part of how the Bill sets out to provide for the needs of the bereaved. Clause 24 already places a legal obligation on local authorities to provide sufficient coroners’ officers and other staff, along with suitable accommodation and facilities to enable the local coroner to carry out all of his or her functions.

The accommodation will need to be adequate for coroners to fulfil their additional obligations under the charter for the bereaved—an important part of the Bill which will be issued under Clause 34. The charter is designed to put bereaved people at the heart of coroners’ investigations. It will obligate the coroner to take into account a bereaved family’s views about the timing of an inquest—an important point we have already debated considerably today—as well as providing information to the bereaved about the location of and facilities available at the inquest’s venue. The charter also states that, wherever possible, there should be an appropriate private room for the use of bereaved relatives and that reasonable adjustment will be made—to take the point of the noble Baroness, Lady Finlay—to meet the needs of those with disabilities. I am grateful to the noble Baroness for emphasising that point.

We recognise that we have a great deal of work to do before these charter provisions can be fully met. Officials have already set in train some preparatory work with local authorities to ensure that they are aware of their future responsibilities under the Bill and that they can take steps now to ensure that families are better served than perhaps they have been in the past, as identified by several of the contributions we have heard in the debate.

The noble Baroness, Lady Finlay, emphasised difficulties with rural communities. I am not sure that my valley was ever green enough to be called a rural community—I hasten to add it is a good deal greener these days with the disappearance of the coal industry. The noble Baroness is right. The difficulties rural communities face in travel can also be reflected in the geographical features of the Welsh valleys and many other places.

There has been a widespread welcome for our plans to move towards a largely full-time coroner service. This will mean an end to some of the existing, smaller jurisdictions. In planning new areas—which will be done in full consultation with the local authorities concerned—the geography of a particular region will need to be taken into account. In the larger geographical regions, the presumption will be that the coroner travels to an inquest, rather than that the bereaved family travels to an inquest centre. That is an important principle. To achieve this, it may be that we will retain a small number of part-time coroners, perhaps in support of a full-time senior coroner for an area, so the workload can be appropriately shared and a disproportionate amount of time is not spent travelling.

Amendment 78 seeks to place a requirement on all local authorities to benchmark their provision of staff and accommodation against other coroner areas. In the reformed system to be created by the Bill, it is likely that the Chief Coroner will indeed gather evidence to establish some key national benchmarks on quality, on service levels and on resources. As I mentioned earlier, some of this work can be completed during the implementation period for these reforms.

The Chief Coroner will also have an ongoing monitoring role. In this, he will be assisted by the new independent inspection regime we are proposing under Clause 31. Under this clause Her Majesty’s Inspectorate of Court Administration will inspect all coroner areas in England and Wales and will report to the Lord Chancellor and to the Chief Coroner on the administration of the system in different coroner areas. If it appears that there is a problem in any particular area with resources, including accommodation, the Chief Coroner in his or her role as national leader of the coroner system will be able to liaise between coroners and the local authorities that fund them to ensure that, as far as possible, improved resources are made available and that these are used in the most effective way.

Although I cannot give to the noble Lord, Lord Thomas, his survey at this stage, the Bill envisages that there is a full appreciation of national resources, that there are benchmarks and that deficiencies can be identified with a view to remedy. Should there be—

It is not quite clear how this funding is going to be achieved. Local authorities will be responsible for what is going to be an upgraded accommodation system. That is quite right; the accommodation needs to be upgraded for all the reasons given by noble Lords. Do the Government expect local authorities to fund this out of existing budgets, so it will be competing with their capital programmes for other equally pressing things, or do the Government envisage that they will provide resources for it as a result of the Bill?

Local authorities are going to be responsible for meeting their obligations under the Bill. It may even be that the Chief Coroner will exercise the option of naming and shaming poorly resourcing authorities if there is no indication of improvement. We hope to bring much greater pressure than has been the case in the past with the individual coroner in a locality wrestling with the issue. We hope to bring a degree of national or at least regional comparison with, in the most extreme cases, the Chief Coroner indicating that standards are not high enough in a locality.

I accept, as the noble Baroness says, that local authorities are not going to be able to throw a switch and solve these problems overnight. No issues with regard to resource allocations are solved in that way. The Bill is meant as a powerful instrument for the improvement of resources. It is not going to be achieved overnight—certainly not in the circumstances where we recognise that local authorities struggle to meet their commitments and have many challenges. The objective of the Bill is to create a framework in which improvement can be effected. I hope noble Lords will recognise that the Bill faces up to the question of a necessary structure to improve resources. What I hope I have identified as probing amendments can be safely withdrawn on the basis that the Bill significantly addresses these issues.

I thank the Minister for that comprehensive reply in outlining the standards. It struck me that an adequately resourced national coroners service might have been an alternative to carrying on with the finances coming from the local authority. I realise we are not amending the Bill to do that—to move the money out of the local authority and into a national service—but a national service could then have a framework with standards against it. That might make it easier to achieve equity and fairness of provision than by trying to name and shame local authorities which I fear might plead poverty and hold coroners inquests up against things such as educational provision, cleaning streets, et cetera. It might still be quite difficult to improve the service in those areas where it needs to be improved most.

Do I take it that, like the ancient Israelites, the local authorities are commanded to make bricks without the necessary ingredients?

That is a little unfair; I have not talked about any of the ingredients, and I am certainly not going to talk about straw. I was indicating that the objective of the Bill is not to calculate resources but to set up a framework by which we can improve the service, identify standards and identify deficiencies against criteria which shift the emphasis more towards the interest and the requirements of the family of the bereaved. Within that framework, we have a structure which can effect significant improvements. We have a little way to go before the Bill becomes an Act, and there are many issues with regard to resources. Let us concentrate, however, as the Bill is meant to do, on the framework which makes proper decision-taking possible and effective. Issues of resources can then follow.

That framework is all very well, and I approve of the Chief Coroner and the inspector to whom the noble Lord has referred. But inquests do not take place in thin air; there has to be somewhere where they occur. As I understand it, the Minister is saying that the Chief Coroner can name and shame local authorities but if they have more urgent calls upon their budget, that is too bad. That leads to what in other contexts we call a postcode lottery. In one area there is an adequate service and adequate provision for a proper hearing, while in another there is not. A local authority can say that it has more pressing needs.

The Government have decided that the coroners service should not operate within the Courts Service, where courts would be available. It is necessary for us to pursue this point now and at later stages of the Bill.

I am delighted to see that the noble Lord, Lord Kingsland, is about to rise to his feet. I have not the slightest doubt that the noble Lord, Lord Thomas, will have plenty of opportunities for pursuing that particular theme.

I am most grateful to all those who have spoken in this debate and to the Minister for what he has said so far.

I should like to understand, as precisely as I can, the Government’s position on this matter. It is quite clear from Clause 3 that they are convinced that it will be necessary, from time to time, to give directions to coroner B for a case to be transferred to coroner A for all the reasons that have been deployed in this debate. It is also quite clear, not only from what has been said but also as a matter of common sense, that there is absolutely no point in making such a direction to coroner B unless the Chief Coroner is convinced that coroner A has the resources to carry out the transferred task. It must follow, must it not, that, before issuing a direction, the Chief Coroner must make a financial assessment about the capacity of coroner A to carry out that task? If that is so, what possible objection can the Government have to our amendment, which says precisely that?

Let us be clear what the debate is all about. I have listened to a construct of a different basis on which the coroners service could be delivered in terms of a national position. We do not believe that; local authorities have expressed to us their clear interest in the coroners service. Therefore, we are obligated within those terms to seek to improve the structure which governs the service and strengthens the position of the Chief Coroner to bring pressure to bear. Within that framework, I do not deny that the issue of resources will become of some import.

The noble Lord asks whether it would be possible to transfer a case to a coroner who manifestly does not have the resources to meet that request. In those circumstances, the transfer could not take place. People will act sensibly within these terms, but the concept behind the transfer is to seek ways in which we can make the service more sensitive to the needs of those whom we are seeking to serve. The noble Lord is right that this must be taken into account, but that is different from putting resources in the Bill at this point. This amendment has attracted a number of others concerning resources. I do not cavil at that, because I recognise the importance of the issue, but the noble Lord will appreciate just what it would mean if we had to underpin almost every initiative in the Bill with a clear allocation of where the resource base was. That is not the nature of the way in which we construct legislation.

I am prepared to accept the noble Lord’s point in general terms, but he will recognise why the Government are not prepared to accept the amendment as it stands. Once we started on the allocation of resources, I had no doubt that the noble Lord, who is pretty fertile in these matters, could produce a plethora of resource issues that relate to almost everything in the Bill. He will appreciate why I am resistant to that process.

The noble Lord, Lord Kingsland, has raised an entirely relevant point in his amendment. Will it be in subsidiary legislation? I think it ought to be somewhere.

The whole point of Committee stage is to raise issues which give the Government a chance to pause for thought. The transfer from one coroners’ court to another might raise quite significant resource issues, but that is rather different from accepting an amendment which starts us down the route of attaching a price tag to almost every clause. That is not the way in which we will make progress in improving the coroners service.

I wonder whether I am the only Member of the Committee who has become increasingly baffled during the past quarter of an hour. My understanding is that in Parliament, as in most other bodies, it is the responsibility of those who bring proposals forward to be able to present some sense of their cost. Without that, it is hardly responsible to make such proposals.

Secondly, has the Minister ever had, as I have, a considerable volume of correspondence on a particular issue describing him, as I have been described, as a “toothless tiger” because I was widely thought to have powers which I did not have? That is the position that the Chief Coroner will find himself in with regard to these issues. Will the Minister find applications from men and women prepared to apply for the post of Chief Coroner in those circumstances?

There are individuals in our national life who carry out roles in which they make recommendations on standards and seek to influence those who have resources without necessarily commanding the resources themselves. A great deal of our inspectorate system works on such a principle. The Chief Coroner is not an inspector; he has a critical role. Nor is he a distributor of all the largesse available for the coroners service; quite the opposite, local authorities are the holders of the funds in those terms. They want to play their part in this. We are concerned that they are able to play their part and to meet standards of service which we want to focus a great deal more on the needs of the bereaved. That is the basis of the Bill.

I say with great respect to the Minister that he appears to be putting up more and more smoke in response to the questions that have been posed by various of your Lordships. This has got nothing whatever to do with increasing resources, either centrally or locally. It has simply got to do with the functioning of Clause 3.

Clause 3 can only function—the directions can only sensibly be made—if they are made to people who are in a position to carry them out. The responsibility for making that assessment is the responsibility of the Chief Coroner. Inevitably, that assessment will have to include the terms of my amendment. I do not want to be driven into a corner on this matter now, unless I really have to be. The noble and learned Baroness, Lady Butler-Sloss, has made the very good suggestion that one alternative to putting this matter in the Bill might be to include it in regulations.

I want to be clear about what the Minister’s response to this is. I hope that what he is going to stand up and say is that he accepts in principle that this is a matter that ought to be addressed and he would like to give consideration to whether or not it should be addressed either in the Bill or in subsidiary measures, whether they be formal delegated legislation or authoritative guidance.

I am very happy to respond to the noble Lord. In fact, I did in my opening remarks indicate that we have considerable work to do on the issue of regulations. We have clear principles, and the general principle will be that if the death occurred in England and Wales, the local authority for the area where the death occurred will be responsible for meeting the costs. That is where the burden will lie, as a principle.

As I said in my opening remarks when referring to the amendment, we will be concerned with regulations to address these issues. I am simply resisting putting this on the face of the Bill. The noble Lord has raised the issue and the Government need to address it—we do not have the slightest doubt about that—but we shall do so in regulations, not on the face of the Bill.

I am most grateful to the Minister for replying in the way that he has. I shall re-table this amendment on Report, in the expectation that something quite concrete will be coming forward from the Government then. Meanwhile, I beg leave to withdraw the amendment.

Amendment 5 withdrawn.

Amendment 5A

Moved by

5A: Clause 3, page 3, line 6, at end insert—

“(4A) When giving notice in writing to coroner B of a direction under subsection (4), the Chief Coroner shall give his reasons in writing—

(a) to coroners A and B, and(b) to an interested person,for the direction to conduct an investigation under subsection (1).

(4B) For the purposes of subsection (4A) “interested person” shall have the same meaning as section 38(2)(a) or (b) as appropriate.”

I feel I should apologise for having such a series of amendments, but I remind the Committee that I have waited some years, as have others, for the coroners legislation to be introduced. When it finally did arrive I simply extracted the long list from my filing cabinet of issues, and premises was one issue among many others. I will be brief. I am grateful to the British Legion for reminding me of the importance of keeping people informed. Amendment 5A provides that when the Chief Coroner gives direction to another coroner to conduct an investigation, the reason is given to the next of kin. It is simply to keep them informed. That would avoid delays in the event that others seek to obtain such information by way of an appeal, freedom of information request or judicial review.

Amendment 45A requires notification to be given if the body is moved. For the vast majority of bereaved people—I will not say everyone, because there are always exceptions to a 100 per cent rule—the body plays a very important part in their accepting and grieving the death. They want to know where the body is, where the final remains rest. It seems compassionate to let them know if the body has been moved as well.

Provisions under Clause 4 require the senior coroner to give a written explanation to interested parties if an investigation is discontinued, where the cause of death is revealed by post mortem. A requirement also to notify the family if the inquiry is transferred to another coroner, or if the body is moved, would therefore seem only to build on the system already in place. I therefore hope that it would not be onerous. It may be important in heading off any complaints, appeals or, worst of all, requests for judicial review of the Chief Coroner’s decision. I beg to move.

I should like to ask the Minister a question arising from my noble friend Lady Finlay’s amendment. It also has a bearing on the debate that we have just had, initiated by the noble Lord, Lord Kingsland. It is really about the movement of cases from one area to another. This idea of notification which is contained here and was implicit in our earlier debates is a good one. My question is about what slack the Minister has identified within the system to make this more than purely an intellectual exercise. Do we know that within the system there are coroners who have the capacity to deal with some of the cases referred to in the last group of amendments and in this one? Therefore, how often is this likely to become a regular exercise or one that might be frequently used?

I rise to speak to my own Amendment 90A, which is in this grouping although it goes to Schedule 4, where the coroner may wish to have a body exhumed. I do not want to go into the circumstances of that because that is not the purpose of my amendment. The amendment would simply add that where such an undertaking occurs, interested persons should be informed. The interested persons I am particularly concerned about are, of course, the next of kin and close family friends. If a body is to be exhumed, that is not something that any member of a family would consider lightly; it must be a terrifying thought in some circumstances, even if one is anxious to get to the truth. It must be a traumatic experience. It is therefore vital that information of such a sort should be made available immediately to close family and friends. I have used the term “interested person” because there is an interpretation of it in Clause 38 and it seemed useful to use that explanation.

I am grateful for the succinct but accurate comments made in support of these amendments. I hope I will not be as prolix as I was on the preceding amendment, because I agree with all the sentiments that have been expressed and that lie behind the amendments. The noble Baroness, Lady Fookes, is right that “interested person” is the accurate definition, and the amendments seek to place on the Chief Coroner and the coroner investigating a death a duty to keep certain interested persons informed of developments in the investigation. The first amendment—the one in the name of the noble Baroness, Lady Finlay—extends as a courtesy to interested persons in cases where a case is transferred to another coroner’s area. The amendment would require the Chief Coroner to inform in writing both the coroners.

I do not agree that the amendment is necessary. The Chief Coroner will make the decision and the interested persons will be kept informed of it. They will need to know where the investigation is being held. We have always said that the views of the bereaved family will be an important factor in the decision. They will be consulted before the Chief Coroner’s decision is taken and informed of it afterwards.

The noble Baroness’s Amendment 45A requires the coroner to inform interested persons of the location of the body of the deceased if it is transferred. Once again, I do not think it is necessary to put it in the Bill. The charter for the bereaved sets out that the coroner will keep the bereaved family informed of developments in the case, particularly relating to post-mortem examinations. This will include both the location of the examination and an explanation of the type of examination that will be carried out.

The amendment of the noble Baroness, Lady Fookes, would require a report to be made to interested parties. It has always been the intention that interested persons receive both a copy of the report and the response to it, as is the case under the current rule as we amended it in July 2008. That commitment will be carried forward to the rules to be made under Clause 36. I hope that I can reassure her on that front.

On the definition of “interested persons”, I do not think that the noble Baroness, Lady Finlay, need have any anxiety. It is not needed in the Bill, because coroners are given a discretionary power to designate a person as interested if they have “sufficient interest” under Clause 38(2)(n). Next of kin who are not specified in Clause 38(2)(a)—that list is extensive—could fall under subsection (2)(n) if the coroner felt that they had the required level of interest in the investigation. All categories of people who would have sufficient interest in the matter are covered.

The noble Lord, Lord Alton, asked me what slack is in the current system to transfer cases. This is largely irrelevant in the present system, which is predominantly part time. The reformed system will have predominantly full-time coroners. The issue is quite clear in those terms.

I am grateful to the noble Lord, Lord Davies. Before he concludes, will he indicate what capacity he thinks there will be in the reformed system, as he just described it, to deal with the current level of inquiries and whether there will be slack within it for the transfer of cases? From what I have seen in areas of the north-west of England with which he will be familiar, there are very few places where there are not sufficient cases to keep a full-time coroner busy.

That is an important point, but the noble Lord, Lord Alton, will recognise that transfer of cases is sometimes sought because of overload, derivative of a particular catastrophe or, as I discussed earlier, when overseas personnel have been killed or have died. Particular localities carry the brunt of those cases and families are expected to travel to those areas in southern and south-west England where bodies are brought back by air. We want to share that around more equitably, and I think that the noble Lord will see the way in which we can seek effectively to do that.

I return to slack in the system. If we prioritise the interests of the bereaved, the transfers will reflect that, and the system will be evened out by the very nature of the randomness of where the bereaved live. If the noble Lord is suggesting that the system will have pinch-points in it, I say that the present system has those, too. We are creating within the framework of the Bill an opportunity to identify problems more effectively and effect a proper response to them.

I am most grateful to the Minister for his comments and assurances and I am glad that we were able to get through this group of amendments with a degree of speed. I beg leave to withdraw the amendment.

Amendment 5A withdrawn.

Amendment 6 not moved.

Clause 3 agreed.

Amendment 6A

Moved by

6A: After Clause 3, insert the following new Clause—

“Investigations into deaths of service personnel

(1) Coroners conducting investigations into the deaths of members of Her Majesty’s Forces shall have the appropriate training for carrying out such investigations.

(2) Where—

(a) an investigation is transferred under section 2(1) or 3(1), and(b) the deceased is a member of Her Majesty’s Forces,the coroner to whom the case is transferred shall only conduct the investigation if he has the appropriate training for conducting investigations into deceased members of Her Majesty’s Forces.”

The proposed new clause stands in my name and that of the noble Baroness, Lady Dean of Thornton-le-Fylde, who cannot be with us today but who is fully behind the sentiments expressed in this clause and the other amendments grouped with it. Perhaps I may sketch in the background to the proposal and, in doing so, declare an interest as president of the War Widows Association of Great Britain and of the Sussex branch of SSAFA Forces Help. Your Lordships will understand, therefore, that I have an interest in military inquests and their impact on the family and close friends of the service man or woman who has died.

In the early days, there was great concern not only because of delays resulting from the impact on coroners in particular areas of the country where bodies were repatriated—that was bad enough, but I shall not dwell on it now—but also because the coroners did not then have the expertise which several have now acquired. A military ethos informs the way in which people who died in conflict are dealt with, making it quite different from the normal duties that are required of a coroner in civil society. It was easy for the families in those early days to feel that the coroner concerned did not have a sufficient grip on what it was all about. Above all, where embarrassment to the Government was caused by the death of servicemen, it was felt that it would be relatively easy for officials to—how shall I put it tactfully?—pull the wool over the eyes of an inexperienced coroner.

Several coroners now are extremely competent and very well versed in the needs of a military inquest. They certainly have not been afraid on occasions to point the finger of blame at, let us say, inadequate protection for a servicemen through no body armour being available, or perhaps inadequate vehicles which have then been the subject of enemy fire. A very tricky coroner’s inquest can take place.

The thrust of the new clause and the amendments grouped with it is the absolute necessity for that expertise not to be lost, which means proper training for any coroners who undertake military inquests. Several bites at the same cherry have been presented and I hope that the Minister might be persuaded to take up at least one of them. He has a choice of which ones he might like, including the amendment in this group in the name of the noble and gallant Lord, Lord Craig, who will, I am sure, speak in due course.

My favoured one is Amendment 114, which asks for one deputy chief coroner to be appointed with specific responsibility for overseeing military inquests and the training of all coroners undertaking military inquests. I put it like that because it is very important that somebody near the top of the system has a specific role and duty and can then undertake the training of other coroners. The key point is for there to be somebody near the top of the pile with that duty imposed on him. That is why I have suggested one deputy chief coroner with that particular duty.

I hope I can persuade the Minister that this is important. I gathered at Second Reading that he takes the view that there is a general duty of training in the Bill and that it is sufficient for the purpose. My view—very firmly held—is that it is not sufficient. It needs to be written into the Bill because time passes, people forget and expertise is lost, so we need something to pin it all in place. For that reason, I feel strongly that there should be something in the Bill that can be there for a considerable time. I assume that we are unlikely to see another coroners Bill in my lifetime, and certainly not in the near future. This is our sole opportunity to make sure that it is right. Therefore, I warmly recommend at least one of these amendments to the Minister. I beg to move.

I rise to speak to Amendment 37 and the other amendments grouped with it. They all have a similar thrust. My choice of location in the Bill was driven by the fact that line 22 of page 8 has the phrase:

“Death of service personnel abroad”.

I do not necessarily hold to that as the right place to put it, but it is very important that there is something in the Bill. The Committee is well aware of the problems that have arisen in dealing with inquests of service personnel tragically killed overseas. As I mentioned at Second Reading, it has taken some years to get satisfactory arrangements made. Only after a considerable time did coroners, particularly in Wiltshire and Oxfordshire, build up considerable experience in dealing with military deaths. This experience is now widely recognised and valued.

There are no indications that the active use of forces overseas will be dramatically cut in the near future. In the past month alone, 12 more operational deaths have occurred in Afghanistan. We must brace ourselves for the possibility of significant further deaths in the coming months and years. In Command Paper 7424, entitled The Nation’s Commitment: Cross-Government Support to our Armed Forces, their Families and Veterans, the Government undertook to provide fair treatment for our Armed Forces because of the unique nature of their service to the nation. Surely it follows that the maintenance of expertise to hold inquests on service personnel in the coronial service is not only essential but should rightly be in the Bill.

The noble Lord, Lord Bach, wrote to me on 22 May, following Second Reading, and his letter is in the Library. He sought to reassure me that measures in the Bill will,

“strengthen investigations into military deaths”.

I read the Bill closely and did not feel great confidence that military deaths would be better investigated, based on what was in the Bill. The noble Lord, Lord Bach, also said:

“As indicated in paragraph 56 of our draft charter for the bereaved, we expect the Chief Coroner to issue guidance to coroners about investigations into deaths of service personnel on active service”.

This, he said, combined with the training of coroners and their officers, for which the Chief Coroner will be responsible, will ensure that,

“all coroners are able to conduct effective investigations into deaths of service personnel”.

In his next sentence the Minister says that an extremely complex investigation could be transferred by the Chief Coroner to a coroner with the necessary skills and experience. Surely this last sentence acknowledges that there is a need for the necessary skills and experience. Indeed, it effectively contradicts his previous assertion that the Chief Coroner will ensure that all coroners are able to conduct effective investigations.

I looked at the latest version of the draft charter for the bereaved. Incidentally, the introduction to the charter states that the new Chief Coroner will probably want to consult again before the reforms are implemented in full in two or three years’ time. This is hardly a definition for firm action on the day that the Bill becomes law, which is, I believe, what is required. Paragraph 56, to which the Minister refers, says that the Chief Coroner will be responsible for setting national minimum standards across a range of coroners’ functions. In terms of services to bereaved families, this could include standards in relation to particular types of death or suspected death, such as deaths on active military service. This is but one example. The draft goes on to specify a variety of other causes of death, such as death as a result of atrocities or other disasters; death from particular illnesses such as epilepsy and sudden adult death syndrome; and death apparently resulting from suicide. These, the draft charter says, are matters for the Chief Coroner to determine when he or she is appointed.

Paragraph 57 of the same draft charter says that this is only a draft and is intended as a guide for those with an interest in the kind of service that it is envisaged will be provided by the reformed service. Surely this is just not good enough. We must seek an amendment to the Bill that gives clear instruction to the Chief Coroner to provide for and maintain the necessary expertise in service inquests, which experience over the past few years has shown to be essential and of particular importance to the next of kin of those who have so tragically lost their lives at a young age. Command Paper 7424 was introduced and debated with much fanfare in this House. The noble Baroness, Lady Taylor of Bolton, said that the Government were unashamedly setting out to provide special consideration for the Armed Forces and their families. The draft charter for the bereaved, on which the Minister wishes to rely, is far too generalised. It lumps military inquests together with a whole variety of others and is not just geared to the particular and present-day needs of military inquests. I urge the Minister and the Government to reconsider this issue.

We have a great deal of sympathy with the amendments tabled by the noble Baroness, Lady Fookes, and the noble and gallant Lord, Lord Craig of Radley. In other parts of the Bill we will look at the expertise, experience and training of medical examiners. I know that people in judicial positions are always a little more reserved about training or particular qualifications. It seems to us that much has changed in this area. The noble Baroness, Lady Fookes, mentioned the fact that we do not come to legislation on coroners terribly frequently. A great deal has happened since any previous look at the service. A great deal has also happened in terms of the military and war.

First, 30 years ago there would have been many more people who had experience of service. As time goes on, the number of people serving in the military goes down and the direct experience and understanding of what being in a war is about gradually becomes more specialised. Secondly, war itself is becoming a very different and highly technical business. Issues of injury, death and the experience of protection have changed dramatically. Often, those who are far from theatre but see it on a television screen may feel that it is more like a video game than what it is really like in situ.

Military law and international law relating to conflict have changed dramatically over the past 10 years or so. This whole area has changed dramatically in many other ways, but I will not tire the Committee by relating them. It is extremely difficult to see how coroners in general could hope to understand all these areas in sufficient detail and depth to be able to deal satisfactorily with them when these matters arise. In so many aspects of professional life we are very much aware that there has to be a degree of specialisation and expertise. Although we have not tabled amendments on this issue, we saw that this opportunity would arise for the Minister to respond to these thoughtful propositions—this menu of opportunities—and we look forward to hearing what he has to say. We want to identify ourselves with the concern that expertise and specialisation are necessary.

The noble Lord, Lord Alderdice, has just reminded us that the day-to-day knowledge of war on the part of a large number of people in this country is perhaps less acute now than it was for previous generations. However, we are at war in Afghanistan and in Iraq and our soldiers have lost their lives there. As the noble Lord said, it is important that we should not forget the reasons why they laid down their lives. Society at large should constantly be made aware of the sacrifice and the nature of those deaths.

Listening to my noble and gallant friend Lord Craig of Radley, who himself gave such outstanding service in the Royal Air Force, I reflected that an uncle of mine had died serving in the Royal Air Force in the Second World War and how important it was for my generation to know the circumstances in which that death occurred. Indeed, my 12 year-old son returned yesterday from a school trip to the Somme where the pupils looked at the circumstances that led to so many deaths during the battles that occurred there in 1916. Each of those children consulted records to look at the lives and deaths of the soldiers who had attended their school before travelling to the Somme. No one is more aware than the noble Lord, Lord Bach, of the importance of recollection, given his experience of dealing frequently with many of these instances at the Dispatch Box. It is significant that he has been joined by his noble friend Lady Taylor, who holds this responsibility today and so frequently has to remind the House of the price that has been paid by our servicemen.

Therefore, it is important that we should know why people have died and how they have died, and that that knowledge should not be lost. How it is recorded is therefore extraordinarily important. As is so often the case, the noble Baroness, Lady Fookes, has done the Committee a great service by bringing forward this amendment to ensure that we adequately debate this matter. I very much liked what she had to say and the spirit in which she said it, asking the Minister not necessarily to agree with the wording of the amendment but to look for words that will achieve her objectives, one of which is training and the assurance that expertise will not be lost as the number of people who are able competently to deal with such very specialist inquiries may have to be narrowed down.

In the earlier debate, the noble Lord, Lord Davies of Oldham, referred to local authorities, some of which were mentioned by my noble and gallant friend, such as Wiltshire where bodies have been flown back. It was suggested that in the future there will be a sharing around of some of the duties of carrying out such coroners’ inquiries. Is there not an inherent contradiction in this argument? If that is to be the case, the very expertise that my noble and gallant friend has identified will clearly not be available in other parts of the country if such inquiries are sent there in the future. Will the Minister dwell for a moment on what will happen if coroners sitting in the future have not had the training or developed the expertise identified by the noble Baroness, Lady Fookes, in moving these amendments?

I wish to say a word in support of the amendment tabled by the noble and gallant Lord, Lord Craig of Radley. It so happens that this Bill comes before us when we are engaged in fighting a formidable foe who appears to be well armed and getting increasing supplies from some sources. We read, sadly, of the deaths of our troops, particularly due to roadside bombs and suicide attacks. It is a formidable campaign in which to be involved. It is wholly appropriate that the Bill should reflect the times in which we live and show sensitivity to the issue of having coroners in charge of the inquests who are fully up to speed with the type of case with which they will have to deal. I suggest that we owe it to our troops and their families—those already afflicted with grief and those who may suffer in the future—to have a Bill that shows that we are aware of the risks being run.

I support the amendment tabled by the noble Baroness, Lady Fookes. I speak from the families’ point of view. I declare an interest as a trustee of the Defence Medical Welfare Service, which provides welfare officers to help the families of troops who are sent back to hospitals in this country and Germany. The families are very sensitive and concerned to have the details. It would be very appropriate to incorporate this amendment in the Bill to ensure that the expertise is available, as the families need to know exactly what has caused the deaths of their loved ones.

This House is always at its best when discussing our Armed Forces. As the noble Lord, Lord Alton, kindly said, I have experience of replying to debates on that subject in the House. Tonight is no exception. I pay tribute to the noble Baroness, Lady Fookes, and to the noble and gallant Lord, Lord Craig. SSAFA, with which the noble Baroness, Lady Fookes, is so closely involved, is a marvellous organisation that I am lucky enough to have dealt with over the years.

The amendments address the expertise of coroners in investigating deaths of all British service personnel. I understand the wish of the noble Baroness and of the noble and gallant Lord to ensure that in a reformed coroners system we do not lose that expertise that has been built up by, for example, the coroners for the counties of Wiltshire and Oxfordshire. Amendment 6A aims to ensure that, where an investigation is transferred from one coroner to a coroner in a different area for whatever reason, the coroner to whom the case is transferred has had appropriate training on investigations into service personnel deaths.

Amendment 37 aims to ensure that a cohort of coroners has the necessary skills to carry out investigations into service personnel deaths. Similarly, Amendment 119 would require regulations on training for coroners who carry out service personnel inquests. Amendment 114 would make a deputy chief coroner responsible for overseeing military inquests and training coroners who undertake them.

There was a backlog. That was caused to some extent because the decision to repatriate all service fatalities initially via RAF Brize Norton in the Oxfordshire coroner’s jurisdiction created a singular and exceptional burden there. We would expect a coroner to be able to complete a routine inquest within six months of its opening. As the Committee well knows, inquests of service personnel can be more complex with a timeframe of around nine to 12 months from the date of death to the hearing of the inquest. Delays are often due to necessary Ministry of Defence investigations, especially service inquiries, and sometimes at the request of the family.

As we know, coroners are funded by local authorities, but extra resources from government have been provided to Oxfordshire, Wiltshire and Swindon coroners for inquests for service personnel killed on operations overseas. Both my department and the Ministry of Defence have looked at what else can be done to speed up the processes—for example, reviewing service inquiry procedures. The MoD established a Defence Inquests Unit in June last year, whose key role is to assist coroners and to progress internal investigation reports to prevent avoidable delays to inquests. The Ministry of Defence has also provided additional logistical support for bereaved families, which I shall not go into now.

I reassure the Committee that, even without these amendments, measures in the Bill will mean that all coroners will be not only able, as my letter to the noble and gallant Lord, Lord Craig, said, but also equipped to deal with service personnel inquests. I want to offer what reassurance I can that the broad policy under a reformed coroner system will be that coroners in Wiltshire and Oxfordshire will continue to be responsible for leading investigations in the tragic event of incidents overseas involving service personnel that lead to two or more fatalities.

I say in passing that the coroner for Wiltshire, Mr David Masters, who has conducted many of the most recent inquests and who has been praised by local Members of Parliament during Commons stages of the Bill, retired on 1 April. However, we understand that the new coroner for that county has appointed him as an assistant deputy for the specific purpose of continuing to preside over these cases.

I said that incidents involving overseas personnel that lead to two or more fatalities will be looked at by coroners in Wiltshire and Oxfordshire. However, there may be exceptions to this. For example, if the families of the two or more fatalities are from Scotland or Northern Ireland, it may be more convenient for a fatal accident inquiry or inquest to take place there. We shall need to have much more detailed discussions about these matters to establish suitable protocols before the Bill is implemented.

There are measures in the Bill to ensure that any coroner is equipped to deal with an investigation into the death of a single soldier in the event that responsibility for the investigation of a particular death is transferred to another coroner nearer to where the deceased’s family lives. Perhaps I may give some examples. First, one of the key roles of the Chief Coroner will be to issue guidance to coroners and their staff about investigations into certain types of death. This will include the deaths of those on active service. Paragraph 56 of our draft charter for the bereaved has already been mentioned by the noble and gallant Lord, Lord Craig. Secondly, the Chief Coroner will make regulations concerning the training required by all coroners and their officers and other staff. I can confirm to the noble Baroness, Lady Fookes, that this will almost certainly include training for those with responsibility for investigations into military deaths. These measures will ensure that all coroners are able to conduct effective investigations into the deaths of service personnel.

However, if there were an extremely complex investigation, under Clause 3 of the Bill the Chief Coroner would be able to transfer the investigation to a coroner with the necessary experience or, under Schedule 8, to a particularly experienced judge, former judge or former coroner. I am afraid that I cannot accept that there is a contradiction between our assertion that all coroners will have the skills and experience necessary to conduct investigations into the deaths of service personnel and, on the other hand, our recognition that there will be exceptional, complex cases that will need to be handled in a different way. Those exceptional cases might involve, for example, multiple fatalities, which would sensibly be handled by a coroner who has conducted such investigations in the past. Those cases will be quite different from routine cases—if any such case can be described as routine—which any coroner should, with training, be able to handle.

The noble Baroness, Lady Fookes, suggested that one deputy chief coroner should have oversight of military inquests. On balance, we do not believe that that is necessary because the Chief Coroner, as part of his or her leadership role for the service, would almost certainly want to be satisfied personally that all investigations and training were being carried out to the highest possible standard in line with the relevant rules, regulations and guidance.

The overriding aim of the reforms in Part 1 of the Bill is to improve the service that bereaved people, whether service families or otherwise, receive from the coroner system. We are confident that, taken together, the measures in the Bill will strengthen investigations into military deaths. When I had the privilege of serving at the Ministry of Defence, I saw at first hand fatalities being brought back to Brize Norton as a consequence of the Iraq war. That is something that will stick in my memory, as it will with anyone who was at Brize Norton on one of those occasions. Therefore, I do not need to be persuaded about how serious a matter this is and how fundamental it is to the way in which we approach things. However, we do not consider that the amendments are necessary. We believe that the Bill already covers the very special interests relating to military personnel who die in service and their families who are left behind. They are indeed very special and different.

I am deeply grateful for the powerful support that I have had from many noble Lords tonight. I know that the Minister feels strongly, and I am grateful for his sympathy and understanding of the situation relating to military inquests. None the less, I shall want to study very carefully what he has said because I remain unconvinced that it is unnecessary to put anything on the face of the Bill. I shall happily take away the thought that the Chief Coroner should have a duty in this regard and I shall be back. In the mean time, I beg leave to withdraw the amendment.

Amendment 6A withdrawn.

Clause 4 agreed.

House resumed. Committee to begin again not before 8.38 pm.