West London Coroner’s Court

Caroline Dinenage Excerpts

Wednesday 16th December 2015 Westminster Hall

[The Parliamentary Under-Secretary of State for Women and Equalities and Family Justice (Caroline Dinenage)]

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

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

[Andy Slaughter]

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

“I will not guess at this stage”

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

[Caroline Dinenage]

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

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

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

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

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

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

[Ruth Cadbury]

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

[Caroline Dinenage]

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

[Ruth Cadbury]

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

[Caroline Dinenage]

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

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

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

[Jenny Chapman]

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

[Caroline Dinenage]

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

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

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

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

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

Question put and agreed to.

Resolved,

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