Public Office (Accountability) Bill (Second sitting)

Lizzi Collinge Excerpts

Thursday 27th November 2025 Public Bill Committees

[The Chair]

I call Lizzi Collinge for, I am afraid, what is likely to be the last question on this—we might possibly get a couple more in.

[Lizzi Collinge (Morecambe and Lunesdale) (Lab)]

Q I will try to be quick, Mr Dowd. Families have told me that they have experienced during coroner’s inquests the following: information having to be dragged out of public bodies, hostile legal teams and a process that is meant to be inquisitorial becoming adversarial. Do you have any comments on whether the Bill will improve that situation?

Deborah Coles: The first thing to say is that the legal aid provisions will quite clearly have a transformative effect, because families will no longer have to go through intrusive funding processes, crowdfund or represent themselves.

In terms of a change in culture and the duty of candour, at the moment, as I explained, we see exactly what families have spoken to you about: a process that is adversarial in nature and victim blaming. Time and again, families describe their experiences as a battle. These are grieving families who have experienced death, very often where the state has a duty of care; something has gone catastrophically wrong, yet they have to try to drag information out of the people responsible. It is utterly unacceptable. If the Bill actually lands on the ground, meaning that organisations have this duty of candour from top to bottom, and people are called to account if they continue to behave in the way you have had described, I feel that it will change the experience.

The other thing to say is that there might be some suggestion that this is going to cause problems within the coronial system, which is our area of expertise. The Bill is trying to stop the battle to drag information out of people. There will be proper disclosure and open honesty from the outset about where things have gone wrong. It should mean that processes are shorter and less traumatising, and that they can deliver the answers that not only families need but we as a society need to learn, so that deaths are not repeated.

Professor Waters: The characteristics you mention were absolutely mine and my family’s experience of the inquest, with Ofsted withholding information or providing redacted information. In fact, it was so heavily redacted that it required us to have a second pre-inquest review, so it extends the process and adds to the expense.

I know there has been some discussion about the legal funding potentially being delayed because it might lead to a bigger budget, but parity does not mean more money. In the case of the Ofsted legal team, the coroner had to instruct them not to bring more than seven members of their legal team into the court, and we had Reading borough council and the NHS trust’s legal team up against us. Actually, balancing might mean reducing the amount of money that public bodies spend.

May I say one more thing, if this really is the last question, because I know we both want to say it? Something else that absolutely needs to happen, whether as part of the Hillsborough law or something separate, is that there must be some kind of national oversight mechanism to make sure that the recommendations that come out of inquests and inquiries are acted upon. As I said, it is two years today since my sister’s inquest, and it speaks volumes that I am still battling, frankly, just to try to prevent future deaths and to get Ofsted to do what it is necessary to make its school inspection system safe. I should not have to do that, There ought to be some independent objective body that makes sure that those recommendations happen, so that it does not happen again.

[The Chair]

We have two minutes left. I call Maria Eagle.

--- Later in debate ---

[Dr Mullan]

Q This is a separate line of questioning, but the question of whether the experience of the coroners process is always a positive one for families is not a new issue. Some of my constituents have had what I think I can fairly say were not positive experiences, where coroners have had to be changed, and only because those constituents raised concerns. Do you still have concerns that there is not consistency in the fair management of inquests, from the perspective of bereaved families?

Judge Durran: Every coroner is an independent judicial office holder. I can give guidance, but every case and every inquest will be fact-specific. One of my responsibilities as chief coroner of England and Wales is to provide leadership with the intention of promoting consistency among coroners. A considerable piece of work in achieving that objective was the “Chief Coroner’s Guidance for Coroners on the Bench”, which is a bench book—a “how to do it”. That has received a very favourable response for helping, I hope, to frame decision-making processes. It is a publication; although its intention is to assist coroners, it is a public-facing document and available for anyone who is an interested person.

Particularly—as I have emphasised at training, which is another of my responsibilities for coroners—bereaved families who are not represented in inquests should have access to that publication, because they can use that document to hold coroners to account in saying, “You are not following the Chief Coroner’s guidance, designed to promote consistency.” I am sad and disappointed that people may not have had a positive experience from an inquest, but we are, I believe, making considerable progress in promoting greater consistency.

[Lizzi Collinge]

Q Constituents of mine—such as the parents of Ida Lock, a baby whose death due to failings in care was preventable—have described inquests to me where the behaviour of public bodies made the inquest adversarial rather than inquisitorial. Information had to be dragged out of public bodies, and there were hostile legal teams. As a coroner, do you recognise that picture? What challenges does that behaviour give to coroners in their duties? Do you think that the Bill will change that situation?

Judge Durran: There is certainly an impression that inquests are becoming more adversarial because lawyers seek to use them as some early form of litigation, with an eye to any consequential litigation down the line. My predecessor and I have done a lot to convey the message that an inquest is inquisitorial—it should not be adversarial. It is a summary hearing, not a surrogate public inquiry. Increasingly, I tell coroners about the existence of the advocate’s toolkits, which have been designed specifically with inquests in process. I have encouraged coroners that if lawyers are seeking to turn an inquest into a public inquiry, they should pause, look at the advocate’s toolkits, remind the lawyers to look at those and remind them of the nature of the proceedings, because it is not the correct forum to make those sort of arguments.

[Lizzi Collinge]

Q Do you think that the Bill will help to improve that situation?

Judge Durran: It is disappointing that the duty of candour has to be written into law. I hope that the Bill is a considerable step in the right direction, as a vehicle to enable a coroner, through conduct reports and compliance directions, to better get people to engage with the true intentions, which is to find out answers to the four questions and primarily how someone died. However, I cannot over-emphasise that the compliance directions and conduct reports add a burden to a strain that is already under strain and under-resourced.

[Maria Eagle]

Q The original Hillsborough inquests, which were the longest in legal history at the time, in 1990, did not answer the four statutory questions in respect of each and every one of those who died who were the subject of them. They were, indeed, used as a way of overturning Taylor. That is what my constituents who I met when I became an MP told me was the effect of that inquest. It was not the inquest; it was actually the Hillsborough independent panel that answered those four statutory questions, but unfortunately that did not happen for 24 years. Do you believe that this Bill, and introducing legal representation for families and the concept of parity, might serve to address that kind of problem that you get when inquests become adversarial—as, increasingly, some of them do—or do you believe it might serve to prompt more inquests to become adversarial? Do you have a concern about that?

Judge Durran: I have a concern because, as I have said, a coroner has to answer four statutory questions. If an inquest engages article 2, the “how” becomes “in what circumstances”, but they are very narrow questions that should be answered. A coroner has to be very clear in answering those four questions in setting their scope—in setting the parameters of their investigation in answering those questions. There is very often a tension between what a coroner feels they need to hear to answer the statutory questions, and some wider questions that family may want answered. That remains a tension that I am not sure that this Bill is necessarily going to answer.

--- Later in debate ---

[Tessa Munt]

Q I recognise the efforts that you are going to at the CQC. I have already declared my interest as someone who has been involved in whistleblowing for 15 years. It is alarming how many relatively senior NHS people end up in employment tribunals because they have been ousted for raising something. That concerns me hugely. I will leave it there, unless you wish to say something.

Dr Chopra: I will briefly come back on that. One of the considerations in the 10-year plan is the role of the Health Services Safety Investigations Body, which will work more closely with the CQC in time. The HSSIB has what is called a protected safe space, which allows people, without fear of accountability and retribution, to raise concerns. One of the things we are concerned about in the Bill is whether the scope of clause 5(1), on other investigations, will include investigations undertaken by HSSIB when it works closely with CQC. It will be important to protect that space for the reasons you mention.

[Lizzi Collinge]

Q First, it is a matter of public record that my husband works for NHS England—for now. I ask these questions as a representative of constituents who have been harmed, including my constituent Vicki, who died, and baby Ida Lock, who died a preventable death. Her death was graded as “Moderate harm”, which was one of the many, many failings that came afterwards. NHS Resolution focuses on resolving issues and harm caused without resorting to legal processes. How will the Bill contribute to that aim?

Helen Vernon: Those are incredibly sad circumstances and sensitive issues. I think it will be a big help and support that aim because, as I mentioned earlier, an open and transparent response right at the start has the best chance of not only avoiding somebody consulting lawyers or initiating a claim just to get answers, but avoiding that claim subsequently escalating into unnecessary and adversarial legal proceedings. We have driven down the number of cases that go into formal litigation by using alternative dispute resolution, which generally involves bringing clinicians and the organisation together with the family. But you can do that only if there is an atmosphere of trust and clear transparency as to the information that is being shared.

[Lizzi Collinge]

Q My understanding is that some NHS organisations currently view being transparent as the legal risk. Do you think the Bill will change attitudes, in that it flips the legal risk on to being non-transparent? I have struggled, in representing my constituents, with the fact that this is about not just processes, or even law, but culture. It is about changing the culture of a care organisation that responds to harm not by trying to find out what happened and stop it happening, but by trying to cover its own back. Will both NHS England and NHS Resolution speak to that?

Helen Vernon: Just briefly, we hope that it will bolster transparency and the existing duty of candour, but perhaps Professor Fowler wants to come in.

Professor Fowler: I certainly agree with that. We have had the opportunity to talk about the sad case of Ida Lock. Thinking about where organisations have not been sufficiently transparent, we see occasions on which it is a failure to understand. I was involved with some training for staff who had worked in an organisation—it is not appropriate to name the organisation—where they had seen considerable failings. They were in tears during this training about reporting incidents because they realised they had been getting it completely wrong. It is incumbent upon us to work with organisations to change culture, but also to educate, train and support people, and to professionalise the approach to reporting and openness that we want to see, but that has to be done in a way in which people feel psychologically safe to do so.

I recognise anxieties about people suffering harm as a result of exercising the freedom to speak up, but it has been very successful when we look at the number of people we have seen coming forward with issues, most of whom I would argue do not suffer detriment as a result. This is about psychological safety, training, encouragement, support, standardising and professionalising around safety. A lot of the work we have done around safety has been about the governance and organisational principles of how it is done, and underlying all of it is a clear statement about systems and culture.

[Lizzi Collinge]

Q Do you think it is accurate that some organisations in the NHS still see being transparent, and admitting harm and problems, as the legal risk?

Helen Vernon: They should not, but as we mentioned, there is inconsistency. Part of our collective role is to make sure that people understand its importance, how to do it well and how to deliver candour in practice.

Professor Fowler: You mentioned closed cultures. I spent six months recently working as an interim in the CQC in the gap between chief inspectors. One of the things we recognised is that where we saw organisations with challenges, there was often also a closed culture. To be clear, that is a minority of organisations, but I think the two go together.

Dr Chopra: I recognise your questions, and I agree with what Aidan said. I have seen instances where what you have described is the case—as Helen said, it is inconsistent—and I have seen brave clinicians who have said, “Right, if it is not going to trigger the organisational statutory duty of candour, I do have a professional duty of candour, and I am going to raise it that way.” I hope the Bill will bolster that, as we have said.

[Seamus Logan]

Q I should declare that I worked in the health service for 33 years—not all politicians are political careerists. You are all very senior people, and obviously very experienced, but I want to get behind the corporate and ask for your personal opinions, based on your experience. My colleague drew attention to the fact that so many people in the health service have tried to blow the whistle and suffered serious detriment; in many cases, people have lost their jobs. If someone had blown the whistle on the infected blood scandal, thousands of lives would have been saved and the public purse would have been saved quite literally billions of pounds. Even with all the measures that have been put in place, why are people still suffering serious detriment when they try to blow the whistle? I am asking for your personal opinions. Professor Fowler, I will put that to you first, because you have experience in the Institute for Healthcare Improvement.

Professor Fowler: This is a very complicated issue. A few cases of people who have suffered detriment around freedom to speak up become very magnified. I genuinely do not see that as the experience of most people who speak up, but we do hear about it. In some cases, there is a great deal of complexity. In some cases, a massive breakdown of relationships within a unit that had started to impact the unit is what required the person to act in the way they did. Getting the balance right is a complex business.

In the past, I had cases where I thought, “This is a serious issue and we need to do something about it,” and was encouraged to think otherwise. That is historical—I am talking 20 years ago—and I have certainly not experienced it recently. I am not someone who has felt that there is an impediment to me speaking up, and I see plenty of examples where people are able to do that, but you do occasionally hear of people who feel they cannot, in difficult circumstances. We are working to change that culture and make it clear that there is detriment to not speaking up rather than the other way round, but it is a complex challenge. There is progress, but there is more to do. I hope that this Bill can be part of that, but there are some cautions to getting this right and getting the balance right.

Dr Chopra: I agree. I think it is about the culture. There is that saying that culture eats strategy for breakfast; in the same way, culture will eat many of these provisions. We have to get the culture right, and we need to do anything that we can to tilt the balance to create a culture of openness and candour. The reason people fear suffering detriment is that they have seen examples; we have to recognise that the high-profile cases that Aidan mentioned do have an impact on people coming forward. In fact, we probably ought to be celebrating those instances where people are able to raise concerns and blow the whistle, and things improve. That might help to start shifting the culture.