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Coroners Bill Team
Coroners Division
Department of Constitutional Affairs
Ground Floor
4 Abbey Orchard Street
London
SW1P 2HP
8 September 2006
Dear Sirs
Coroners Bill Consultation
Thank you for giving us the opportunity to respond to this
consultation. Our response will support and repeat many of the
points made by Zoe Stow, in her submission dated 30.8.2006.
RoadPeace, as the charity representing the interests of people who
suffer the sudden violent death of loved ones through a road crash,
followed by inquest procedures that often leave them with more
questions than answers, welcomes the aims of the Bill for an
improved service and in particular a more effective coroner's
investigations.
RoadPeace has campaigned since its foundation 15 years ago for
more meaningful inquests and verdicts, and has contributed to all
relevant consultations and enquiries since then, including to the
Coroner Review Group, based on their experience of thousands of
road death cases.
More effective inquests
The reason improvement of inquests is so important to RoadPeace
and road crash victims, is because apart from a small number of
cases that are being prosecuted in the Crown Court, when inquests
are not re-convened, all road deaths are followed by an
inquest.
In many of those cases, due to the lack of priority given in law
to road deaths, the inquest is potentially the only opportunity for
families to find out how their loved one came by his or her death,
though sadly in too many cases at present they do not get this
information.
Since most road deaths occur on public roads in circumstances
that will be repeated again (How wrong was the coroner at the first
death by car in 1896, when he hoped such a death would never happen
again!), and the majority of sudden child deaths will be the result
of a road crash, all road deaths should continue to be followed
by an inquest - but a much improved inquest - unless prosecuted in
the Crown Court.
Much earlier than RoadPeace, in 1950, Professor Goodhart, KBE,
called for Expert enquiries into road deaths, to ensure they were
investigated in a thorough, scientific manner to find their causes:
"We cannot get this information from coroner's inquests, which
ought to be abolished in all motor cases...if these enquiries were
held, then we would reduce the death roll on the roads as has been
done in the coal mines and in factories..."
We are concerned that road deaths will continue to be
marginalised, since the Bill, in Clause 75 - Meaning of "relevant
offence"- only mentions the indictable charges Causing death by
dangerous driving or careless driving while under the influence of
drink or drugs. What about all the other fatalities caused by road
crashes?
More effective road death investigations
Despite road deaths being a leading cause of sudden deaths, with
over 90% resulting in an inquest, road death investigation has
never been a priority for the coroner system. Yet this is where
most lives could have been saved if lessons had been collated and
shared.
While the promised legal training of coroners is long overdue,
coroners holding inquests into road deaths should also be
required to have training in road traffic regulations and road
safety issues, such as speed limits on different types of roads
and for different types of vehicles, the Highway Code, increased
risks with speeding, drink driving, use of mobile phones, fatigue,
overtaking, pressure of tyres, road surface, etc.
If coroners are to have greater powers to request information,
it would be very useful if they could adopt a national system of
requiring drivers in fatal crashes to undergo, for example eye
sight tests and requiring mobile phone record checks re usage
around the time of the crash, tachometer checks and records as to
medical fitness. In a recent case that came to RoadPeace's
attention, the family were informed by the coroner that he could
not request the medical records of the driver, despite an issue re
fitness to drive.
Coroners recommendations to authorities are mentioned - p. 27,
Clause 12, but their adoption and outcome should be monitored - we
know of no practice of collating or following up. For
recommendations to be meaningful, the Bill should provide for a
system of national monitoring and sharing of information.
Timing of Inquests
Re Beresford.
Road deaths at present, unlike
other homicides, in most cases result in summary rather than
indictable charges, which require the laying of information within
six months, and the Bill does not provide for this situation.
Nor does it address (Clause 18, Subsection (2)) the requirement in
Re Beresford, namely that the Inquest must precede the summary
hearing since it is the law, as there appears to be
no means of enforcing the Rule, which is regularly
disregarded. After a meeting with RoadPeace some four years ago,
the Attorney General and Solicitor General promised that this Rule
would be observed and the CPS was informed by the Attorney
General's office at that time, yet it continues to be
disregarded.
Where there is to be a charge of murder, manslaughter or one of
the indictable traffic offences, the Bill provides for the Coroner
to be informed by the Courts and the Inquest will be adjourned and
is unlikely to be resumed. The proceedings in the Crown Court
ensure that the family have very full information about what
happened. The exception will be where the defendant pleads guilty,
in which case the inquest ought to be resumed to allow the family
to learn the full facts of the death.
In the majority of road deaths, however, only summary charges
for minor traffic offences are brought and a magistrates' court
hearing is a brief proceeding where very little detail is given, so
that the family rely on the Inquest for information. It is
therefore important that the Inquest is resumed.
It is also vital that the resumed Inquest precedes the
summary hearing. The rule in Re Beresford, reinforced in
DPP v Smith, states that the Inquest must precede the summary
hearing but if Coroners or Magistrates choose to ignore this -
either deliberately or inadvertently - there is no sanction. At
present, some Coroners ignore it if they have a backlog, or in some
cases as a matter of routine.
The new Bill must include a statement of the rule in
re Beresford and a means of enforcing it, as well as a mechanism
for exchange of information between Coroners and Magistrates as it
does in the case of Crown Court offences.
Some of the reasons for this:-
a) There should be consistency, which is not the case at
present.
b) It is illogical for the hearing in the Magistrates Court to
take place before the Inquest has decided how someone had died.
c) We have known a number of cases, where if the rule had been
followed, information obtained from the Inquest would have enabled
CPS to bring charges, or more serious charges. DPP v Smith is such
a case.
d) There is no procedure to ensure that Coroners are aware of
summary charges in connection with the death or that Magistrates
are aware that the incident was a fatal one.
e) The case of R v Simmonds held that Magistrates may take the
consequences of a summary traffic prosecution into consideration in
sentencing, but there is no mechanism to ensure that they are aware
of the consequences. Nor is there a mechanism for recording Section
3 prosecutions involving a death, with the result that there are no
statistics available for the number of Magistrate Court
prosecutions following a road death, something RoadPeace has been
pointing out for many years.
Appeals and Complaint System
The Bill offers a Complaints system and an Appeals system, which
are welcome in principle. There is, however, far too much reliance
on the Chief Coroner to address all problems internally. It is
understood that this is offered as more accessible and less
expensive for families, but the complaints received by RoadPeace
are chiefly about the excessive power and discretion of
Coroners.
As an organisation with experience of so many cases, RoadPeace
is aware of considerable inconsistency in the practices of
individual Coroners and the real distress caused by their arbitrary
use of their powers. Coroners have stopped families from seeing the
body of their loved ones with no proper reason, and in a very
recent case, where the police wanted to take a family to the scene
of a fatal collision they were told not to do so by the Coroner.
The fatality took place on a public highway and the family had
every right to go there.
Problems also arise from the difficulties of lay people in
dealing with the Coroners' system and manner of working, as well as
the difficulty of determining what is the Coroner's responsibility
and what is the Police's. The Police themselves regretted the lack
of definition of roles in the ACPO evidence to the DCA Select
Committee and the Coroners Officers Association regretted that the
Bill gave no definition or status to their role.
None of this is addressed in the Bill.
An Appeal to the Courts is needed but not restricted
to points of law.
The Coroner's discretion means that he will have legal power to
act in a way, which may be highly objectionable to an interested
party and to make decisions, which should be open to scrutiny by
the courts.
The power for the High Court under section 13 of the 1988
Coroners Act to compel a Coroner to hold an Inquest, or to order a
second Inquest and quash the original verdict must be
retained.
The Chief Coroner has, in our view, far too much power and
discretion for the system to be fair and balanced. In addition, if
the Chief Coroner was the coroner at the Inquest, it seems that
there is no appeal at all because there is no appeal
to him or from him to the Court of Appeal. The limited power to
appeal to the Court of Appeal under section 61(3) only applies to
parties to an appeal under section 60 to the Chief Coroner, not to
parties to an Inquest held by the Chief Coroner. Under section
61(5), the Chief Coroner may not hear an appeal from his own
investigation, but no alternative is offered.
Section 61(3) should be amended, for example to read 'Any party
to an investigation by the Chief Coroner' or any party to an appeal
under section 60.........
The right to appeal must apply to Chief Coroner's
investigations, too.
Complaints
Complaints may be dealt with internally initially but with an
opportunity to take it outside the Coroners system to the Lord
Chancellor as a last resort.
Coronial Advisory Council
This should include people with experience of a number of cases
not just their own. This Government have been more willing than any
other to listen to individuals and give them a role. However, the
views of organisations with experience of hundreds of cases
acquired over time are not given appropriate weight. It is to be
hoped that those, who have specialist knowledge will be given the
opportunity and not just those who may have a very personal view
and experience.
The appointment process should be open and transparent.
Coroners Officers and staff
'Coroners Service' must be defined.
Coroners' staff are mentioned in the Charter but
the Bill does not define their role or responsibilities. It is
interesting that the position 'Coroners officer' is
not mentioned. Coroners Officers must be given a role and
responsibilities defined in the Bill and Charter. Responsibility
rests with the Senior Coroner to ensure that they carry out their
duties properly and this must be stated.
Families will inevitably rely on the words of Coroner's
Officers, who may have little or no training or knowledge. On
innumerable occasions, families have been mislead about their
rights eg to view the body, to ask questions or even attend the
Inquest, as well as the facts of what happened. Until recently,
this was frequently due to a misconception that families should be
kept uninformed 'for their own good' as 'it would only upset them',
but there is now clear advice from psychologists that to exclude
families is more distressing and damaging.
Coroners Rules
There is considerable scope in the Bill to make rules and
regulations and although it is understood that there is no
intention to be less than transparent, the combined effect of Bill
and new Rules may create unforeseen problems for the bereaved, or
Coroners, or other parties. The proposed new Coroners' Rules could
be added as an appendix to the Bill, so that interested parties can
have as full a picture as possible of how the proposed new system
will work.
Coroners Recommendations
Inquests are supposed to identify lessons for preventing future
deaths, yet to date because of the failure to investigate road
deaths thoroughly, as already mentioned above, the causes are
seldom identified and recommendations made. For those rare cases
where they are, we know of no procedure or system of monitoring if
and how these recommendations are being followed, let alone of the
outcome, and the Bill does not provide for this.
Juries at Inquests
When the declared intention of the Bill is to identify lessons
for preventing future deaths, it is difficult to understand why a
jury would apparently no longer be summoned under Section 8(3) (d),
namely if "the death occurred in circumstances the continuance or
possible recurrence of which is prejudicial to the health or safety
of the public or any section of the public".
We know that this rule has been routinely breached by coroners
in respect of road deaths, to which it applies to this day,
following the abolition of automatic juries into road deaths, but
we think that juries should be at least retained for deaths at
work/in the course of work. This is both for transparency and
because of the importance and value of satisfactory and safe
working conditions and practices, which jurors would be able to
judge.
The fact that Coroners are to be more closely connected with
local authorities reinforces the need to demonstrate that there is
no bias in favour of local business interests.
Verdicts
There is great dissatisfaction with the routine "Accidental
death" verdict in road death inquests, which in most cases is
considered to be illogical, wrong and deeply offensive. A
'narrative' conclusion, for example 'killed in a road crash' would
be preferable.
There should also be recording and monitoring of verdicts in
respect of particular types of deaths and not have them all put
together, as seems to be the case at present.
Deaths Abroad
The most common sudden deaths overseas are road deaths and these
should always have a UK inquest. We believe that there should be a
right for relatives of UK citizens killed abroad to have the
inquest in the UK. This could lead to an improvement in public
safety - very important when so many UK citizens travel abroad at
all times of the year and face road danger. For instance, many
travel agencies and gap year companies fail to provide any guidance
on road travel, unlike threats from other causes, such as malaria,
HIV, robbery, etc. The certainty of an UK inquest would improve the
chances of a better investigation into the death in the country
where it occurred.
THE CHARTER
It is vital that the bereaved are given full information, at the
earliest opportunity, about their rights and organisations that can
help them. The responsibility for this must rest with the Senior
Coroner in each area. The Coronial Council should have a
responsibility to review procedures put in place to ensure that
this is done and to include it in their annual reports.
They should also monitor information handed out by the Police or
Coroners to see that it gives proper information and does not
mislead. Literature routinely given to road victims is actually
misleading over their rights. For example, it states that they may
ask questions if invited by the Coroner, when they have the right
to ask questions, whether invited or not.
One of the main aims of the Coroner Bill is to produce more
effective investigations - in our view the most effective
investigation, which would also most satisfy the bereaved families,
is an investigation that leads to a reduction in repeat occurrences
- such an evaluation should be part of the Charter.
Key practical questions that need to be addressed:
- who delivers the service to families on behalf of
the coroner?
- What will be their training and who will monitor
their performance?
- When will families have the right to see
information and will they receive copies of statements?
- What about their right to free transcripts?
Specific Points on Text
Section 4.
'Most appropriate relative' may be difficult to determine in modern
society, where divorce is so common. Both parents, for example,
must have an equal right. A process/hierarchy / definition is
needed.
Section 8
Offer to explain by Coroner or his staff. Families need to hear
from the Coroner himself if they are only to be given
an explanation about the investigation. But, as we said above,
road deaths should always be followed by an inquest in view of the
great continuing threat of road danger and the great potential of
improved inquests in preventing similar deaths from
occurring.
Section 24
There is no mention of requesting permission to retain organs or
tissue in the first place?
Section 26 Deaths abroad
The most common sudden deaths overseas are road deaths and these
should always have a UK inquest. See also above on this.
Section 28
Families cannot be expected to be proactive at such a time in
notifying Coroners of their wish to be consulted. This is similar
to the present situation where families can be represented at the
post mortem if they inform the Coroner but the right has no value
as no one knows that they have it. Families must be informed of
their rights.
Summary
A. Many of the problems over unsatisfactory Inquests
are the result of Coroners having too much discretion and too
little accountability. The Bill will not alter this.
B. Coroners holding inquests into road deaths should
be required to have training in road traffic regulations and road
safety issues
C. The Appeals System should be strengthened with an
appeal to the courts against Coroners' decisions, whether on a
point of law or otherwise.
D. The complaints system must have the possibility of
a complaint to the Lord Chancellor as a last resort.
E. Recommendations by Coroners should be monitored
for their application and effectiveness.
F. There should be a right for relatives of UK
citizens killed abroad to have an inquest in the UK.
G. Juries should be retained for deaths at work/ in
the course of work.
H. Verdicts should be accurate and meaningful
I. There must be a clear definition of the role and
responsibility of the Coroners Officer, as well as qualifications
and training requirements.
J. Coroners must have a responsibility to provide
information to the bereaved on specialist organisations offering
help and this must be monitored.
Yours sincerely,
Brigitte Chaudhry MBE
Founder & President
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