Most coroners are receiving an appropriate response, but that might not be the whole story
Where, after an inquest, a coroner believes that it might prevent other deaths, he can write to an appropriate authority, reporting the evidence he has heard. Any such report is sent under rule 43 of the Coroners Rules, and the coroner must copy it, and any response, to the Lord Chancellor. An analysis of those reports has just been published. Its contents might be seen as reassuring, but one or two significant concerns remain.
Statistics
In the six months from 1 April 2009, there were 164 inquests in which rule 43 reports were issued. A third of these concerned ‘hospital deaths’, and nearly a fifth, ‘road deaths’. Eight per cent, meanwhile, concerned work- or health and safety-related deaths, and a similar proportion, mental health-related deaths. The new analysis contains nothing, however, to indicate how these classifications were reached: was it according to the place or means of death or to its immediate cause, or to either the content or the recipient of the rule 43 letter? That deficiency is significant, for it might render the statistics unreliable. If, for example, someone were to die in front of a train, having absconded from the hospital where she had been receiving compulsory psychiatric treatment, would any rule 43 letter be classified as mental health-related; or as concerning a hospital death or one in custody; or as ‘railway-related’? This concern is compounded by the brief summaries provided in the new analysis, which suggest that some ‘deaths in custody’ actually raised distinct mental health concerns. Only one death, furthermore, was classified as ‘railway related’.
Wider implications
The new analysis provides details of some rule 43 reports that might have wider implications. In the ‘drug- and medication-related’ category, these include the death of a man who, believing it to be ecstasy, swallowed a substance used for de-worming animals. The coroner wrote to the Home Secretary and subsequently, the substance was brought within the Misuse of Drugs Act 1971. The analysis also mentions the unfortunate church warden, who died when he fell from his own bell-tower. After hearing that the man had not been wearing a safety harness, the Coroner wrote to the Archbishops’ Council, inviting it to take appropriate action. The Council, however, replied that as each parochial church council is autonomous, there was little it could do. It is only in this part of the analysis that we get a flavour of the responses coroners receive, but it is clear that recipients don’t always accept the content or the implication of rule 43 reports.
Coroners
In the period in question, rule 43 reports were issued in 61 of the 114 coroner districts. (The number of coroners that made no reports – 53 - is slightly down on the previous period’s figure). The most reports again came from the Greater Manchester South district, where ten reports compare with 18 in the earlier (and longer) period, but also from Brighton and Hove, which could only previously claim two reports. The City of Manchester, however, and Cardiff and the Vale of Glamorgan, are two coronial districts in which the number of reports fell considerably, to four and six respectively, from 12 and 15. The new analysis acknowledges that the highest-reporting districts are not representative of the whole. When they are discounted, the average number of rule 43 reports in the relevant six-month period is 1.06 per coroner district, or 1.98 per district making such a report.
Responses
Rule 43 now also requires recipients to respond to reports, and to do so within a specified period. On the face of it, the figures in the new analysis are encouraging, for they suggest that where a report was issued, no response was outstanding that was due within the same reporting period. That might not, however, be the whole story.
The format of the analysis allows to be listed as outstanding only responses to reports issued within the current reporting period. It provides no information about responses listed as outstanding in last report, and there were more than a hundred of those. Before April 2009, for example, the Manchester City coroner sent a rule 43 report to an electronics company. We know that the report concerned the maintenance of ‘cherry-picker’ machines and a response was outstanding at the end of the reporting period. What we cannot tell, however, is when, or even whether, that response was received.
Where organisations receive coroners’ reports, it seems most are complying with the amended rules. But they aren’t receiving them all that often. The official analysis suggests that on average, fewer than three rule 43 reports are made in each coroner district per year. And the limited scope of that analysis can itself minimise the embarrassment caused to those who persistently fail to respond.
Showing posts with label to prevent other deaths. Show all posts
Showing posts with label to prevent other deaths. Show all posts
Wednesday, 21 April 2010
Thursday, 18 September 2008
There is a already a duty to respond to the coroner
HM Assistant Deputy Coroner for Inner West London
As yet, we don’t have a new Coroners Act. What we do have is the promise of a Bill and some idea of what it might contain. (Ministry of Justice, 2008a, Coroners Bill – Changes made resulting from consultation) Amongst other things, there will a duty to respond to a coroner’s concerns. In the meantime, the existing rules have been strengthened to much the same effect.
Eventual powers
According to the document in which the Government makes its promise, a coroner who believes that action should be taken to prevent the recurrence of fatalities similar to one he or she has investigated will be able to report the matter to anyone with the power to take such action. (Ministry of Justice, 2008a, op cit, page 3) This reflects proposals in the draft Coroners Bill and support from within Parliament itself. (Secretary of State for Constitutional Affairs, 2006, Draft Coroners Bill, Cm 6849, clause 12(2); House of Commons Constitutional Affairs Committee, 2006, Reform of the coroners’ system and death certification, Eighth Report of Session 2005-06, HC 902, paragraphs 201-211)
Although this resembles rule 43 of the Coroners Rules 1984, it differs from that provision because it would [1] both allow a coroner to report the matter to the new Chief Coroner and compel any organisation that received such a report to respond; and [2] enable the Chief Coroner to monitor reports and responses, and to summarise them in his or her annual report to the Lord Chancellor. (Ministry of Justice, 2008a, op cit, page 3) In fact, the difference is not as great as it might have been. That is because rule 43 has recently been amended, so that reports may be sent, and responses required, even before any new Act comes into force.
Interim powers
The amendments, which were made by The Coroners (Amendment) Rules 2008, came into effect on 17 July 2008. (SI 2008 No 1652)
Making a report
Where, on the basis of evidence heard at an inquest, he or she believes action should be taken, the amendment allows a coroner to make a report to prevent not just similar fatalities, but “other deaths”. (Rule 43(1)(b)) This represents a significant change, because, we are told, it “will allow the coroner to report issues that may be peripheral to the current case but nevertheless prevent death(s) in the future.” (Ministry of Justice, 2008b, Guidance for coroners on changes to Rule 43: Coroner reports to prevent future deaths, paragraphs 2.1 & 2.2) This change should not, however, lengthen inquests or broaden their scope. (Ibid, paragraph 2.4)
The amended rule and the guidance upon it each say, somewhat confusingly, both that a coroner who intends to make a rule 43 report must announce that intention before the end of the inquest and that a failure to do so will not prevent such a report being made. (Rule 43(3); Ministry of Justice, 2008b, op cit, paragraph 2.5) One wonders what the word ‘must’ is intended to mean here.
The content of a report
The amended rule does not say what information must be included in any new-style report, for this will be in the discretion of the coroner and depend upon the circumstances of each case. Coroners should, however, tell those to whom they send a report that a response must be provided within 56 days, and that it might be released and published. (Ministry of Justice, 2008b, op cit, paragraph 2.7)
Sharing a report
Subject to any representations (as to which see below), a rule 43 report must be copied to anyone whom the coroner has recognised as a properly interested person and to the Lord Chancellor, and may be sent to “any person who the coroner believes may find it useful or of interest”. (Rule 43(4)) This last is a very wide provision. It may include “regulatory bodies or organisations with an interest in the subject mater of the report”. (Ministry of Justice, 2008b, op cit, paragraph 3.4)
Having received a rule 43 report, the Lord Chancellor may publish it and/or copy it “to any person [whom he] believes may find it useful or of interest” (provided that person hasn’t already received the report from the coroner). (Rule 43(5)(b)) The Lord Chancellor has been given this power so that “issues which were subject to reports in one coroner district which may have relevance to other coroner districts [may be] identified and disseminated nationally”. This should, in turn, allow “emerging trends to be identified and lessons that could be applied at a national level to be highlighted.” (Ministry of Justice, 2008b, op cit, paragraphs 1.3-1.7)
Responding to a report
No one that receives a rule 43 report is obliged to act upon it. They will, however, have to respond to it, and ordinarily, to do so within 56 days. The response must set out any action that has been taken or proposed, and if there is no such action, it must explain why. (Rule 43A(1))
A coroner may extend the 56-day period for a response, either before or after it has expired (Rule 43B) and for whatever further period he or she considers appropriate. The guidance says that an extension might be appropriate where, for example, the report: [1] “is sent to the incorrect person or division in an organisation, especially a large organisation[,] and is not promptly received”; or [2] “requires significant policy work to be undertaken before a response may be sent”. (Ministry of Justice, 2008b, op cit, paragraph 4.6)
Although the amendment does not impose a sanction, any failure to respond to a rule 43 letter should be followed up by the coroner, and “Where a response remains outstanding after reasonable attempts, then the coroner may inform the Lord Chancellor.” If there is a continuing failure to respond, the latter may mention it in any document he publishes about rule 43 reports. (Ibid, paragraph 4.8)
Making representations
An organisation that does not wish its rule 43 response to be shared with others may make representations to the coroner in that regard. This might be because: [1] “the response contains confidential or classified information”; [2] “the release of the response might have a prejudicial effect on ongoing or upcoming legal proceedings”; or [3] “regulatory enforcement action is being carried out under confidentiality rules.” (Ibid, paragraph 5.7)
Any representations must be in writing, (Rule 43A(4)) and it will be up to the coroner to decide whether to accept them and, if so, how to respond. (Ministry of Justice, 2008b, op cit, paragraph 5.6)
Even if he or she accedes to any representations, a coroner must still prepare a summary of the response for release and publication. (Rule 43A(6) & (7)) It is this summary that will be copied to interested parties and might be shared with others. Although the Lord Chancellor may not overrule a coroner’s decision in this regard, he must be sent not only the summary, but also the original rule 43 report. (Ministry of Justice, 2008b, op cit, paragraphs 5.9 & 5.10) He may only, however, publish the summary. (Rule 43A(3)(a) & (7); Ministry of Justice, 2008b, op cit, paragraph 6.2)
Comment
Although, in an appropriate case, the coroner must be told what is to be done to prevent further deaths, he cannot require a particular course of action to be taken. Rule 43 has certainly been strengthened, but the obligations it imposes need not be difficult to meet.
Eventual powers
According to the document in which the Government makes its promise, a coroner who believes that action should be taken to prevent the recurrence of fatalities similar to one he or she has investigated will be able to report the matter to anyone with the power to take such action. (Ministry of Justice, 2008a, op cit, page 3) This reflects proposals in the draft Coroners Bill and support from within Parliament itself. (Secretary of State for Constitutional Affairs, 2006, Draft Coroners Bill, Cm 6849, clause 12(2); House of Commons Constitutional Affairs Committee, 2006, Reform of the coroners’ system and death certification, Eighth Report of Session 2005-06, HC 902, paragraphs 201-211)
Although this resembles rule 43 of the Coroners Rules 1984, it differs from that provision because it would [1] both allow a coroner to report the matter to the new Chief Coroner and compel any organisation that received such a report to respond; and [2] enable the Chief Coroner to monitor reports and responses, and to summarise them in his or her annual report to the Lord Chancellor. (Ministry of Justice, 2008a, op cit, page 3) In fact, the difference is not as great as it might have been. That is because rule 43 has recently been amended, so that reports may be sent, and responses required, even before any new Act comes into force.
Interim powers
The amendments, which were made by The Coroners (Amendment) Rules 2008, came into effect on 17 July 2008. (SI 2008 No 1652)
Making a report
Where, on the basis of evidence heard at an inquest, he or she believes action should be taken, the amendment allows a coroner to make a report to prevent not just similar fatalities, but “other deaths”. (Rule 43(1)(b)) This represents a significant change, because, we are told, it “will allow the coroner to report issues that may be peripheral to the current case but nevertheless prevent death(s) in the future.” (Ministry of Justice, 2008b, Guidance for coroners on changes to Rule 43: Coroner reports to prevent future deaths, paragraphs 2.1 & 2.2) This change should not, however, lengthen inquests or broaden their scope. (Ibid, paragraph 2.4)
The amended rule and the guidance upon it each say, somewhat confusingly, both that a coroner who intends to make a rule 43 report must announce that intention before the end of the inquest and that a failure to do so will not prevent such a report being made. (Rule 43(3); Ministry of Justice, 2008b, op cit, paragraph 2.5) One wonders what the word ‘must’ is intended to mean here.
The content of a report
The amended rule does not say what information must be included in any new-style report, for this will be in the discretion of the coroner and depend upon the circumstances of each case. Coroners should, however, tell those to whom they send a report that a response must be provided within 56 days, and that it might be released and published. (Ministry of Justice, 2008b, op cit, paragraph 2.7)
Sharing a report
Subject to any representations (as to which see below), a rule 43 report must be copied to anyone whom the coroner has recognised as a properly interested person and to the Lord Chancellor, and may be sent to “any person who the coroner believes may find it useful or of interest”. (Rule 43(4)) This last is a very wide provision. It may include “regulatory bodies or organisations with an interest in the subject mater of the report”. (Ministry of Justice, 2008b, op cit, paragraph 3.4)
Having received a rule 43 report, the Lord Chancellor may publish it and/or copy it “to any person [whom he] believes may find it useful or of interest” (provided that person hasn’t already received the report from the coroner). (Rule 43(5)(b)) The Lord Chancellor has been given this power so that “issues which were subject to reports in one coroner district which may have relevance to other coroner districts [may be] identified and disseminated nationally”. This should, in turn, allow “emerging trends to be identified and lessons that could be applied at a national level to be highlighted.” (Ministry of Justice, 2008b, op cit, paragraphs 1.3-1.7)
Responding to a report
No one that receives a rule 43 report is obliged to act upon it. They will, however, have to respond to it, and ordinarily, to do so within 56 days. The response must set out any action that has been taken or proposed, and if there is no such action, it must explain why. (Rule 43A(1))
A coroner may extend the 56-day period for a response, either before or after it has expired (Rule 43B) and for whatever further period he or she considers appropriate. The guidance says that an extension might be appropriate where, for example, the report: [1] “is sent to the incorrect person or division in an organisation, especially a large organisation[,] and is not promptly received”; or [2] “requires significant policy work to be undertaken before a response may be sent”. (Ministry of Justice, 2008b, op cit, paragraph 4.6)
Although the amendment does not impose a sanction, any failure to respond to a rule 43 letter should be followed up by the coroner, and “Where a response remains outstanding after reasonable attempts, then the coroner may inform the Lord Chancellor.” If there is a continuing failure to respond, the latter may mention it in any document he publishes about rule 43 reports. (Ibid, paragraph 4.8)
Making representations
An organisation that does not wish its rule 43 response to be shared with others may make representations to the coroner in that regard. This might be because: [1] “the response contains confidential or classified information”; [2] “the release of the response might have a prejudicial effect on ongoing or upcoming legal proceedings”; or [3] “regulatory enforcement action is being carried out under confidentiality rules.” (Ibid, paragraph 5.7)
Any representations must be in writing, (Rule 43A(4)) and it will be up to the coroner to decide whether to accept them and, if so, how to respond. (Ministry of Justice, 2008b, op cit, paragraph 5.6)
Even if he or she accedes to any representations, a coroner must still prepare a summary of the response for release and publication. (Rule 43A(6) & (7)) It is this summary that will be copied to interested parties and might be shared with others. Although the Lord Chancellor may not overrule a coroner’s decision in this regard, he must be sent not only the summary, but also the original rule 43 report. (Ministry of Justice, 2008b, op cit, paragraphs 5.9 & 5.10) He may only, however, publish the summary. (Rule 43A(3)(a) & (7); Ministry of Justice, 2008b, op cit, paragraph 6.2)
Comment
Although, in an appropriate case, the coroner must be told what is to be done to prevent further deaths, he cannot require a particular course of action to be taken. Rule 43 has certainly been strengthened, but the obligations it imposes need not be difficult to meet.
