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Coroners (Recording of Suicides) Debate


27th April 2011

Jonathan Djanogly responds to a back bench MP's debate on the recording of suicides by Coroners.

The Parliamentary Under-Secretary of State for Justice (Mr Jonathan Djanogly): Thank you, Mr Robertson, and good afternoon.

I congratulate the hon. Member for Bridgend (Mrs Moon) on securing this debate. I am certainly aware that coroners' use of narrative verdicts at inquests is a subject in which she has taken a keen interest. Indeed, as she mentioned, we have met before to discuss this topic, in her capacity as chairman of the all-party group for suicide and self-harm prevention. I welcome the opportunity that this debate provides to reaffirm the Government's commitment to improving the coroner system for all those who come into contact with it.

The hon. Lady set out the statistics about the number of suicides in the UK. I know that last October she held an Adjournment debate in the main Chamber on suicide, discussing the subject more broadly, when the Minister of State, Department of Health, my hon. Friend the Member for Sutton and Cheam (Paul Burstow), responded and discussed the Government's new suicide prevention strategy.

I want to begin today by setting out the background to the use of narrative verdicts by coroners. Coroners are independent judicial office holders, who are appointed and paid for by local authorities. Except for a few technical areas, the Ministry of Justice has no operational responsibility for coroners and is responsible for coroner law and policy only.

Coroners are required by law to inquire into violent, unnatural or sudden deaths of unknown cause, and into deaths that occur in prison or police custody. When investigating a death, it is the coroner's duty to establish, first, who the deceased was, and secondly, how, when and where they died. At the close of an inquest, coroners are required to return a verdict covering those questions and to certify the verdict in an inquisition.

A suggested list of verdicts that may be returned, commonly referred to as "short-form" verdicts, is contained in the Coroners Rules 1984. These are: natural causes; accident or misadventure; suicide; unlawful killing; lawful killing; industrial disease, or open verdict. An open verdict, of course, is where there is insufficient evidence for any other verdict. I should point out that the standard of proof that needs to be satisfied if the coroner is to return a verdict of suicide is the criminal standard, that is "beyond reasonable doubt". Therefore, suicide can never be presumed and a suicide verdict cannot be based on ambiguous evidence. A verdict of suicide can only be returned if the coroner is satisfied that the death occurred as a result of a deliberate act by the deceased and that in doing so they intended that the consequence would be their own death.

It is also worth bearing it in mind that the list of verdicts provided by the Coroners Rules 1984 is not mandatory for coroners to use in all cases. Indeed, the list is only supplied as a suggestion. That is particularly important as inquests are detailed fact-finding exercises that involve the careful discovery and interrogation of facts. It follows that it is sometimes difficult to achieve a tidy reduction of a lengthy consideration of facts into a one-word or two-word verdict.

Before 2004, coroners sometimes found cause to return verdicts that were narrative based. Those were used in cases in which it was not possible to return a short-form verdict because of a series of findings that was not conducive to a single, short-form verdict. That approach was approved in case law. However, in 2004, the House of Lords handed down its judgment in Middleton v. Coroner for the Western District of Somerset.

Inquests are the principal way in which we discharge our obligations under article 2 of the European convention on human rights and the judgment in Middleton held that short-form verdicts might not always be adequate to satisfy the requirements of that article. The House of Lords went on to clarify that, in some cases, coroners might need to interpret more broadly the requirements of the Coroners Act 1988 and determine not simply "how", meaning "by what means", a person came by their death, but rather "how", meaning "by what means and in what circumstances." In the light of the Middleton judgment, therefore, coroners are at times bound by case law to return a narrative verdict. That is the reason for such a substantial increase in the use of narrative verdicts since 2004.

I realise, however, that hon. Lady's primary concern is not to suggest that there should be any limit placed on coroners' discretion to return narrative verdicts. Such a suggestion would impede their judicial independence and would be wholly inappropriate. Additionally, I would not like to suggest that the hon. Lady is concerned about the standard of proof that needs to be applied when considering the verdict of suicide.

It is clearly inappropriate to suggest that coroners apply the civil standard of proof to a verdict as serious as suicide. Indeed, it is understandable that coroners might return narrative verdicts for cases where suicide is suspected but cannot be proved. That might be because the deceased was intoxicated at the time of death, or was suffering from depression, and it cannot be proved that they were fully aware of their actions. A coroner would have to consider such issues in the hon. Lady's example of death by hanging in a cell. It is fair to say, therefore, that, arguably, such deaths include some suicidal elements, even if they cannot be deemed as "suicide" at the close of an inquest.

A key concern of the hon. Lady, as I see it, is the effect that the increased use of narrative verdicts might have on the accuracy of mortality statistics, in particular in deaths that could involve some elements of suicidal intent. That is because, it is argued, some narrative verdicts do not give statisticians enough clear information to indicate whether the event leading to the death was carried out intentionally or accidentally. Statisticians are, understandably, not permitted ever to infer what happened and must use the information provided by the coroner. However, if they cannot derive any intention from the action of the deceased, they must record the death as an accident. I appreciate that that might lead to inaccuracies in national mortality statistics, the associated risk being that local authorities might not be able identify, procure and provide adequate preventive measures against, for example, suicidal intent.

The hon. Lady went on to say that some coroners are seen as a law unto themselves. I must repeat that they are independent judicial appointments and, as such, they cannot be forced into doing the same thing. It is important to realise that a chief coroner would not have had any powers of coercion in any event. To address such issues, however, I will outline the work on the issue that is currently underway in my Department, in conjunction with the Department of Health, the Office for National Statistics and the Coroners' Society of England and Wales.

My Department has issued guidance to coroners on narrative verdicts in the past. We are currently considering revising that guidance, with a view to highlighting some of the concerns discussed in the debate and elsewhere. In addition, my officials will consider exploring whether any further training can be given to coroners on the use of narrative verdicts. I understand that such training has been given in recent years, but we can certainly look to repeat it. We have no plan for private hearings for suicide inquests-that was a new idea, which I will look at, and I will come back to the hon. Lady on her suggestion.

The Government plan to launch shortly for formal consultation a new strategy for suicide prevention. The plan builds on some of the successful measures of the previous suicide prevention strategy and takes into account the changing demographics within our society and the current economic climate. Development of the new strategy has been supported by leading experts in suicide prevention, including members of the national suicide prevention strategy advisory group under the chairmanship of Professor Louis Appleby. The strategy will set out its high-level objective to deliver a reduced rate of suicide among the general population and improved support to those bereaved or affected by suicide, through a series of shared areas for action and working with other key partners in the public, private and voluntary sectors.

In relation to that, the Office for National Statistics published the latest edition of "Health Statistics Quarterly" in February, which included a short paper, "Narrative verdicts and their impact on mortality statistics in England and Wales". It is interesting to note that, while the paper confirmed that the use of narrative verdicts has increased in recent years, it concluded that that increase has not had a detrimental effect on the Office for National Statistics' mortality statistics. At the same time, however, the paper also cautioned that a continued rise in the use of narrative verdicts could start to affect the accuracy of those statistics.

As I explained when I met the hon. Lady, the Office for National Statistics is currently reviewing its current coding practices, in conjunction with the Coroners' Society, and I will take an interest in that matter. The work has been ongoing and will also feed into any work that might be taken forward on the possible implementation of part 1 of the Coroners and Justice Act 2009. In particular, the Ministry of Justice will look to liaise with the Office for National Statistics on the development of any new coroners' rules and regulations.

I hope that the hon. Lady is therefore somewhat reassured that such an important matter is receiving proper consideration. Finally, I caution that, as the work is taken forward, we must be careful not to impinge on coroners' judicial independence, or to do anything that might prevent them from following established case law.

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