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Final
Report
In
July 2001, Home Office minister Beverley Hughes MP
appointed a commitee to review and report on death
certification and the Coroner Services in England,
Wales and Northern Ireland.
To see the terms of Reference and the composition
of the Committee, Click
Here
Consultation
Report
Last year. the commitee published a consultation document.
It proposed, inter alia, that there would no
longer be an automatic right for families to have
an inquest into work-related deaths. To see what the
consultation document said about work-related deaths,
Click Here
To download the whole document, Click
Here
To see CCA’s preliminary views on the Coroner's
Review consultation document, click
here
To
read a briefing on the current law and procedures
of inquests, Click
Here
|
To
read about forthcoming Inquests, Click
Here |
Final Report: Index of Issues
This briefing sets out the key points that have been
recommended by the Coroners Review Team with particular
reference to work-related deaths.
The report is 300 pages long so this briefing is not
comprehensive. However it does set out the main points.
If you would like to download the full report, Click
Here
Administrative
Inqury or Public Judicial Inquest?
The Report proposes that deaths - which are reportable
to the coroner - will be subject to either an an 'administrative
inquiry' or a 'public judicial inquest'. The purpose
of both these types of inquiry will be similar (see
below) – though the mechanism of the inquiry
will be significantly different
Para 49 of Chapter 7 sets out the circumstances where
a public judicial inquest - rather than a private
administrative inquiry - will be held:
| Circumstances
in which Public Judicial Inquests hould be held |
| 1 |
any
death of a person held in prison, police custody,
or a bail or asylum hostel, or of a person compulsorily
detained under mental health legislation,unless
the Statutory Medical Assessor certifies that
the death was beyond reasonable doubt caused by
natural disease |
| 2 |
any
traumatic death occurring apparently or possibly
as a consequence of police or other law and order
operations |
| 3 |
any
traumatic work-place death in which industrial
process or activity is implicated (emphasis
added) |
| 4 |
any
traumatic deaths occurring in public or commercial
transport vehicles or vessels, or in public
ervice or commercial aircraft (emphasis
added)
|
| 5 |
any
death of a child which the coroner or Statutory
Medical Assessor after consulting relevant child
protection interests unable to certify as being
beyond reasonable doubt from natural disease without
neglect or ill-treatment |
| 6 |
any
death from elf-harm which the coroner is unable
to certify beyond reasonable doubt as not involving
lack of care or the active involvement of any
third party in procuring the death or which does
not involve a pattern of similar circumstances
requiring public scrutiny |
| 7 |
any
category of death reported for investigation where
there is sufficient uncertainty or conflict of
evidence over the cause or circumstances of the
death to justify the use of a forensic judicial
process |
| 8 |
where
there is the likelihood that a public judicial
inquest will uncover important systems defects
or general risks not already known about (emphasis
added) |
| 9 |
any
other death in which the coroner after consulting
with others, including the family considers that
there is a public interest which is best served
by holding a public inquest (emphasis added) |
At
present all deaths reportable to either the Health
and Safety Executive, Local Authority or other Government
bodies are subject to a public inquest in front of
a jury. (To read about what is being proposed about
juries, see below).
It is now being proposed that there will only be public
judicial inquests into "any traumatic work-place
death in which industrial process or activity is implicated"
or "any traumatic deaths occurring in
public or commercial transport vehicles or vessels,
or in public service or commercial aircraft".
It is not clear what is meant by 'work-place' deaths
and whether the death of a member of the public who
died from work-related activities, outside of the
immediate vicinity of the 'work-place' would be subject
to a public inquest under the new criteria.
Deaths
from industrial disease do not fall into any of the
above categories and so there would not have a 'public
judicial inquest'. In relation to these, the report
states at para 59 of Chapter 7 that:
| 59 |
Similarly,deaths
from asbestosis and other occupational diseases
would all be the subject of a proper and family-accessible
investigation. There would, however, be a public
inquest only when there was a conflict or uncertainty
of evidence which justified a judicial examination.We
distinguish this category of deaths from traumatic
work place deaths which we consider should be
in the category of mandatory inquests.This is
because the occupational diseases involved are
usually of long-standing, the public policy
of how to deal with them is settled, and they
relate to industrial practices which have long
since been outlawed.
|
Work-Related
Road Traffic Deaths would also not be subject to public
inquests.
The
report does empahsise the discretion the coroner would
have in deciding to hold an inquest into a death,
and the right of a bereaved family to appeal against
a decision on the part of the coroner not to hold
an inquest. Paras 54 and 55 of Chapter 7 state:
| 54 |
The
coroner would thus have discretion to hold an
inquest whenever he thought the public interest
would be served by doing so.This discretion might
be used where there was a need to allay suspicion
or where a death was prompting local or national
controversy in circumstances where a non-inquest
investigation would not provide an adequate resolution. |
| 55 |
Families
wishing for a public open inquest for a death
not in one of the mandatory categories would be
able to appeal against the decision not to hold
a public inquest on the grounds that an inquest
was essential to safeguard the public interest
or public safety,or to adjudicate on conflicting
evidence. |
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Purpose
of investigations by Coroners.
It is proposed that the purpose and scope of investigations
by coroners - whether administrative inquiries
or public judicial inquest - will be extended beyond
simply determining (a) who the deceased was and (b)
how, when and where the deceased came by his death
- which is the current situation.
Para 37 of Chapter 7 states:
| We
recommend that the investigation should seek to
establish as many of the following as are necessary
in the circumstances: |
| (a) |
the
identity of the person who has died; |
| (b) |
the
time and place of death; |
| (c) |
the
medical cause of death; |
| (d) |
the
immediate circumstances in which the death was
discovered, including location, position of
the body, by whom and when it was discovered;
|
| (e) |
events
immediately leading up to the death, in particular
the movements and activities of the dead person,
and the movements or roles of others where these
might be relevant to the death whether because
of the possible involvement in the death of one
or more third parties or because of their responsibility
for ensuring so far as possible the safety of
the dead person; (emphasis added) |
| (f) |
identify
any aspects of the dead person’s circumstances,
situation or history possibly relevant to the
death, including medical history, and/or lifestyle
or behaviour; |
| (g) |
identify
any management or regulatory systems relevant
to the protection of the dead person or others
facing comparable risks, and information on how
these bore or failed to bear on preventing the
death; (emphasis added) |
| (h) |
identify
the role or roles of any emergency services that
were or might have been summoned to the death. |
This
is an important expansion of the subject areas that
coroners will specifically be inquiring into and should
have a significant impact upon the investigations
undertaken by the coroner into work-related deaths
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Scope
of the Inquest
In relation to the scope of the inquest, Chapter 8
of the Report sets out the level of inquiry that can
be made into these issues.
| 53 |
The
scope of the inquest has traditionally been narrowly
set, concentrating on the immediate rather than
the underlying cause,and the phrase “how
the deceased came by his death” has not generally
been held to include wider concepts of causation.
In recent years the higher courts have tended
to widen somewhat the scope of the examination
to allow for relevant systemic issues to be considered.
At present there are also unresolved issues about
how far the inquest procedure in its present form
may in some types of case comply with the obligation
on the State to investigate deaths implied in
Article 2 of the European Convention on Human
Rights, though the coroner ’s inquest is
not the only process through which that obligation
can be met. |
| 54 |
It
is clear that there is some discrepancy between
coroners in their approach to issues of scope,
and that very tight definitions of scope are a
factor tending to diminish public confidence in
the inquest as a means of inquiry, particularly
in complex or contentious cases. |
| 55 |
In
the last chapter we recommended that the bounds
of any coroner investigation should so far as
practicable and necessary establish the identity
of the person who has died, the time and place
of death and its medical cause. Other issues
to be covered should be the immediate circumstances
in which the death was discovered, the events
immediately leading up to it and the actions
of any individuals involved in those events,
any relevant aspect of the dead person’s
circumstances, situation, or history, any management
or regulatory systems relevant to the protection
of the dead person or others facing comparable
risks, and the role of any emergency services
that were or might have been summoned to the
situation.This implies a wider scope than has
been traditional, though in more recent years
many inquests have sensibly covered this sort
of ground.
|
| 56 |
We
emphasise that these are the questions to be addressed
so far as it is necessary and sensible in the
individual case to address them to find the cause
and circumstances of the death and whether it
might have been preventable. In many cases, whether
dealt with by an investigation or a public inquest,
the issues that need addressing will be relatively
narrow. But in cases where wider issues arise
it is sensible that they should be included within
the parameters of inquiry. |
| 57 |
Detailed
decisions on scope should be made by the coroner
or judge taking the inquest, after giving the
family and other participants an opportunity to
express their views. These judicial decisions
would be subject to appeal within the new coronial
jurisdictions that we recommend. They would not,
as now, need to go to judicial review. (emphasis
added) |
| 58 |
The
“sequence of causality” examined in
the inquest should be carefully limited to the
circumstances and timescales necessary for the
purposes of the investigation and inquest as we
have defined them. Longer-term and speculative
issues should not be within the scope. For example,
in a case where someone with a history of mental
illness had died in prison apparently through
his or her own actions, we would regard the past
medical history as within the scope in assessing
the cause of the death and the role of the prison
authorities (if they were or should have been
aware of it), and the treatment given in the prison
would be within the scope. But we would regard
as outside the scope an examination of the suitability
or otherwise of the health treatment of the individual
at an earlier stage of life, or general policy
issues about the scale or criteria on which mentally
ill people are found in prisons. |
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Disclsosure
of Evidence prior to an inquest
One of the issues of most concern to bereaved families
is that they have no right to disclosure of evidence
prior to an inquest. This makes it difficult for them
and their representatives to prepare for an inquest.
The
Report recomends that there should be a presumptoin
in favour of disclosure of documents. The report states:
| 22 |
One
of the examples most often given by lawyers and
families of inconsistencies in coroners’
practices is over disclosure of documents. Before
any inquest starts the coroner will normally have
collected various documents and reports. There
will usually be an autopsy report, for example.In
a hospital death there will also be reports from
the doctors. If the death has occurred in prison
the coroner will normally have the prison management
report.There are likely to be witness statements
from any private individuals who witnessed the
death or have evidence to give on its circumstances.
There may well be police investigation reports
on road deaths, and Health and Safety reports
on workplace deaths.
|
| 23 |
There
are no rules requiring any written evidence to
be disclosed in advance to families or other interests
participating in the inquest, even though they
will normally be able to question witnesses who
provided such reports. Such questioning is of
course limited in its usefulness when the written
evidence of the witnesses is not available. The
Home Office does, however,voluntarily provide
advance copies of the prison management report
to the family and other participants in advance
of inquests into prison deaths.Some coroners do
provide advance disclosure of some documents.
Others generally do not. |
| 24 |
The
absence of any advance disclosure provision
in the Rules no doubt reflects the traditional
view that the inquest is a fact-finding inquiry
and that its processes are designed to enable
the coroner to achieve that function, and that
disclosure practices found in adversarial litigation
are not suitable to the inquest.
|
| 25 |
Nevertheless
families who find that at the inquest they see
for the first time complex and important reports
which have been in the hands of for example the
hospital and its lawyers for a long time in advance
of the proceedings are bound to feel that the
cards are stacked against them. |
| 26 |
It
is important that documents disclosed in advance
of inquests should not be made public by anyone
who receives them,or passed on to anyone else.This
will include the media and in cases where there
might be a future trial extremely careful handling
will be necessary.Nor should there be any approach
to their authors or to any people named in them. |
The
report makes the following recomendations:
| 27 |
We
recommend that for every inquest the coroner hould
be required to keep a schedule of all the documents
held by him. |
| 28 |
We
recommend that the new Rules Committee should
devise a set of rules on disclosure which reflect
a presumption in its favour but contain such afeguards
or limitations as can be shown to be necessary
for the effectiveness of other essential investigations
and legal processes such as prosecutions.The
rules should contain safeguards against improper
use of the material and should prohibit any approaches
to its authors or people named in it. (emphasis
added) |
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Which
inquests will have Juries
At present all work-related deaths which at present
have a right to an inquest (see above) also have a
right to have an inquest in front of a jury:
The Report decided to reduce the number of inquests
with a jury.
| 48 |
One
school of thought, represented by some but not
all of the coroners, lawyers and judges with whom
we have discussed the issue, is that the fuller
reasoned judgments to be expected from the new
approach would be a better substitute for a summary
jury verdict and that juries would not fit in
easily to the process of drafting the longer more
complex conclusions. [See below] On this
view, juries would no longer be involved in inquests. |
| 49 |
The
contrary view is taken by some families who have
been through prison or workplace death inquests,for
example. They see the jury as an important citizen
presence, counterbalancing the case weariness
that they think can incline the coroner service
towards the big established public service and
corporate interests. |
| 50 |
This
view is supported by human rights legal interests
who also point to the potential of juries to bring
a dimension of gender balance and racial diversity
to inquest proceedings. |
The
report recomended that most work-related deaths will
not be be held in front of a jury: the only work-related
death where there will be a jury sitting is whe where
the employer or other responsible organisation is
a 'state body', which raise 'Right to Life' issues
under Article 2 of the European Convention on Human
Rights .
The report stated:
| 51 |
We
think it would be a big step to remove juries
altogether from the inquest system, and probably
an imprudent one. We regard their participation
as important in cases where someone compulsorily
in the care of the state has died in unclear circumstances,or
where a death may have been caused by agents of
the state.We do not consider that with fuller
and more reasoned findings as the outcome of inquests
juries are essential in other cases. |
| 52 |
We
therefore recommend that juries should be empanelled
in such cases and in others which fall within
Article 2 of the European Convention on Human
Rights but not in other cases. |
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Role
of the Juries
The report recomends the following role for a jury:
| 53 |
| 1 |
they
hould be able to ask questions of witnesses,ubject
to the coroner ’s rulings on questions
of relevance; |
| 2 |
they
hould choose the classification of the death,for
example whether it was caused by the actions
of one or more other person or a deliberate
act of elf-harm or injury by the person
who has died; |
| 3 |
the
coroner should identify for them critical
conflicts or uncertainties of factual evidence
for them to resolve, giving such guidelines
as he considers justified on the reliability
of particular testimony; |
| 4 |
the
coroner hould keep a record of the exchanges
between
himself and the jury;
|
| 5 |
the
coroner hould inform them of the main analytical
and systems findings he is minded to make
and give them an opportunity to say whether
they agree with them,and record in the inquest
finding any comment that they make. |
|
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Outcome
of inquests: Verdicts
The Report recomends that coroners or juries should
no longer be able to give a 'short form verdict' -
like 'accidental death', 'open verdict', or 'unlawful
killing' - in relation to the death.
It
sets out a number of reasons in Chapter 8 why, in
its view, verdicts are problematic:
| 9 |
The
verdict list is a mixture of classifications of
types of death by cause or circumstance and explicit
or implied judgments about the legality or preventability
of the death or the legality of the actions that
caused it.The natural causes,drug categories,industrial
disease,abortion and stillbirth labels are examples
of the first,and the lawful/unlawful killing verdicts
the clearest examples of the second. |
| 10 |
However
in the context of the inquest the accident/misadventure
label is also problematic.This is partly because
different coroners disagree on the relative meanings
of the two terms –some do not use “misadventure
” while others use it to describe the fatal
outcome of an activity which has some definite
risk. |
| 11 |
More
fundamentally,many families of people who meet
traumatic deaths in the workplace or through
road or other transport crashes, or public service
vessel collisions or sinkings find it objectionable
to have them classified as “accidents”.
They feel strongly that such deaths are usually
avoidable and that it is unacceptable for the
coroner system to appear to shrug them off as
implicitly inevitable mishaps. The value of
the category as a statistical classification
must be small, since it covers such diverse
events as falling off ladders, being the victim
of a medical mishap,or perhaps unintentionally
carrying a potentially suicidal activity too
far. In fact 42% of inquest deaths are found
to be “accidental” or “misadventure”
since the label is applied to nearly all road
and transport deaths, and workplace deaths,
as well as to some suicides and drug-related
deaths.
|
| 12 |
“Unlawful/Lawful
killing ” is equally problematic as an inquest
outcome. It is the business of the criminal justice
system to determine what is murder or manslaughter.The
processes of criminal investigation and trial
are more suited to that purpose than any process
achievable in the coroner’s court.The coroner
’s court does not have the same rules of
evidence or provide the protections against wrongful
incrimination required inter alia by the European
Convention on Human Rights. |
| 13 |
The
retention of “accidental death ” and
of “unlawful/lawful killing ”in the
range of officially encouraged inquest outcomes
is a source of
misunderstanding and conflict for families attending
inquests. |
| 14 |
To
a family which feels,rightly or wrongly,that a
relative ’s death was caused by a serious
and culpable failure on the part of an employer
in the health and safety protection field,or of
the police in a police shooting death, for example,the
inquest system seems to offer a choice between
a bland finding of “accidental death ”
and a severe but in their opinion more meaningful
finding of “unlawful killing”. If the
coroner, mindful of the care shown in the civil
and criminal justice systems to protect all parties
from casual incrimination or imputations of liability,steers
the proceedings away from “unlawful killing”,
the family is likely to feel that the system has
offered them a glimpse of a meaningful outcome
but then made it virtually unattainable. This
is to design conflict and disappointment into
the system. |
It
then sets out a result of its consultation process
on these issues:
| 18 |
In
response to our consultation paper the families
and support groups concerned about the handling
of traffic and workplace deaths re-emphasised
their objection to the “accident ”and
“misadventure” categories.Some gave
support to retaining “unlawful killing ”,
mainly on the grounds that prosecutions for manslaughter
– whether corporate or personal –in
these fields are rarer than they think desirable,and
in the traffic death field that prosecutions for
causing death by dangerous driving or manslaughter
are also less frequently brought or persisted
with than they would like to see. |
| 19 |
A
number of commentators, including some coroners,
pointed out that the verdict system as it now
is makes it very hard for the inquest to deal
fairly with situations where there has been some
problem of approach or mishap in the run-up to
the death but it falls short of “unlawful
killing ’or the test for neglect. |
| 20 |
Another
important consultation input was from the Office
of National Statistics who said that if the
outcomes of inquests are wholly narrative and
analytical they would expect difficulty in deciding
how deaths should be classified in the mortality
statistics. Similar concerns were expressed
by researchers and others with interests in
the fields of suicide, workplace and traffic
deaths.
|
| 21 |
We
consider that the essential role and function
of the coroner ’s inquest should be to find
the facts about the cause and circumstances of
deaths in cases where there is a clear need to
use a judicial process for that purpose. |
| 22 |
There
is an inevitable potential for conflict with other
judicial processes
which deal with criminal and civil liability.The
relationship between an
inquisitorial process to find the facts and adversarial
process to attribute
fault is bound at times to be uncomfortable. |
| 23 |
The
sensible course is not to make the fact-finding
process and outcomes more like the criminal and
civil liability processes but to put a greater
emphasis on what the coroner’s inquest can
achieve but the other processes cannot. |
| 24 |
This
means:
| a |
putting
more emphasis on the narrative and fact-finding
role of the
inquest,and on its analysis of whether there
were failures in the
circumstances leading to the death which
had they not existed might have prevented
it; |
| b |
ceasing
to encourage the use of outcome labels which,
positively or by implication, determine
civil of criminal liability or its absence |
| c |
developing
short descriptions which enable deaths to
be accurately
placed in the mortality statistics,and which
communicate simply the
circumstances of the death,but remain so
far as possible free of
determinations of liability. |
|
The
report then went on to make the following recomendations
in para 25 of chapter 8
| 25 |
We recommend that
| a |
the
outcome of the inquest should be primarily
a factual account of the cause and circumstances
of the death, an analysis of whether there
were systemic failings which had they not
existed might have prevented it, and of
how the activities of individuals bore on
the death. The analysis should in suitable
cases examine whether there was a real and
immediate risk to life and whether the authorities
took, or failed to take, reasonable steps
to prevent it; |
| b |
the
narrative and analytical account of the
cause and circumstances of death hould be
succinct and include a distillation of the
evidence in no greater detail than is necessary
to provide a reasoned judgement and resolve
significant points of contention or uncertainty; |
| c |
the
analysis should include the regulatory or
safety regimes designed to protect people
from risk in the circumstances of the death,
and whether or not they were properly observed
or were, so far as the evidence shows, adequate;
by implication,determine civil or criminal
liability or its absence; |
| d |
since
researchers and statisticians have a legitimate
and important interest in inquest outcomes,
there should continue to be some classification
of each inquested death, but it should be
in terms of type and not in terms implying
criminal or other liability or its absence.
Existing short-form verdicts hould no longer
be used. |
|
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Inquest
Outcome: Sending Material to Law Enforcement Agencies
At present, when a jury returns a verdict of unlawful
killing, the coroner will pass the file of evidence
to the Crown Prosecution Service so that they can
determine whether or not a prosecution of manslaughter
is appropriate.
Since the report recomends that there will be no verdicts
(see above) this practice would no longer continue
to exist. However the report states:
| 50 |
In
a case where an inquest, or an investigation,
is held and evidence is tendered which in the
coroner’s judgement discloses matters relevant
or potentially relevant to the police, the Health
and Safety Executive, the Crown Prosecution Service
or any other law enforcement agency, the coroner
should at the conclusion of the inquest send his
findings on the causes and circumstances of the
death, along with any relevant
supporting evidence, to the agency or agencies
concerned. |
| 51 |
He
should, in the case of an inquest, announce his
intention to do so at the end of the inquest findings.
He should not express any opinion on any question
concerning the lawfulness of any act or the legal
liability of any person or body. |
| 52 |
It
is likely that this circumstance will arise rarely
in any case where there is the prospect of a homicide
charge, a charge of causing death by dangerous
driving or charges of infanticide or assisting
suicide as set out in the current Rules 26 and
28. This is because in such cases it is likely
that the inquest would have been adjourned,either
following a request from the police or Crown Prosecution
Service,or by the coroner himself. |
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Inquest
outcome: Coroners' Recomendations
Currently
Rule 43 of the Coroners Rules states that:
“A
Coroner who believes that action should be taken
to prevent the ecurrence of fatalities similar to
that in respect of which the inquest is being held
may announce at the inquest that he is reporting
the matter in writing to the person or authority
who may have power to take such action and he may
report the matter accordingly.”
Para
46 of Chapter 8 of the Report made the following recomendations:
| 46 |
| We
recommend that: |
| a |
coroners
should send promptly to any public or other
body a clear and succinct account of any
inquest or investigation finding relevant
to the body ’s ervices, activities
or products and to the safety of its users
,customers or staff; |
| b |
the
intention to make such a report and its
broad content, should be announced as part
of the inquest outcome.Where such reports
follow an investigation not an inquest the
coroner shall make a brief public announcement
about the general circumstance of the report
but not disclose details of individuals; |
| c |
copies
of recommendations hould be sent to any
statutory regulatory service which regulates
the activities of the recipient body, and
to any inspectorate which inspects its work.Where
there is no regulator or inspectorate,the
report should be sent to the body ’s
auditor; |
| d |
copies
hould also be sent to any other corporate
body or institution which has influence
over the area of activity concerned uch
as training or education bodies and trades
unions; |
| e |
the
responsibility for acting on, or deciding
not to act on such reports lies with the
recipient bodies. The main responsibility
for pursuing matters with the recipient
body should lie with the regulator, inspectorate
or auditor, but the coroner should be informed
within ix months of the recipient’s
decision on the report of as soon as possible
thereafter if the decision has not by then
been made. Coroners should keep families
informed oif such response; |
| f |
the
regulatory bodies or inspectorates should
in their own annual or periodic report describe
any coroners's recomendations or findings
of significance and say whether they are
satisfeid with the responses that have ensued. |
|
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Special
Recomendations relating to Work-Related Deaths
The
report made the following recomendations:
| • |
inquests
into work-related deaths should be undertaken
by specialist coroners |
| • |
The
HSE and other regulatory bodies should give reasons
to bereaved for their decisions not to prosecute |
| • |
The
proposed Coronial Council’s should look into
"the role and effectiveness in workplace
deaths of the coroner service in relation to other
agencies in meeting the requirements of families
and the wider public interest through its investigations."
|
These
recomendations came out of he following discussion
in Chapter 10 of the Report
| 20 |
Where
the police are investigating the possibility of
a manslaughter charge following a road or a workplace
death or a charge of causing death by dangerous
driving the inquest is adjourned in the same way
and where appropriate resumed later. |
| 21 |
However,when
“lesser” traffic or health and safety
offences are under investigation the inquest may
go ahead before this is brought to a conclusion
either through a prosecution or otherwise,though
practice seems to vary considerably over whether
this is done. |
| 22 |
The
family support groups from whom we have heard
in these two areas feel strongly that the inquest
should precede any health and safety prosecution
or magistrates court proceedings against the vehicle
driver. They argue that the inquest may disclose
material relevant to the prosecution and that
it may establish clearly that a death involving
attributable fault occurred. One of their most
persistent complaints is that traffic or health
and safety prosecutions for offences less serious
than manslaughter do not in their opinion give
enough weight to the fact that though the offence
committed may have been less serious in a technical
or legal sense, someone died as a result of it. |
| 23 |
The
TUC ,in relation to workplace deaths, argue
strongly that the inquest serves a necessary
purpose which overlaps but is different from
the health and safety prosecution
“They
[inquests ] explain by investigation what
happened, so that some conclusions can be
reached,and where appropriate preventative
methods can be applied.They do not perform
the same function as a police,HSE,or other
regulatory investigation ,although they will
necessarily cover some of the same ground
– those are about prevention, too, but
they directly serve the needs of the regulatory
agency, rather than the colleagues and family
of the victim, and there is no real mechanism
for the families and colleagues to determine
whether a police or HSE investigation has
been satisfactory.…..One other concern
is that without public inquests the decision
about
whether to prosecute will fall to a wholly
private process involving the CPS, the HSE
and the police and so on.”
|
| 24 |
The
Health and Safety Executive takes a similar position.It
argues strongly that the inquest should precede
the health and safety criminal proceedings and
that the investigation for the inquest should
be largely separate from the HSE investigation
of health and safety offences.It points out that
inquests are delayed because of the difficulty
in getting accommodation and arranging for juries,and
that the consequent delay in starting health and
safety prosecutions weakens their chances of success
because evidence goes stale.It points to significant
legal constraints on its ability to share information
it has gathered for its statutory investigations
with families. |
| 25 |
Coroners
with whom we have discussed these issues are apt
to say that they have a very limited capacity
of manpower and skill at their disposal to conduct
their own investigations of workplace deaths,
that in cases where there is the possibility of
a manslaughter charge there are often significant
delays in getting decisions on whether it is going
to be brought, and that obtaining information
from the HSE and/or or police for the ,purpose
of the inquest can itself take a long time.
|
| 26 |
A
new protocol agreed between the Association of
Chief Police Officers, the British ransport Police,the
Director of Public Prosecutions and the Health
and Safety Executive and the Local Government
Association has been issued. It aims to improve
coordination between the various prosecution and
investigatory authorities. It confirms the general
policy of holding inquests back while a manslaughter
prosecution is considered or brought. It also
confirms the policy of holding inquests in advance
of decisions on whether to bring prosecutions
for health and safety offences, unless to wait
would prejudice the case.It says that the CPS
should always take into account the consequences
for the bereaved of the decision whether or not
to prosecute, and of any views expressed by them.Where
there is to be no CPS prosecution the CPS will
set out its reasons in writing and send them to
the bereaved, and will offer to meet them to discuss
the reasons for reaching the decision.
|
| 27 |
We
have looked at these issues against the objectives
we have suggested in Chapter 7 for the coronial
death investigation service.These are:
| a |
to
satisfy the public that there is an independent
and professional process for scrutinising
deaths of uncertain cause or circumstances |
| b |
to
help families understand the causes and
circumstances of the death of the family
member in cases of significant uncertainty
which cannot be resolved through other process; |
| c |
to
contribute along with other public services
and agencies to the avoidance of preventable
deaths. |
|
| 28 |
Using
the coroner investigation or inquest as a preliminary
proceeding to a criminal or other prosecution
is not amongst the functions we foresee for it.
It would not be sensible to go back in the direction
of its historic role as a committal process, though
if material of relevance to a prosecution should
emerge in an inquest it should of course be communicated
to the relevant authority. |
| 29 |
In
current circumstances the coroner’s investigation
or inquest may in work-place deaths have an important
role in helping families to understand the causes
and circumstances of the death ,and also the workplace
colleagues of the victim. |
| 30 |
The
inquest may also have a role in defining general
risks and reducing future fatalities in similar
circumstances,though exercise of that that role
must be secondary to that of the dedicated health
and safety agencies. |
| 31 |
There
is nevertheless risk of duplication between the
coroner’s work in this field and the work
of the specialist agencies,and the scale of that
duplication would increase if the coroner service
were fully equipped with the technical expertise
and manpower needed to investigate all workplace
deaths independently of the police, the Health
and Safety Executive and the local authorities.
Even if the necessary additional resources of
specialist skill were available there would be
an issue as to whether they were better deployed
in the coroner service or to reinforce the investigatory
resources of the Health and Safety Executive and
the other agencies. In practice coroners are bound
to be significantly dependent on the police and
the specialist health and safety investigators
for the evidence needed in a workplace death inquest. |
| 32 |
The
new Liaison Protocol should lead to some improvements
in clarity of process and responsibility amongst
the prosecution and enforcement agencies, and
perhaps to prompter handling of cases. |
| 33 |
We
have three recommendations from the perspective
of the coroner
service, two of them related to the longer-term
but the first to the medium term. |
| 34 |
The
first recommendation is that when the new national
coroner jurisdictions are set up investigation
of workplace deaths should be regarded as a specialist
function on which expertise would be concentrated
in one coroner in each of the new coroner areas
or perhaps even one coroner in each region. A
similar specialisation should be encouraged in
a small number of coroner’s officers working
with that coroner. Expertise in handling the cases
might thus increase, and the risk of duplicating
skills within the coroner service be reduced. |
| 35 |
The
other recommendations are that:
| a |
The
Health and Safety Executive and the other
enforcement agencies should consider how
far they could offer bereaved families the
same opportunities to give a view of whether
they should prosecute as the CPS is committed
to doing,and make the same commitment to
explain their decisions to families.To
the extent that this can be done,the pressure
on the coroner service to provide factual
explanations might usefully decrease. |
| b |
For
the longer term the Coronial Council ’s
programme of monitoring the coroner ervice
hould include a tudy of the role and effectiveness
in workplace deaths of the coroner service
in relation to other agencies in meeting
the requirements of families and the wider
public interest through its investigations.It
is clear from the material we have received
that there are strong convictions in this
area and it is desirable systematically
to explore the underlying facts. |
|
| 36 |
In
the meantime we consider that the 300 traumatic
workplace deaths ayear should normally be the
subject of public inquests and have included them
in the suggested list of criteria for inquests
in Chapter 7. We do not propose that they should
be jury inquests. |
| 37 |
On
traffic deaths we consider that the determinants
of whether there
should be a public inquest should be mainly,as
in other cases,whether,
for example,any criminal proceedings have resolved
relevant issues and there are significant uncertainties
and conflicts of evidence which need a public
forensic process to unravel.Where that test is
satisfied the inquest should be held. Where it
is not the coroner should use the evidence that
is available from the police investigation to
provide the family with an account of the cause
and circumstances of death as we recommend should
follow other coroner investigations which are
not the subject of an inquest. |
|
