The Chair of the Community Safety and Leisure Scrutiny Panel outlined the Panels findings, conclusions and recommendations following a scrutiny investigation into the Coroners Service.
The Board considered the following recommendations of the Panel based on the evidence submitted which they believed would make a significant difference and contribute to a swifter conclusion for inquests.
(a) (Conclusion paragraphs 98 to 104 of the Final Report)
Staffing levels and experience are major factors in processing an Inquest swiftly. The 8 staff presently allocated is found to be greater than the indicated norm expected. However, it is understood that only two of these staff are qualified field officers. It is therefore recommended that greater emphasis is placed on ensuring that all staff are trained and capable of undertaking this function which would provide improved flexibility of this resource.
(b) (Conclusion paragraphs 107 to 108 of the Final Report)
A Guide to Coroners and Inquests is presently available. However the Panel considers that a Coroners Charter which is specifically targeted to Teesside, detailing the roles and expectations of the Local Authority, NHS and Police within the Teesside Coroners Service should be developed. It is therefore recommended that a Charter is developed in agreement with the partner organisations.
(c) (Conclusion paragraph 109 of the Final Report)
The issue of young people dying from unexplained causes is a concern. From information received the panel recommends that in such cases where a young person dies from unexplained reasons and has a sibling that the sibling should automatically be screened for Cardiac disorder. The panel recommends that this action be introduced immediately and contained within the proposed Coroners Charter.
(d) (Conclusion paragraph 110 of the Final Report)
Improved technology is already operating with Cleveland Police which is believed would assist the administrative process of the Coroners Service. Acknowledging there are issues of confidentiality and training to be addressed the panel recommends that this system be introduced swiftly which would track and automatically generate the appropriate reminders and correspondence.
(e) Conclusion paragraphs 111 to 112 of the Final Report)
The analysis and information received relating to financial information and charges to the Coroner by the NHS were found to contain a number of variables. Consequently, the panel recommends that the Councils Auditors undertake a Value for Money exercise into the Coroners Service. To ensure, that in such times of austerity the charges and costs are not excessive and not out of line with other jurisdictions.
(f) Conclusion paragraph 111 of the Final Report)
As the increase in costs over the five year period are above the level of inflation and place additional pressures on the Council it is recommended that the Council and the Coroner meet with the NHS to discuss their charges and moderate future increases.
(g) Conclusion paragraph 120 of the Final Report)
That the Teesside Coroner engages with the Ministry of Justice and agree a process for engaging with the local press for the purpose of producing some positive publicity about the Coroners Service. Also that the Coroners office ensures that families are regularly appraised of the reasons of a delay when the inquest is taking longer than the expected time. (The national average should be a benchmark to alert families of the reasons for the present position which is beyond that benchmark).
(h) (Conclusion paragraphs 113 to 118 of the Final Report)
Consideration has been given to implementing a process where an inquest is opened following a post-operative death. The panel recommends that this practice outlined to the panel be implemented and that discussions be concluded with Medical Directors of the Hospitals involved. The principle being that a date is agreed with the appropriate people which ensures all witnesses or organisations are aware that reports are to be prepared and submitted within two to three months.
Presently, the average time for the conclusion of an inquest in Teesside is substantially greater than the National Average. In addition to this the panel is aware that there is a substantial backlog of inquests to be concluded. Consequently, the panel recommends that arrangements are made through the Chief Constable for Cleveland Police to immediately apply a short term additional resource to substantially reduce this back log of cases to a manageable level.
(j) (Conclusion paragraphs 121 to 122)
As Cleveland Police provide the Coroners Officers for Teesside and Hartlepool and are managed within one unit. It is recommended that the Ministry of Justice give serious consideration to the merging of the Teesside Coroner Service with the Hartlepool Coroner Service and making the Coroners jurisdiction coterminous with the Cleveland Police support area and thereby improving the efficiency of the service.
(k) (Conclusion paragraphs 123 to 124)
There are clearly operational tensions between the Coroners office and the Police. The panel considers these tensions are no doubt driven by operational pressures, however they must be addressed. The panel therefore recommends that a meeting involving the Chief Constable and Coroner and operational staff be convened to openly address and resolve these differences.
(l) The Panel recognises there is not one solution to resolve the delays in Teesside. Consequently, the panel recommends that detail is presented to the panel in six months which outlines the time taken, backlog, staffing levels and action against each recommendation to assess the progress achieved.
In supporting the recommendations Members specifically referred to the proposal that the Councils Auditors undertake a Value for Money exercise into the Coroners Service and the intention to monitor the implementation of the recommendations. The Board considered that steps should be taken with the appointing body for the Coroner with a view to increasing greater democratic accountability of the Coroner and its Service including the submission of six monthly performance update reports.
Members referred to the importance of the scrutiny investigation and the public support which had been demonstrated in undertaking such a review.
ORDERED that the findings and recommendations of the Community Safety and Leisure Scrutiny Panel be endorsed and referred to the Executive subject to the inclusion of an additional recommendation regarding accountability and submission of six monthly performance update reports as outlined above.