CORONERS BILL

CORONERS BILL: Order for Second Reading read.

Assoc. Prof. Ho Peng Kee: Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

Sir, the provisions on Coroner's Inquiries are currently found in the Criminal Procedure Code (CPC). This Bill is a result of our review of the CPC. Like the CPC, public feedback was sought through a Consultation Paper on an earlier draft of this Bill over a period of four weeks last year. Useful feedback was received, some of which have been incorporated in the Bill now before the House.

Sir, in terms of presentation, other jurisdictions such as the United Kingdom, Hong Kong, New Zealand and Australia have also enacted standalone Coroner's legislation. Substantively, the proposed changes will update our coronial system, more clearly defining its role and strengthening its procedures so that it will better serve the public interest.

Sir, the Bill contains three key proposals. First, it changes the present fault-finding nature of a Coroner's Inquiry to a fact-finding one. Second, the Bill

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widens the technical expertise available to the Coroner. And third, the Bill re-scopes the Coroner’s jurisdiction, giving it a clearer focus.

Shift to a fact-finding inquiry

Sir, let me first elaborate on the shift to a fact-finding inquiry. The current regime under the CPC requires the Coroner to hold an inquiry to determine the circumstances under which the deceased came by his death and also whether any person is criminally concerned in the cause of the death.

Under the Constitution, it is the Public Prosecutor who decides whether or not a person should be prosecuted. There is therefore no need for the Coroner to come to any conclusion on criminal responsibility in a Coroner's Inquiry. The Public Prosecutor may take cognisance of the Coroner’s findings of fact in deciding whether or not to prosecute.

Hence, clause 27 of the Bill states that the purpose of an inquiry into the death of any person is to inquire into the cause of and circumstances connected with the death. The Coroner will focus on ascertaining the facts and circumstances behind a death, instead of apportioning blame. Other jurisdictions such as the United Kingdom, New Zealand, Australia and Hong Kong have also adopted such a fact-finding approach.

Widening of technical expertise

Sir, the second key proposal of the Bill is to widen the technical expertise available to the Coroner. This will be especially useful in cases involving medical negligence where medical and other technical expertise may be tapped by the investigators and the Coroner.

Hence, clause 4 empowers the Chief Executive of the Health Sciences Authority (HSA) to appoint any pathologist as a

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forensic pathologist. Clause 16 provides that a Coroner or the Public Prosecutor may, if he considers it appropriate to do so, direct a forensic pathologist to investigate the cause of and circumstances connected with the death.

In addition, as the present law does not provide for the appointment of assessors, clause 32 gives the Coroner the discretion to appoint up to two assessors with skill and experience in the matter to which the inquiry relates to assist him in the hearing of any inquiry. This approach of leveraging on lay expertise has also been adopted in other bodies such as the Strata Titles Board. Indeed, a similar clause is found in the Subordinate Courts Act and Supreme Court of Judicature Act.

To facilitate investigation and any subsequent inquiry, clause 8 imposes a duty on persons-in-charge of hospitals, clinics or places of official custody to preserve the deceased's medical and healthcare records. Failure to comply, without reasonable excuse, is an offence.

Coroner’s jurisdiction

Sir, the third key proposal of the Bill re-scopes the Coroner's jurisdiction, giving it a clearer focus. Clause 24 first sets out the current position where the Coroner has jurisdiction to hold an inquiry where a body is found in Singapore or death occurs here. It then goes on to extend the Coroner's jurisdiction to cases where the cause of death occurs in Singapore or where death occurs or results from an occurrence on board a Singapore-registered civilian vessel or aircraft. An example is where a person dies on board an SIA flight or where a person dies as a result of something he ingests during an SIA flight. In the above situations, other than the one where the body is found in Singapore, the Coroner will have jurisdiction to conduct an inquiry into the

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death even without there being a body, for instance if the body was destroyed.

I must add, however, that even though the Coroner may have jurisdiction, in some cases, such as when death occurs on a Singapore registered ship that is berthed in a foreign port, the Police will still not have the powers to conduct investigations abroad. If the Coroner decides to hold an inquiry, Police may have to seek the assistance of their foreign counterparts.

Sir, clause 25 sets out when it is mandatory or discretionary for a Coroner to hold an inquiry. The approach we have adopted is consistent with the approaches taken in other jurisdictions such as Hong Kong, New South Wales, Victoria, South Australia and British Columbia where the respective Coroners legislation stipulates the circumstances in which an inquiry is mandatory or discretionary. This approach will result in a more efficient use of resources and better serve the public interest, by, for example, enabling the Coroner to focus the Court's resources on the more complex cases.

Under clause 25(1), an inquiry is mandatory for any death which occurs in Singapore where a person dies while in official custody, where the death is the result of capital punishment, where the Public Prosecutor so requires under clause 26, or where death occurs in Singapore in any of the circumstances set out in the Third Schedule. These would constitute the majority of reportable deaths such as medical treatment-related deaths; deaths by unknown causes or that occur under suspicious circumstances or caused or suspected to be caused by an unlawful act or omission; deaths of persons whose identities are unknown, deaths from law enforcement operations, deaths involving a public vehicle or commercial transport vehicle and deaths in any workplace or as

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a result of any accident at a workplace. The list of reportable deaths is set out in Schedule Two.

Sir, for the rest of the reportable deaths, clause 25(2) provides that the Coroner may decide not to hold an inquiry if he is satisfied that the death was due to natural causes and that it is unnecessary to do so, or if he is satisfied that there is no public interest to do so. An example of a situation where there is no public interest to hold an inquiry would be a suicide or accidental fall where the facts are clear and the family does not request for an Inquiry to be held. In deciding whether or not to hold an inquiry, a Coroner may take into account a range of factors such as the desire of any member of the immediate family of the deceased for an inquiry, whether the death had occurred outside Singapore, and whether an investigation into the death has been conducted outside Singapore. When a Coroner decides not to hold an inquiry, he has to report the facts to the Public Prosecutor, stating his reasons for not doing so. If the Public Prosecutor is of the view that an inquiry ought to be held, he can require the Coroner to hold one.

In any case, Sir, the Police will investigate all instances of reportable deaths. In the event that no inquiry is held, as per current practice, a Certificate of the Cause of Death will still be issued, based on the evidence before the Coroner.

Finally, let me highlight some other provisions of the Bill.

Presently, Coroners are appointed under section 10 of the Subordinate Courts Act. The appointment provision has been moved from the Subordinate Courts Act to clause 3(1), which provides for the appointment of a State Coroner and Coroners by the President, on the recommendation of the Chief Justice. There is no change to the appointing authority. There is also no change in the

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qualifications of a Coroner who, under clause 3(2), has to be a Magistrate or District Judge appointed under the Subordinate Courts Act. In the case of the State Coroner, he must be a District Judge appointed under the Subordinate Courts Act. Under clause 3(3), the State Coroner is charged with the general administration of the Coroners Act.

Sir, clause 5 provides that a person who becomes aware of a reportable death is obliged to make a police report as soon as reasonably practicable. Failure to do so, without reasonable excuse, is an offence. An example of a reasonable excuse would be if the person knew that another person had already reported the death. As mentioned earlier, the list of reportable deaths is set out in the Second Schedule. The coronial systems in New South Wales and Victoria also impose the duty to report deaths which are reportable deaths. Failure to do so is a criminal offence. We believe that this will further improve our coronial system and better serve the public interest.

Sir, lastly, the Bill makes related amendments to the Private Hospitals

and Medical Clinics Act (PHMCA). The amendments to the PHMCA arising from the proposed changes to the Coroner’s Bill will enable the existing mortality reviews that are already in practice at public and private hospitals to be enhanced and extended to other healthcare institutions.

Sir, I beg to move.

Question proposed.

4.45 pm

Dr Lam Pin Min: Mr Speaker, Sir, thank you for allowing me to speak on this Bill.

This Bill is good and timely as it defines clearly the work and jurisdiction of the Coroner, shifts its focus to fact-finding rather than fault-finding, and for

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the first time, schedules that define reportable deaths and Coroner’s cases are clearly spelt out.

The Coronial system was established in England in Medieval times. The duties of Coroners then included investigating sudden and unnatural deaths and also inquiries into treasure troves. The Coronial system underwent numerous changes in England and local Coroners are often medically qualified.

The English Coronial system was introduced to many of its colonies, including Singapore. Whilst the system may differ in different countries depending on when they were introduced, the basic features of being a quasi-criminal proceeding, focussing on whether criminal conduct caused the death remained. The first Coroner of Singapore appointed was Mr Andrew Farquhar in December 1827. The laws on coroners remained largely unchanged and the processes were prescribed by the Criminal Procedure Code.

This Bill is therefore a by-product of the Ministry’s review of the Criminal Procedure Code.

Allow me to highlight some of my concerns on the Bill and to seek clarifications from the Minister on certain issues.

This Bill defines the appointment of the State Coroner and Coroners and sets out their qualifications and functions. Clause 3 of the Bill stipulates that the Coroner must be a judicial officer appointed under the Subordinate Courts Act and in the case of the State Coroner, a District Judge appointed under the same Act. This Bill makes no mention of the seniority and experience of the Coroner. However, can a non-judicial officer, such as a medical doctor or other professionals, be appointed? If not, what are the considerations for deciding otherwise? In

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England and Wales, the Coroner must be a lawyer or doctor of at least five years standing. In addition, the UK also regulates the training requirements of appointed Coroners.

Clause 4 of the Bill stipulates that the CEO of the Health Science Authority can appoint any pathologist as a forensic pathologist. Similarly, there is no mention of the seniority and experience required. Is there currently a pre-approved list of accredited pathologists from which the forensic pathologist can be appointed from? In the UK, there is a home office pathologist register from which the forensic pathologist can be appointed. What is the rationale for the provision for this appointment by the CEO of Health Science Authority? Why not the Minister or the Attorney-General?

Clause 6 imposes a duty to report all deaths which occur in the course of arrest or detention or while the deceased is in official custody, except in cases of lawful execution of a death sentence. This duty is on the person effecting the arrest or detention or the person in whose custody the deceased was, to report the death. Failure to do so is an offence.

Clause 8 imposes a duty on persons in-charge of hospitals, medical clinics or places of custody to preserve all medical records and healthcare records pertaining to the deceased. The penalties for failure to report death and preserve medical records respectively are fines not exceeding $10,000 for both and/or to imprisonment for a term not exceeding six months and 12 months respectively. I would like to clarify with the Minister the rationale for the difference as it gives the impression of one offence being more severe than the other.

With the criminalisation of non-reporting, it is likely that there will be a

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surge in the number of medical Coroner’s cases. What is the current workload of Coroners and forensic pathologists? Will the anticipated increase overwhelm our Coroner’s system?

Clause 12 sets out the procedure for the Coroner to view the body and make preliminary investigations. It allows the Coroner to view and identify body by a live video link or any other such means as the State Coroner may approve, to make an important decision of whether an inquiry is needed. Will this provision trivialise the investigative process? What safeguards are there to ensure that proper identification and investigations are carried out and that important information will not be missed if the Coroner is not at the scene to view the body?

Clause 32 provides for the appointment by the Coroner of not more than two assessors with skill and experience to assist in the hearing of any inquiry. However, the Bill seemed ambiguous with regard to the exact role and function of the assessor and the skills and experience required. Clause 32(3) also states that the remuneration of the assessor sitting in the inquiry shall be payable out of moneys provided by Parliament. Can the Minister elaborate on the remuneration procedure and its source, and how the rate will be determined? Will it be payable through the Parliament’s budget or from a budget to be nominated by Parliament?

The Bill provides no provision for appeals against a decision made by the Coroner. In the United Kingdom, appeals against the local Coroner’s decision can be made to the Chief Coroner. What avenues are available to relatives should they disagree with the decision of the Coroner?

It is often asked, "What is the difference between Coroner’s case and Sentinel events?" It is important that clear guidelines be made available as non-

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reporting of supposedly Coroner’s case can result in persecution. Can the Minister clarify whether all sentinel events resulting in death will be classified as a Coroner’s case? In addition, will all Sentinel events leading to death be subjected to autopsies so that the actual cause of death can be determined? Are there clear guidelines for Coroner to decide if the case be signed off without autopsy or otherwise?

Sir, the introduction of this Bill is certainly welcome as it clearly clarifies the Coroner’s jurisdiction, refocuses the role of Coroner to that of fact-finding, increases its effectiveness and enhances public confidence.

With that, I support the Bill.

Assoc. Prof. Ho Peng Kee: Sir, I thank Dr Lam Pin Min for speaking in support of the Bill. He raises a number of queries on selected aspects of the Bill which I will now address.

Sir, on the appointment of Coroners, Dr Lam observes that the Bill does not specify the requisite seniority in terms of years of experience. As I have said in my speech, the seniority requirements are tied to the appointment of District Judges or Magistrates as Coroners who under the Subordinate Courts Act must be qualified persons of not less than five years and one year's standing respectively. While a State Coroner must be a District Judge, the other Coroners may be District Judges or Magistrates who as judicial officers, hearing civil and criminal cases in the Subordinate Courts on a daily basis, are well placed to perform the role of Coroners.

This leads me to the next point that Dr Lam makes which is whether other professionals such as doctors can be appointed as Coroners. Sir, I note what the Member shares that in the UK, a Coroner can be either a lawyer or doctor

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of at least five years' standing. On this point, our view is that as functionaries of the State, judicial officers are in the best position to conduct independent fact-finding inquiries. But, we recognise that the circumstances of death in each case can be varied and may involve medical technicalities, that is why we have provided in the Bill for the appointment of forensic pathologists to assist in investigations and also of assessors from any technical field, including the medical field to provide expert input when required during an inquiry. So this will enhance the quality of investigations and also ensure that inquiries are not hampered by the lack of medical or other technical expertise. So, essentially, what we have done is to keep the basic approach of having Judges as Coroners who will be in-charge of the inquiry and, if necessary, complement his legal oversight with the relevant professional expertise, including medical expertise.

Dr Lam makes a few points about the appointing authority and qualifications of forensic pathologists. On whether we should specify the requisite seniority or experience before a person may be appointed a forensic pathologist, currently the task of examining Coroner cases is carried out by qualified and trained forensic pathologists from the Health Science Authority (HSA) who hold post-graduate qualifications in this specialised field. The Bill essentially formalises this arrangement. All practising forensic pathologists in Singapore are presently employed by HSA. I think currently there are six, which require that such practitioners are not only registered as pathologists under the Singapore Medical Council's Register of Specialists but also hold relevant post-graduate qualifications in forensic pathology. By the time a medical practitioner attains the necessary qualifications and completes specialist training to qualify as a forensic pathologist, he or she would have had at

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least five to six years of supervised training and on-the-job experience.

But Dr Lam also asks why forensic pathologists are appointed by the Chief Executive of HSA under the Bill, and not the Minister or the Attorney-General. Sir, the short answer to that is that HSA is a public authority charged, among other roles, with providing professional, investigative, analytical and other services in health sciences to the Government. It is therefore appropriate for the Chief Executive of HSA to appoint forensic pathologists to carry out functions under the Act.

Unlike the UK, there is no need to keep a Register of Pathologists from which forensic pathologists can be appointed. The UK Home Office Register was established to ensure that forensic pathologists who provide services to Coroners and the police maintain professional standards. This is necessary because in the UK, forensic pathologists can operate out of private practice or a variety of institutions. Indeed, some Coroners in the UK may also outsource the work to hospital pathologists. So their historical development is quite different.

In Singapore, all forensic pathologists must register with the Medical Council's Register of Specialists under the specialty of pathology. Forensic medical services are provided by the forensic pathologists employed by HSA which maintain professional standards through an internal peer review system and the performance appraisal that includes a professional component that is evaluated annually. HSA's Forensic Medicine Division is also fully accredited with the US National Association of Medical Examiners which requires its forensic pathologists to comply with certain performance standards.

Next, what are the skills and experience required of assessors and how they are

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paid. Sir, essentially, an assessor advises the Coroner at an inquiry which involves technical, scientific or highly specialised matters so that the Coroner is better informed in making his determination. The value of an assessor lies in the fact that he is a non-partisan expert assisting the Coroner. The types of skills and experience required of an assessor will really depend on the facts of the case. For instance, whilst medical experts may be required in medical-related deaths, engineers will be useful. Their input will be useful for inquiries into workplace-related deaths.

As for the remuneration of assessors, this is to compensate them to some extent for their time and expertise. The law currently already provides for the remuneration of assessors who assist the Courts in other proceedings. Sir, as I have said in my speech, the provision in the Coroners Bill is based on those in the Subordinate Courts Act and the Supreme Court of Judicature Act. Essentially, the Courts will have to provide for the assessors' remuneration in their budget submissions to Parliament.

Then, next, Dr Lam asks why the penalties for failing to report a reportable death to the Police and failing to preserve medical records are different. First, just to clarify that there is a general duty to report a reportable death in clause 5 by any member of the public for which the penalty for non-compliance is a maximum fine of $1,500 or imprisonment not exceeding one month or both. The penalty for failing to report a reportable death to the police under clause 5 is in line with the penalty in section 176 of the Penal Code which is an offence of intentionally omitting to furnish information on any subject to a public servant when one is legally bound to do so. This obligation applies to the public at large. Now, the intention is to ensure that the police receives information on reportable deaths so that they can conduct investigations.

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Then next, there is a specific duty to report deaths that occur in official custody in clause 6 which I think Dr Lam points to. The penalty for this is stiffer, and rightly so, because this reflects the public interest in ensuring the investigation of any death that occurs in official custody.

Finally, there is an even stiffer penalty for failing to preserve medical records. The preservation of medical records is vital as it helps the forensic pathologist determine whether a death is medical-related.

To fail to preserve the medical records for the requisite period is tantamount to disposal of evidence. By way of comparison, the destruction of documents or electronic records, which may be required as evidence in Court, under section 204 of the Penal Code, is punishable with imprisonment of up to two years or with fine, or with both. The law takes a serious view of such offences.

This explains the disparity in the maximum penalties, in terms of the equivalence in the Penal Code. But, of course, I think the point to note is that in any given case, the Court has the discretion to impose an appropriate sentence according to the facts of the case and the level of culpability involved.

Will criminalising the failure to report result in an increase in the number of Coroners' cases involving medical-related deaths? First, I should say that as of now, the failure to report is already an offence. This Bill does not change the position, although as Dr Lam rightly points out, the instances of reporting are now made clearer, as set out in the Second Schedule. So, essentially, it should not lead to an increase in the number of Coroners' cases involving medical-related deaths.

As to the current workload for Coroners and forensic pathologists: every year, approximately 4,000 Coroners'

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cases are handled and about 50% of these undergo autopsies. Dr Lam asked if it is acceptable for the Coroner to view and identify a body by a "live" video-link or any other such means, as the State Coroner may approve, in order to make the important decision of whether to hold an inquiry. Sir, this provision will enable the Coroner to harness technology in appropriate cases, where the Coroner may be indisposed to be physically present to view the body, without having to cause unnecessary delay to the progress of time-sensitive investigations. This will expedite the release of the body to the next-of-kin after the Coroner has viewed and identified it.

But let me assure Dr Lam that the norm will still be the current practice of the Coroner going down physically, right to the mortuary every morning to view and identify the body, and that includes weekends and public holidays. I should add that the decision, whether or not to hold an inquiry, is actually not determined by the viewing or identification of the body, but really by the factors that I have set out earlier under clause 25.

Now, let me quickly address two other concerns that have been raised. Dr Lam asked if all Sentinel events resulting in deaths would be classified as Coroners' cases. For those of us who are not doctors, I understand that Sentinel events refer to unexpected deaths or major injuries in healthcare institutions that are associated with the treatment, lack of treatment or delay in treatment. Sir, indeed, there will be instances where a death occurring in a hospital will trigger both a Sentinel event report as well as a report to the Coroner. On the other hand, a major injury arising may be a Sentinel event but need not be reported as a Coroner's case, as there is no death. In any case, the point is that these two reporting systems serve different purposes, and are reviewed and managed separately.

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Sentinel event reports are made by the hospital's quality assurance committees to the Ministry of Health for the principal purpose of identifying and addressing any systemic issues. On the other hand, when a death is reported as a Coroner's case, this triggers a Police investigation that may eventually lead to criminal charges being preferred. As such, there are separate guidelines for reporting Coroners' cases and Sentinel events. As to when an autopsy is required, yes, I believe there are factors to be considered on this. The key point is, really, the purpose of an autopsy is to determine the cause of death. The Coroner taking professional advice from the forensic pathologists will decide if a reported case can be signed off without the need for an autopsy.

Finally, Sir, as to whether the Coroners' findings are appealable: the Coroners' findings are not subject to appeal or criminal revision. But a person with sufficient standing, such as an immediate family member, may apply for judicial view. The Public Prosecutor may, at any time, direct the Coroner to reopen a concluded enquiry or if an enquiry was not held in the first place, to conduct one.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. – [Assoc. Prof. Ho Peng Kee].

Bill considered in Committee; reported without amendment; read a Third time and passed.