Coroners (Determination of Suicide) Bill: Bishop of St Albans sets out proposals; Bishop of Exeter supports

On 28th October 2022, the Bishop of St Albans brought a revised version of his Coroners (Determination of Suicide) Bill before the House of Lords for its second reading. The Bishop of Exeter spoke in support of the bill. The bill was read and sent to a Committee of the Whole House:

The Lord Bishop of St Albans: That the Bill now be read a second time.

My Lords, I declare my interest as a vice-chair of Peers for Gambling Reform.

I am glad to bring before the House the Coroners (Determination of Suicide) Bill, now in its third iteration. This latest version is significantly different from the previous two; it has taken on board many of His Majesty’s Government’s criticisms and attempted to resolve them. Indeed, the Minister who dealt with the Bill in the previous Session, the noble Lord, Lord Wolfson of Tredegar, had hoped to speak today from the Back Benches but has to be in court. He has, however, given his permission to say that he supports the aims of the Bill. Because we have tried to respond to the points made by the Government, I will listen attentively to the Minister as he outlines their response, given that I believe their concerns have largely been dealt with.

The genesis of the Bill is the frustration that many of us in your Lordships’ House have felt when we have tried to bring in sensible reforms to the Wild West of online gambling, which is causing untold suffering in communities across our nation. More than a third of a million adults in our country are now diagnosed with a gambling addiction. More than 62,000 teenagers, who in law are not even allowed to gamble, have been diagnosed with a gambling problem. With an estimated more than 400,000 suicides every year due to problem gambling, we need to address this problem in a sensible way. On a number of occasions when I and other noble Lords have raised the issue in the House, the Government have resisted our attempts to bring some order to this sector, simply claiming, “We don’t understand the size of the problem.” The Bill is a proposal for one way of obtaining more data.

Although the first two versions of the Bill included explicit references to gambling, those have now been removed and replaced with a means to record a wide range of causative factors in suicides. Previously there were concerns that the recording of such factors would interfere with the traditional remit of the coroner and the inquest process. Noble Lords will be aware that for centuries coroners have been given the task of answering the questions “Who?”, “What?”, “When?” and “How?” but not “Why?”. That is a criticism that I have taken seriously. I have endeavoured to ensure that the recording of causative factors explicitly occurs following the conclusion of an inquest and will therefore have no impact on the official death certificate or, indeed, the inquest process.

I point out in passing that many coroners, either informally or through the use of a prevention of future deaths report, already comment on the causes of many suicides. For example, Mr Andrew Walker, a senior coroner from north London, has spoken publicly on many occasions recently following the death of Molly Russell, who took her life by suicide. I quote from his statement:

“Molly subscribed to a number of online sites … some of these sites were not safe as they allowed access to adult content that should not have been available for a 14-year-old child to see … Molly had access to images, video clips and text concerning … self-harm, suicide or that were otherwise negative or depressing”.

Even on the train this morning I read another comment by a coroner talking about the question of “Why?” This is something which is happening, and coroners seem to be doing it fairly regularly.

The Bill requires the Secretary of State to draw up guidance on what factors the coroner must consider and the form in which these factors should be recorded. Furthermore, citing fears from coroners that the Bill would oblige them to record a factor or factors in instances where they feel insufficiently able to make that determination, provisions are included to require an option of “no discernible factor” to be included in the guidance.

Obviously, I would expect and hope that gambling-related harm is included as a factor in the Secretary of State’s guidance. Still, the purpose of having the guidance and collection method drawn up by the Secretary of State is to enable a system of generalised data collection which could be streamlined across different coronial jurisdictions. This is crucial, as under Clause 1(6) of the Bill the Office for National Statistics will be required to collect the opinions recorded on the factors causative to suicides in the UK in order to publish them on an annual basis. This information will prove crucial in informing the Government’s suicide prevention programme, alongside the research and work performed by charities and other organisations.

Additionally, new provisions are outlined in Clause 1(7) which prevent information relating to risk factors being released in any way that could lead to the identification of the deceased. Clause 1(8) prevents risk factors collected being used as evidence in any court proceedings. These provisions, though unusual, stem from concerns that the Government had about whether the recording of risk could later be used to attribute civil liability to either individuals or businesses. By preventing the disclosures of identities or the use of risk factors as evidence, this concern would be clearly mitigated.

On the technical aspects of the Bill, these updated provisions create a strong framework to enable the recording of factors causative in a death by suicide without interfering with the coronial process, placing undue responsibilities on the coroner or creating judicial difficulties. I hope that this updated version of the Coroners (Determination of Suicide) Bill will commend itself to His Majesty’s Government and that they too will recognise the importance of collecting information on the risk factors that cause suicide in the UK.

Suicide prevention cannot simply be about interventions to prevent suicide, though I do not discount the importance of this. People rarely commit suicide without reason. In fact, there is nearly always a reason, known in coronial circles as the “causative factor”. It is only by addressing these causative factors that we can have an effective suicide prevention strategy. This necessarily requires accurate knowledge of the main, leading factors driving suicides in the UK today.

A number of Members of your Lordships’ House who are part of Peers for Gambling Reform have argued that one cannot reduce the estimated 409 annual gambling-related suicides—that estimate is by Public Health England—without a comprehensive package of better treatment for those suffering and better regulations to curb the excessive harms caused by online gambling.

In 2020 there were 5,224 suicides in the UK. Aside from age, gender, location and method, we know virtually nothing about the causes, which limits our capability to devise strategies to reduce the number of suicides—something which His Majesty’s Government have committed to doing. This Bill, in a modest way, would enable the accurate recording of risk factors across various coronal jurisdictions in a safe and secure manner, without compromising the identity of the individual or the inquest process.

I recognise that the ability of the coroner to not record anything might limit the accuracy of the data but I am hesitant to place an unfair burden on coroners, and recognise the importance of taking this forward with their support rather than against their will. Nevertheless, the perfect should not be the enemy of the good, and I believe the framework presented in this Bill will provide a good framework for the collection of this information. I beg to move.


Extracts from the speeches that followed:

The Lord Bishop of Exeter: My Lords, I support the Bill, mindful of the rise in the number of suicides and attempted suicides in our country in recent years. As a nation, we are adept at collecting statistics but less good at reflecting on them. As TS Eliot lamented, where is the wisdom we have lost in information? When it comes to addressing the underlying causes and triggers of suicide, not having accurate information compounds the problem. The Bill seeks to address a lacuna in our processes.

The available evidence shows that the Covid pandemic sheltered a second pandemic of poor mental health. A friend once described his depression as “malignant sadness”. Young people are some of the most vulnerable in our society, and, as we all know, various factors, including gambling debts, can push a depressed person over the edge. In addition to the 409 gambling-related suicides estimated by Public Health England, studies have demonstrated that people who suffer from gambling disorders are 15 times more likely to take their own lives.

If the Government’s suicide prevention strategy is to be effective, it is vital that we have as accurate a picture as possible. We have to move from anecdote to evidence, and our coroners are well placed to help us. The Bill provides a simple and effective way of collecting evidence of gambling-related harm. It is not about the apportionment of blame, which is not the role of the coroner, and it does not attempt to restrict or limit the practice of gambling. Rather, it simply attempts to identify the causative factors of suicide. I have no doubt that widening the Bill to record the causative factors of suicide—not just those that are gambling-related—will provide a great deal of useful information for the Government and groups concerned with public health. I am confident that, in its stages in this House, there will be a full and proper opportunity for the questions and concerns of the Government and others to be addressed.

Having talked with some coroners, I am conscious of the pressure that the coronial service operates under—to my mind, it is overstretched and underresourced. That said, the role of the coroner continues to evolve, as we see with increasing use of narrative conclusions, for example. We have to find a way of registering causative factors in a suicide. Registering comorbidities and anonymously collating this body of evidence would enable the Government’s suicide prevention strategy to be more effective. I invite noble Lords to join me in supporting the Bill.

Baroness Bakewell of Hardington Mandeville (LD): My Lords, I congratulate the right reverend Prelate the Bishop of St Albans on his tenacity in bringing forward his Bill for a third time, and for his excellent introduction to this morning’s debate. I declare my interest as a vice-chair of Peers for Gambling Reform.

We all seem to be in agreement: deaths because of suicide are devastating for families and friends since, as with all sudden deaths, there is no opportunity to say goodbye, and for those left behind there can be a lingering feeling that they should have noticed and done more to prevent it happening. However, those suffering from addictions, especially gambling, are often extremely good at hiding just how deeply they have become embroiled and the level of their debt as a result. Where it is possible to assess what drove an individual to take their own life, the coroner should record this. Only by knowing just what the scale of the problem is with regards to gambling will we be able to assess the signs of addiction and intervene to prevent the tragic loss of life. Most people can set themselves limits, gamble safely and enjoy the process, but for others it is a downward spiral into addiction, engulfing them in a sense of hopelessness and lack of control. They think they have conquered their addiction, until emails in their inbox invite them to have five free bonuses.

I raise two well-known case studies where gambling was a contributing factor in a death by suicide. The first is the high-profile case of a young electrical engineer, aged 25, on an annual salary of £60,000 who, in 2017, took his own life after losing £119,000 over five days, having been enticed with VIP designation and given multiple free cash bonuses. The second is a father of two children, a primary school teacher aged 40 who, having previously self-excluded from gambling for two years, began gambling again while on furlough after receiving free bonuses before eventually driving 100 miles to take his own life.

Lord Bellamy (Con, Minister of State – Ministry of Justice): My Lords, may I also congratulate and thank the right reverend Prelate the Bishop of St Albans for again providing the opportunity to debate this important and sensitive issue and for his strenuous and tenacious efforts to improve the Bill to meet the points made in previous debates? In fact, the Bill is now wider than it was before in that it extends to all suicides, instead of just those related to gambling. This is an extremely important area and the Government very much share the thoughts expressed this morning on the importance of gathering quality information on the circumstances that can lead to a suicide.

There were a number of extremely moving contributions this morning. I make particular mention of the need for better data on assisted suicides, the point made by the noble Baroness, Lady Berridge. I also mention her points about gambling addiction, and those made by the noble and learned Lord, Lord Brown. However, despite these efforts, the Government are not yet in a position to support the Bill, essentially for three reasons which I will briefly set out. The central question is the one raised just now by the noble Baroness, Lady Merron, which is whether the coronal system is the right way forward for this exercise. The Government do not support the Bill for three reasons.


For those three principal reasons—the extreme difficulty of investigating the why in every case under the compulsory requirements in the Bill; the difficulty, even if we did investigate it, of knowing whether the information is reliable for statistical purposes; and the existing prevention of future death reports, which fill that gap—the Government oppose the Bill. Finally, I support the comment made by the noble and learned Lord, Lord Thomas, to the effect that it would be constitutionally inappropriate for the Secretary of State to give directions to independent judicial officers such as coroners. That point, in my respectful submission, is entirely right and is a further but subsidiary reason for opposing the Bill.

The Lord Bishop of St Albans: I thank noble Lords for their speeches. I will not go into them in detail, because we hope to come back to this at a later stage, when we can explore them further. I shall just respond to the Minister though, because it seems to me that there is a potential inconsistency in the reasons he has given.

For example, the Minister said that it is very difficult for the coroner to determine “why”. Yet, he conceded in his third point that they are already able to issue the precise reasons why under the prevention of future deaths report, which could not be made unless some sort of view was taken on what had caused the deaths. I totally take the point a number of noble Lords have made, that this is a very inexact way forward; it is certainly not perfect. The Bill has got to its third iteration because at every stage, when people have told me, “I wouldn’t do it like that”, I have asked them how they would do it. I can see all the problems, but I hope that with the help of noble Lords, not least those noble and learned Lords who have brought their considerable legal expertise—I am delighted to have such eminent judges, people who really understand the law, commenting on this—we can improve it.

Our system of taking Bills through Parliament is one of improving them together. I say to the noble and learned Lord, Lord Thomas: let us look at the issue. Is it the Secretary of State or is it the Chief Coroner? Perhaps he could bring us an amendment on that. Let us sort out these problems. These are areas where I have no experience at all; I am just a jobbing Bishop from the sticks. We have these legal experts here who can help us, so I thank them very much and hope they will enable us to improve the Bill as we bring it back.

I want to go back to the basic facts. There are more than 400 suicides a year. We heard stories in the Select Committee of families who have been rent apart and will never be the same. Take the story of Jack Ritchie. His parents have been in this place several times and are now campaigners. Their whole lives have been destroyed, as they watched their son get destroyed. They could see that it was going to happen but felt powerless to do anything. We have to do something. The Bill may not be perfect but, please, let us see what we can do to improve it so that we can get the data to allow us to inform His Majesty’s Government’s suicide prevention strategy—not just on problem gambling but on other forms of addiction and other areas. This could be a significant way forward if your Lordships could help me forge it into something better. I beg to move.

Bill read a second time and committed to a committee of the Whole House.


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