Westminster’s Creepy Coroner 

By TheColemanExperience February 15, 2013

On 23rd October 2002, Chris Pond MP raised serious and urgent questions relating to the conduct of Westminster coroner, Paul Knapman.

He sought to highlight the shocking treatment of families of victims of the Marchioness boat tragedy by the creepy coroner.

For some unexplained reason, Knapman horrifically allowed the victims hands to be cut off and their body parts and tissues to be removed without permission and treated concerned family members with utter contempt:

The Commons debate was as follow:

I am grateful for the opportunity to place before the House the concerns about the conduct of the Westminster coroner felt by people who have come into contact with him following the loss of loved ones.

I thought carefully before seeking this debate. No Member should lightly raise in the House criticisms of an individual, especially when that individual is a judicial officer responsible for such high profile investigations as the Marchioness disaster and the Clapham and Paddington rail inquiries. However, I consider that the concerns about the conduct of the Westminster coroner, expressed over a long period, raise questions not only about his own record but about the trust that the public can place in the coroner system more generally.

The Westminster coroner, Dr. Paul Knapman, is no stranger to criticism. I first came across him through my involvement with the families and friends of those who had lost their lives in the sinking of the Marchioness pleasure boat in 1989. I worked with those families to press for a full public inquiry into the tragedy, which my right hon. Friend the Deputy Prime Minister, granted in 1999. I know those people as determined and courageous, struggling to come to terms with the tragic loss of their loved ones—a task made more difficult, I have to say, by the behaviour of the coroner, Dr. Knapman, at the first inquest. Yet in a letter of 22 May 1991, Dr. Knapman described the bereaved as

a number of mentally unwell relatives and survivors who mutually support each other”.

In 1994, the Court of Appeal found that his comment to the Daily Mail, when he described the mother of one of the Marchioness victims as Xunhinged”, was not merely injudicious and insensitive but bound to be interpreted as a gratuitous insult. Lord Justice Simon Brown said that the coroner’s Xapparent bias” towards the victims’ families may have been a factor in his refusal to grant a second inquest. The Westminster coroner attracted further criticism when it became known that he had authorised the removal of the hands of 25 of the Marchioness victims for identification purposes. Lord Justice Clarke, in the public inquiry into the Marchioness disaster and river safety, was especially critical of the decision to mutilate the bodies of the victims when other means of identification were readily available. Lord Justice Clarke put the matter effectively in his report: 

The important point is that hands were not being removed as a last resort, but were being removed in all cases. As a result, hands were removed notwithstanding that dental records were being obtained or had been obtained or possibly in one case just after a dental match had been made.”

In one case, a victim’s hands were removed even though the belt he was wearing contained a photograph of him, a blood donor card and the keys to his flat. Inevitably, that caused distress to the relatives of the deceased—once they were informed. However, that was not until two years later. Information about the victims’ hands having been withheld, it is perhaps not surprising that 23 Oct 2002 : Column 379 relatives were refused the opportunity to see their loved ones to pay their last respects. Some never again saw the people they had lost. It was some years after that event, and following criticism from Lord Justice Clarke, that Dr. Knapman expressed his regret at that decision. He said: 

I did not fully recognise the distress that further disfigurement of the bodies might cause.”

That reveals a remarkable lack of imagination in a man responsible over many years for dealing with bereaved relatives, and it underlines the importance of training for coroners and their staff in basic human skills. To add insult to injury, a pair of hands was found in the bottom of the coroner’s freezer, not months but three years after they had been removed. It may be that they were never used for identification purposes. Without consulting the relatives, the hands were incinerated, without the option of being reunited with the body.

All that is public knowledge. The public inquiry report was especially critical of the fact that human tissue had been treated so casually. At the very end of his inquiry, Lord Justice Clarke learned that tissue samples taken at the post-mortem examinations of four of the Marchioness victims had been overlooked until they were discovered at Westminster mortuary in December 2000. That was more than 11 years after the individuals concerned had died. Hearing that news, the families made arrangements for the interment of that human tissue, including the choice of a remembrance plaque. However, today, I was told that the items referred to could no longer be found.

Mr. Michael Portillo (Kensington and Chelsea): I am most grateful to the hon. Gentleman for his courtesy in giving me a moment of his time. He may recall that I was Minister of State for Transport at the time of the Marchioness disaster. The terrible morning when we learned that so many people had been lost in that tragic accident is one of the most abiding memories of my life, and I have tremendous sympathy for the relatives of those who died. However, Paul Knapman is my constituent and I know that the Lord Chancellor wrote to him to admonish him for some of the events connected with the Marchioness disaster. Paul Knapman wrote back to the Lord Chancellor to express his contrition. I believe that the Lord Chancellor is of the view that the matter should be allowed to rest there, and I appeal to the hon. Gentleman to accept that also.

Mr. Pond: I thank the right hon. Gentleman for that contribution and I know that he knows well the circumstances of the Marchioness tragedy. I have welcomed the admonishment by the Lord Chancellor, to which I shall refer later, and also the response from Dr. Knapman. However, as I hope to show, several other concerns need to be taken into consideration. It may be that the unfortunate circumstances of Dr. Knapman’s conduct in the Marchioness tragedy and subsequent events have been reflected in other cases.

One such was the case of Susan Annis, whose parents have contacted me and my hon. Friend the Member for Crawley (Laura Moffatt), who is unable to contribute to this debate because she has other duties this evening. Miss Annis was a 31-year-old nurse who was the first of

23 Oct 2002 : Column 380 a series of victims of one of her colleagues, Kevin Cobb, who attacked women sexually, having administered midazolam, a sedative since dubbed a date-rape drug. Although Dr. Knapman detected midazolam in Susan’s body, he attributed no significance to it, even though four deaths due to the drug had already been reported to the Committee on Safety of Medicines. A colleague of Susan Annis, Dr. John Parsley, wrote to Dr. Knapman to raise doubts about the open verdict, in view of the presence of the drug. In a letter dated 26 March 1997, Dr. Parsley warned:

I believe that drugs in the same class as midazolam have been used in assaults.”

Dr. Knapman wrote back saying:

It takes us no farther”,


I am taking matters no farther”.

He later dismissed Dr. Parsley’s warning as a Xred herring”. He also did not report Dr. Parsley’s concerns to the police. New information suggests that Dr. Knapman may well have known that midazolam was in the same class as a drug banned in America as a date-rape drug. At present, that evidence is confidential and I am passing it to the Minister after the debate for her to consider whether she or her ministerial colleagues wish to take the matter further.

It was only when Dr. Parsley went to the police two years later, having heard that Kevin Cobb had been arrested for rape, that it became clear that Susan had died at the hands of a serial rapist, rather than from unexplained but unsuspicious causes. The tragic conclusion must be that if the coroner had taken more heed of the warnings raised by a medical colleague and had referred those to the police, Kevin Cobb might have been apprehended sooner and other women would not have been subjected to sexual assaults.

Susan Annis’s parents submitted a complaint to the Home Office about the way in which their daughter’s death was treated by the coroner. The Home Office replied that the Home Secretary had no powers to investigate or comment on the conduct of individual inquests, because

coroners are independent judicial officers”.

However, the Home Office passed on Dr. Knapman’s response to the complaint. It included a somewhat chilling statement that

in his district, several times a year relatively young people (under 30) die where there is no cause of death found”.

No cause of death was found by Dr. Knapman in the case of Susan Annis, but we know now that she was unlawfully killed. In how many of the several other unexplained deaths every year in the district covered by Dr. Knapman is the cause of death not found because the proper questions are not asked, or evidence is overlooked? I ask the Minister to consider whether her Department or the Home Office should look again at those cases in which the Westminster coroner has recorded an open verdict, to see whether the verdict is a secure conclusion in each case. The hurt and humiliation because of the treatment of their loved ones’ remains were not confined to the Marchioness families. In August 2000, Dr. Knapman wrote to the parents of Susan Annis refusing their

23 Oct 2002 : Column 381 request to see the file on their daughter’s inquest and telling them that they would have to ask the police if they wanted to see post-mortem photographs. Astonishingly, in the same letter, written almost four years after Susan’s death, the Westminster coroner added a paragraph that concluded:

Xthe brain is still in storage at the Maudsley Hospital. I therefore have to ask you whether you would be content for it now to be incinerated in the usual way?”

That was the first that the parents had heard that the brain of their daughter had been removed and that she had been laid to rest without it. I have referred to the concerns expressed to me about the conduct of Dr. Knapman in two particularly high-profile cases. Some of it will have been new but most of it will not. In answer to a parliamentary question tabled by me, my hon. Friend the Parliamentary Secretary, Lord Chancellor’s Department reported that, following Lord Justice Clarke’s inquiry, the Lord Chancellor concluded, as the right hon. Member for Kensington and Chelsea (Mr. Portillo) has reminded us, that

the Westminster coroner’s actions on this occasion fell below the standard to be expected of a judicial officer”,

and that

he issued a formal admonishment.”—[Official Report, 6 November 2001; Vol. 374, c. 200W.]

The Westminster coroner has been shown the yellow card. I ask the Minister to review the conduct of Dr. Knapman over time, not only following the Marchioness tragedy but in other cases, to judge whether it might now be time to show the red card. There are wider lessons to be learned about the role of coroners. I welcome the current review of coroners and death certification, which was partly stimulated by the conduct of the coroner in the Marchioness inquiry. A basic requirement is for the careful recording of information, not—as in the case of the Marchioness post mortems—notes collected in an A5 notepad. Without that careful recording of information, it is very difficult for relatives or other concerned parties to know whether an inquiry has been properly carried out.

I have already referred to the need for training of coroners and their staff to enhance the social skills needed to deal with the bereaved sensitively. In that context, I welcome the review’s early identification of a defect in the system—failing to establish clear participation rights for bereaved people, including the provision of information. Most important, relatives must have a right to see the bodies of their loved ones. Whether they decide to exercise that right is up to them.

No families should ever again be treated as the Marchioness bereaved clearly were: as a troublesome nuisance. The coroner’s review gives us an opportunity to learn the lessons of the past. If it does, it will be a lasting tribute to the work of those bereaved families who have fought so hard to ensure that in future no families find that they have to cope with humiliation as well as grief.”

” In how many of the several other unexplained deaths every year in the district covered by Dr. Knapman is the cause of death not found because the proper questions are not asked, or evidence is overlooked? I ask the Minister to consider whether her Department or the Home Office should look again at those cases in which the Westminster coroner has recorded an open verdict, to see whether the verdict is a secure conclusion in each case.”

The full report can be read here:

Questions remain such as:

Did an investigation ever take place into Knapman’s conduct?

Did the Home Office look into all open verdict cases recorded by the coroner?

Are the results of other high-profile inquests undertaken by Knapman secure or should they too be reopened?

Why did Her Maj make Knapman a Deputy Lieutenant for Greater London along with Westminster Councillor Robert Davis?

Why have they both apparently been replaced?

We have absolutely no idea.



Original Article


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