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If your care service is unfortunately involved in a death that will be referred to a Coroner, we can provide you with an experienced healthcare legal team that understands the procedures, appreciates the sensitivity of the situation and recognises how to protect your service from potential criticism.

Coroner’s inquests are a frequent occurrence with the care sector. Deaths may be referred to the Coroner for a variety of reasons, including where the cause of death was unknown or has an unnatural element, the individual had not seen their doctor during their final illness or where death has occurred during an operation.

The Coroner will be under an obligation to investigate these deaths, which will frequently result in an inquest hearing. The Coroner has two main functions. The first is to establish who the deceased was, and how, when and where they died. The Coroner’s secondary function is to prevent future deaths if he becomes aware of any circumstances which may cause or contribute to a death in the future.

The investigation and inquest process will usually involve witness statements being provided by members of staff or the care provider, GP, hospital and others, to the Coroner. Frequently those statements will provide details of the individual’s care needs and how those needs were being met, together with details of any specific incident which may have led to the death. Most witnesses will also be required to attend an inquest hearing to provide live evidence. This can be a stressful and daunting process for staff, particularly if they have never attended an inquest or been to court.

An inquest hearing is held in public and it is not uncommon for press reporters to be present. Any criticism of the service can result in adverse publicity, alongside the risk of a report to prevent future deaths or action by CQC. It is important to ensure that you and your staff are adequately prepared in advance of any inquest hearing and that you have taken steps to ensure the best possible evidence is before the court, in order to minimise any risk to your business. In some cases, you may be entitled to apply for interested person status and to obtain advanced disclosure of the evidence the Coroner is likely to hear.

How can our healthcare solicitors help?

Coroners are required to complete their inquests within six months unless there is good reason for not doing so, therefore it’s important to respond to their requests for information quickly.

We can help you with the process of gathering statements from relevant witnesses, such as care staff, and preparing of bundles of appropriate evidence efficiently, so you can deliver what’s needed to help the Coroner carry out their investigation, whilst also helping you present evidence to the Coroner in the best light.

As well as helping you with the practicalities, we can also help you manage any fallout from the inquest. Coronial investigations can lead to criticism of a care service and we can make sure you are properly protected from this.

Our services in relation to coroner’s inquests include:

  • Advice to interested persons or witnesses about procedure
  • Making legal submissions to the Coroner on topics such as whether there should be a jury, what evidence the Coroner should hear and who should attend the hearing
  • Preparation for inquests, including, if appropriate, instructing experts; engaging with the Coroner; preparation of witness evidence and advising you on risk and risk management strategy
  • Preparation with witnesses in advance of an inquest hearing, to ensure they are adequately prepared
  • Representation during the inquiry itself, including any necessary legal submissions to the Coroner relating to the evidence, case law and appropriate conclusion
  • Making representations to authorities who may prosecute for criminal breaches, and handling any criminal proceedings which may result
  • Defending any enforcement action which may be taken by your regulator following an inquest
  • Dealing with claims for compensation flowing from fatal accidents or other injuries, and providing legal representation in court

We have represented care providers and GPs in all parts of England and Wales in inquests in relation to fatalities at care homes, supported living services or other settings. Our significant experience in this area means we have a solid understanding of the law and appropriate strategy for inquests.

We have also represented interested persons in construction deaths, aeroplane crashes, gas explosions and other similar catastrophic events.

What is the inquest process?

Every case is different, but generally, the Coroner will begin by collecting written evidence. This may include post mortem reports, care records, witness statements from care staff, GPs, hospital clinicians and others.

The Coroner will often then hold a pre-inquest review, which is essentially a case management hearing, to make decisions such as whether a jury is required, whether Article 2 of the European Convention of Human Rights is engaged, which witnesses are required and so forth.

Ultimately, the Coroner will hold an inquest hearing at which live evidence will be heard and the Coroner will reach a conclusion about who the deceased was, and how, when and where he died.

If there is any risk of you or your staff being criticised, you should seek advice early to determine if you may be an interested person or entitled to any disclosure. This will also affect your entitlement to ask questions of witnesses and make submissions to the Coroner about the conduct of the inquest, the evidence or the appropriate conclusion.

If in doubt, it is always best to seek legal advice early to help determine what risks you may face and to ensure you are providing the best possible evidence from the outset.

Frequently Asked Questions

If you have prepared a witness statement to assist the Coroner, this does not necessarily mean you will have to attend the hearing. The Coroner will decide who should be called to give live witness evidence at the hearing. If the Coroner requires your attendance at the hearing, you will be asked to attend on either a voluntary basis, or you may receive a formal witness summons. Alternatively, the Coroner may decide to read your statement. You may hear this being referred to as Rule 23 evidence.

A Properly Interested Person (also known as a PIP or an IP) can be a member of the deceased’s family or anyone who has a connection or proper interest. For example, if a person died in a care home, the home will often be considered as a Properly Interested Person. The Coroner decides who should be given Properly Interested Person status. This enables the individual or company to additional rights, such as the ability to apply for a copy of full disclosure and allows them to ask the witnesses questions at the hearing.

The Coroner will ask the witness questions first of all. Any Properly Interested Person or their representative may then ask the witness questions.

Coroners have a duty to consider whether it is appropriate to make a report to prevent future deaths. These reports are known as prevention of future deaths, PFD reports or Regulation 28 reports. If a Coroner has concerns about future deaths, they will write a report requesting the person or organisation to set out what action has been taken to reassure the Coroner that the concerns have been addressed to prevent future deaths. The report and the response(s) will be sent to the Chief Coroner and may be sent to the family of the deceased and others. Where inquests involve a health and social care provider, the Coroner will usually send a copy of the PFD report to the Care Quality Commission (CQC). They may also be published.

It is difficult, although not impossible, to challenge the conclusion or outcome of an inquest. However, the process is complex and there are strict timescales to bring a challenge.


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