The Role of the Coroner and the Inquest Process - PowerPoint Presentation

1. The Role of the Coroner and the Inquest Process Patrick Noonan: Lead Coroners Officer to HM Senior Coroner Cumbria1

2. Coroners Jurisdiction and LegislationThe Coroners and Justice Act 2009The Coroners Act 1988 S13 and S30Coroners (Investigation) Regulations 2013Coroners (Inquest) Rules 2013Coroners Allowances, Fees and Expenses regulations 2013Chief Coroners Guide to the ActGuidanceLaw sheetsCase law2

3. JurisdictionS1 CJA 2009Made aware of a body within the coroners areaReason to suspect that they have diedViolent or unnatural deathCause of death is unknownDied in custody or otherwise in state detention3

4. Reason to suspect?The term is not defined by the ActAdvice given by the Chief Coroner October 2013 A genuine suspicion based on a objective assessment, upon something of substance for the duty to investigate to be triggeredSome good reason - not speculation or guesswork4

5. Violent deathIf the death flows from any sort of traumatic event, accident or deliberate act, self-induced or otherwise.Examples:RTCSuicideMurderFalls Self harm eg stabbingFireCrushed Dog attack5

6. Natural vs unnatural deathsNo statutory definition as to what is natural/un-natural deathNatural death - a naturally occurring illness running its course/normal progression of a natural illness without any element of human interventionA natural cause of death may become unnatural in certain circumstances, where the death was wholly or partly caused or accelerated by any act, intervention or omission other than a properly executed measure, which was intended to prolong life. 6

7. UnnaturalDrugs overdoseAcute alcohol intoxicationDrowningFallsDeath following incorrect medical treatmentPressure soresIndustrial disease7

8. UnknownSome Post Mortem conclusions remain unascertainedAre these natural or unnatural?DecompositionDuty to investigate under Section 1 CJA 2009 is triggered.8

9. Death Referrals50% of deaths in England and Wales are referred to the CoronerNo statutory requirement to report to the Coroner. This may change with the introduction of the Medical Examiner when the Notification of Death Regulations are introduced.The only statutory duty that exists is upon a medical practitioner pursuant to Section 22 of the Birth Deaths and Registrations Act 1953 – transmit to the Registrar a certificate setting out the cause of death (MCCD).9

10. How are death referrals received?The Coroner will receive referrals from:PoliceA medical practitioner or RegistrarChief Coroner Guidance No 23 - Use of appropriate electronic formPermanent record and avoids miscommunicationProvides cause of death where possibleReduces the number of calls to/from Coroners Office enabling Coroners officers to do the work10

11. Medical Certificate of Cause of Death (MCCD)Licenced medical practitionerNatural deaths onlyTreated patient in their last illness and either Saw the deceased within 14 daysOr after deathConsequences of an incorrect MCCDFamily unable to register the deathCase is referred to the coronerDelay in funeral11

12. What cases should always be referred to the Coroner?The death related to any medical procedure/treatmentOccurred during an operation before full recovery from the effects of an anaesthetic or was in any way related to the anaestheticOccurred within 24 hours of admission to hospital (unless the admission was purely for terminal care)The death is linked to an abortionThere are any other unusual or disturbing features surrounding the death12

13. Options for ConsiderationNo further action (NFA)Form 100A – Notification to the Registrar of natural death – no duty to investigatePost mortem – Form 100B – Notification to the Registrar of natural death following a PM – No duty to investigate.Investigation without an inquest (discontinued)Investigation with an InquestTransferForm 120 & 121 – cases suspended due to criminal proceedings and are not resumed.13

14. Types of Investigations with an inquestIndustrial DiseaseRoad Traffic CollisonSuspicious deaths with no suspectNo cause deathsSuicidesFatalities at work Falls (in and out of hospitals and in care homes)Hospital Deaths14

15. Section 5(1) & (3) CJA 2009The purpose of an investigation (with an inquest) is to ascertain:Who the deceased was;How, when and where the deceased came to his/her deathThe particulars required by the Births Deaths and Registrations Act 1953 (known as determinations and findings)Neither the Senior Coroner…nor jury…may express any opinion on any matter other than the matters mentioned above.15

16. Section 10 CJA 2009After hearing the evidence at an inquest into a death the Senior Coroner (or the jury) must make a determination as to the questions mentioned in section 5(1).Any determination may not be framed in such a way as to appear to determine any question of: a) criminal liability on the part of a named person, or b) civil liability 16

17. Hospital deaths (1)Natural vs UnnaturalRecognised complications of treatment and surgerySome cases will require investigation to clarifyNeed to clearly distinguish issues for a complaint or claim from those for the inquestManaging the families expectations17

18. Hospital deaths (2)General rule – Article 2 ECHR and HRA 1998 is not engaged in hospital deathsA jury is not necessary in most casesConsider an independent PMIn exceptional cases, an expert may be instructedIn complex medical deaths – a pre inquest review hearing may be necessary to identify issues/interested persons etc18

19. Falls (1)Increasing numbers, as elderly population rises.Falls may be witnessed/unwitnessed in the community/care home/hospitalConsider medical background and if there is a history of falls, or any underlying natural cause?Has scanning been undertaken?Is there a need for a PM or can a doctor provide a statement?19

20. Falls (2)Falls in the care home and hospital:Was a falls risk assessment undertaken?Was a nursing care plan in place?Was a bed rails risk assessment undertaken?Was the correct monitoring provided?Was the incident report completed at the time?Was the patient assessed by a doctor or nurse practitioner?Was a CT required or undertaken in a suitable time period?Has there been an internal investigation - is it completed?20

21. Witnesses (1)Relevant witnesses to the events/scope of the inquest will be called to verify the circumstances. There is no need to call all witnessesThe coroner will use the witness statements to decide which witnesses are required to attend court to give evidence. Statements will be disclosed to the family of the deceased and any other Interested persons in an inquest bundle, containing relevant statements/reports.Medical records if relevant in a paginated bundle21

22. Witnesses (2)Statements from medical and nursing staff who were involved in providing care to the deceased will be obtained to verify the events. Senior staff witnesses will be called where appropriate.Author of Root Cause Analysis (if there has been one)Where appropriate the Coroner will consider whether an earlier diagnosis/treatment would have prevented death?22

23. Witness statements (1)Take the time to write your statement – do not rush!!Start your statement with your details/employer details/your grade – area of specialityTell the Coroner what your involvement was with the deceased and when – so dates/times. Include all relevant information.Give factual information – do not copy out the contents of medical records.Give reasons for any actions you took or why certain action was not appropriate – reason? 23

24. Witness statements (2)Avoid medical jargon and abbreviations – use simple and plain language that can be easily understood. Explain medical terms where they cannot be avoided and for example, the results of any tests taken.Include the details of any professional colleague that was also involved in the care of the deceased. Conclude your statement by clearly stating the last date/time you were involved in the care of the deceased.Read/sign and date your statement. 24

25. Preparing for & attending the inquest (1)Read your statement prior to the inquest taking place & take a copy with you to the hearing.Consider going to the venue ahead of the hearing to familiarise yourself with the court layout.Observe an inquest taking place.Arrive in good time on the day of the inquest and dress appropriately.Familiarise yourself with the deceased medical file and records in the event you may need to refer to it.25

26. Preparing for & attending the inquest (2)When giving evidence – take your time. Speak clearly and slowly, so that all present at the hearing can hear your evidence. Ensure you have understood the question before you answer it. If you have not understood the question – say so. Answer the question you have been asked. If the Coroner needs further information/clarification, they will ask for it. Address your answers to the Coroner.Be honest with your answers. Try not to be defensive. Don’t speculate.Remember, the deceased family may have waited a long time to ask their questions – take your time and do not rush.26

27. Regulation 28 Reports to Prevent Future deaths (PFDs)(1)Regulation 28 of the Coroners (Inquests) Regulations 2013 and paragraph 7 of Schedule 5, Coroners and Justice Act 2009, places Coroners under a duty to write a report to a person, organisation, local authority or government department/agency where the Coroner believes that action should be taken to prevent future deaths.The importance of Regulation 28 PFDs is emphasised by the fact that what was a previous discretion to issue a report, is now a legal duty on the Coroner. The Coroner will exercise his legal duty power to write a report if it appears there is a risk of other deaths occurring in similar circumstances. 27

28. Regulation 28 reports to Prevent Future deaths (PFDs)(2)The Coroner no longer has to wait until hearing the evidence in court to issue a report. The report can be written at any stage during the investigation, which could be before the inquest takes place, provided the Coroner has considered all the documents, evidence and information relevant to the investigation. The report is sent to the people or organizations who are in a position to take action to reduce the risk, who must reply within 56 days to say what action has been taken.All reports and responses must be sent to the Chief Coroner.28

29. Questions??Patrick Noonan Lead Coroner’s Officer to HM Senior Coroner (Cumbria) T: 0300 303 3180 (Option 3)     01900 706074 (Direct)F: 01900 706915E: patrick.noonan@cumbria.gov.uk  Coroner’s Office |Fairfield| Station Road |Cockermouth |CA13 9PT29