Coroner’s Investigation and - PowerPoint Presentation

1. Coroner’s Investigation and Learning from DeathsAndrew HarrisSenior Coroner, London Inner SouthProfessor of Coronial Law, Queen Mary London University2nd February 2023

2. Deaths in England and Wales500,000 deaths E & W: Dr issues MCCD31% reported to coroners ↓43% reported have autopsies ↑17% of reported to inquest: ↑Coroner may enquire, investigate, inquest and issues Record and whatever stage enquiries end leads to MCCD for Registrarwww.gov.uk MoJ coroner statistics 2022

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4. Medical Cause of DeathDr should state MCD (BDRA 1953) whether or not going to coroner/pathologist, mentioning contributory causes1c underlying caused 1b caused immediate cause 1aAntecedent cause needed: “Aspiration” insufficientEntries in II contribute to death, on balance of probability, but do not (directly) relate to disease in 1To best of knowledge and belief: lower than probableSeek advice of Medical Examiner** Requirement to take reasonable steps to determine MCD: No. 38 Guidance for RMPs on Notification Regs 2019

5. Source of Referrals to CoronerHospital Doctors - apply death Notification regulations advised by MEsPolice refer deaths in community, mostly unknown cause, declaration as to non suspiciousA small number from other sources -Registrars, Hospices, GPs, or members of publicTransfers from other coronersDirections from Chief Coroner

6. Notification of Death Regulations 2019*Exposure/ contact with toxic substance – acute not chronic but all industrial. Implications of Kissi-Debra?Use medicinal product, psychoactive substanceViolence, trauma, injury, self harm – any time eg old RTANeglect/ self neglect (lack of care ? contributed)Unexpected, mistake, procedure ? contributedOtherwise unnatural (not entirely from disease)In State Detention – under mental health sectionMCD not known, after consultation (not with coroner)*Where reasonable cause to suspect that death is due to or contributed by, more than minimally, trivially or negligibly

7. Investigatory duty of CoronerCoroners and Justice Act 2009 (CJA) A senior coroner who is made aware that the body of a deceased person is within that coroners area ….. if the coroner has reason to suspect that… the cause is death is unknown orthe deceased died a violent or unnatural death orthe deceased died while in … state detention (s1(2) must as soon as practicable conduct an investigation into the person’s death (s1(1))Preliminary enquiries (s1(7))

8. Coroners InvestigationsCoroner may take no further action e.g. where content that natural death but coroner notified as recent medical interventionCoroner may consult NOK and if MCD accepted by family, autopsy may be avoided and Form A issuedCoroner may open autopsy at outset – unnatural, MHA, industrial diseaseAutopsy may be ordered and if natural MCD and no reason to continue investigation, can be discontinued with Form BIf investigation opened, further clinical enquiries re family concerns or possible failures in care.Decisions depend on sufficient information, submissions, advice

9. DEATHCause of deathnatural and knownFamily take MCCD to Registrar of DeathsBody can be collected, buried, cremated or repatriatedCause of deathnot known or unnatural Refer to Coroner: enquiriesCremationformAutopsyForm AForm B ConsentedautopsyClinician issues MCCD Open investigationDiscontinue investigationRecord of Inquest sent to RegistrarOpen inquestM ENFA

10. Unnatural medical cause: may be natural in lawWhere a medical intervention fails to prevent death from the underlying fatal cause, even if treatment was wrong, or negligent failure to treat, death is naturalR v Birmingham Coroner ex p Benton (1997)Most deaths following emergency treatments are referred, and coroner usually finds naturalSome investigation of complications in elective treatment: context sensitive how many go to inquest. Expert evidence may be needed on how ill and likely outcome before treatment and its effect

11. Natural medical cause may be unnatural in lawMothers BP not monitored post delivery, dying of brain haemorrhageR v Inner North London Coroner ex p Touche [2001] EWCA Civ 383; Thomas abandonedMay be more than one cause, either making it unnatural ; only look for dominant cause in opening.. Look for combination of circumstancesWholly unexpected deaths from natural causes which would not have occurred but for culpable human failureWhere there is a possibility of “neglect”, even of contributory cause, investigate if unnatural (not negligence) Only possibility of alternative cause of death needed to investigate (delay in diagnosis of septicaemia)Bloom v ADC North London v Whipps Cross Hospital [2004] EWHC 3071 (Admin)

12. Missed diagnosis may not need investigationTransverse myelitis. Fever, SOB, abdominal distension.Diagnosis = constipation.Unexpected death. No known cause.Autopsy: 1a small bowel ischaemia and infarction 1b Twisted mesenteryWhether to open investigation depends on reason to suspect culpable human failure.Usually has distension, given antibiotics, had urgent MRI.Issued B.

13. High risk interventions may not be investigatedPMH 70y CVA, MI, CRF awaiting renal transplant. Elective repair aneurysm with dissection. Very high risk.1a Embolic stroke 1b AAA with dissection (operated)Bleed and CVAs during op. Not regain consciousness. Discuss with clinicians. Not unexpected. No PME. Form A. Consider main cause, time frame, level of risk, NOK views

14. Complications of operations investigated where unexpected or different evidence Pancreatitis. Jaundice. Cholecystectomy for gallstones. Post op ITU. Laparotomy.Family wanted earlier admission; inform of stent surgery and GI bleed not mentioned in death reportPME: 1a sepsis Ib Pancreatitis and gallstones (operated)Investigation - GI bleed also cause of death from ruptured hepatic artery at surgery and pancreas necrosis;“Nat causes and conseq nec medical treatment” Should have had specialist biliary surgeon (PFD)

15. Cause of falls and ♯ NOF81y, MI, dementia, diabetes; Fall ♯NOFHypotensive post op, death Day 21a Pulm oedema 1b IHD II ♯NOF (operated) OsteoporosisWhat does coroner do?Consult NOK – no concerns about care. Consult ME - Osteoporosis and old age caused Fall and ♯NOF. Pulmonary oedema post operative.Coroner - Not unnatural as underlying natural cause. Form A

16. Interested PersonsStatutory (S47 CJA)close relative, personal representative (includes civil partner, step-parents, half sibs)life insurer, TU if occupational, enforcing authority, IOPC, gov appointeeAny person being criticized in connection with deathMedical Examinerpolice where homicide related offenceAny other C thinks has sufficient interestLd Ch may issue guidance on IPs participation and role of Cor officers (CJA 42)Coroner must handle family distress empathetically but treat all IPs equally.Rights include notifications of autopsy, investigation, transfer, inquest, and rights to make submissions and to question witnesses

17. Coroner’s InquestRole of Coroner is to determine answers to 4 questions (only): who, where, when and how a deceased person came by their death. How is usually “by what means” and not wider circumstances (A2)Coroners may therefore only investigate the quality of end of life care in cases referred to them where relates directly to cause of death. Establish why you are giving evidenceto explain technical mattersto give reasons for clinical decisionsto answer questions from familyas you are being criticised and may have contributed to death

18. Witness EvidenceYou can be compelled to give statement/ exhibit; can submit why notMake sure you know why you are called: often to explainYou can be compelled to attend but have privilege against self incriminationAnswer question, speak slowly, lay language, stick to your expertise, ask if poor understanding, need breakThe evidence is what is heard in court unless readYou can be questioned by coroner and IPs; inconsistency, deviation and deception damage credibility of all your evidence

19. NHS Learning from deathsInternal mortality Review; MMR meetings; Clinical auditExternal investigations: HSIB, NCPOD, MBrace, PPOMedical Examiner – coroner may ask about care deficits. Is IP.Personal learning – be prepared to answerConsider self referral to professional body if appropriateDepartmental or professional discipline changesSUI / RCA being replaced by Patient Safety Incident Response Framework (fewer, in depth). Cor: Witness re action plans. Interagency governanceCourt recognizes trauma for professionals – strong learning stimulus

20. Coroner Preventing Future Deaths in E&WAnything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and (no longer “similar death”)in the coroner's opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances,the coroner must report the matter to a person who the coroner believes may have power to take such action.Paragraph 7, Schedule 5, Coroners and Justice Act 2009;

21. E&W Regulation 28 ReportsAbout 450 / yr, 1 in 600 inquests; 36% hospitalNo longer can make recommendationComplete report within 2 weeks of inquestCan copy to others e.g. Royal College, MinisterWrite response in 56/7, state action or why noneNo enforcement; Publish unless good reasonCopied to IPs and Chief CoronerRegulations 28 and 29 of the Coroners (Investigations) Regulations 2013

22. Revisiting PFD reportsExamples of failures of care or service provisionReports issuedAction plans madeCoroner does not learn whether medium or longer term plans come to fruition or whether necessary engagement of other agenciesUltimately unclear if beneficial change occurs until similar death represents to coroner’s court

23. Post operative care of child of 2yPost elective op intra-tumoral haemorrhages. Astrocytoma.Failure of referral by Paed contributedExpert: poor recording GCS, late intubation, poor mgt seizures, handover. Unskilled nursesTrust non-compliant with RCN guidance on paed nursing. Not recruited to 5 posts @16/12Paed monitoring, training, NPractnr, trigger escalation to anaesthetist, Exec recruitment campaign paed nursesDH/HEE: 6.9% gap!. Training Investment 7.4%. Has it happened?

24. PFD: no obstetric theatre41/40 induced FtP; 1hr 40 mins Categ 2 LSCSApgar 9, few PN obs; found at 2 hrs ?causeHIE contributed by neglect (lack of obs)RCOG: defined no. CTGs and theatres neededTrust: no dedicated obstetric theatre ooh, Theatre next to labour ward will be emerg 24hrBusiness case ODA and nurses: how successful? Increase x3 ELSC theatre sessions: reportedly has happened

25. Therapeutic overdose of Fentanyl in childCP aged 10 sees non UK locum in A&ER 25 mcg patch Fentanyl and dischargeWho checks fitness to practice of locums, secures full past history, monitors locums?GMC: can’t disclose possible concerns to TrustTrust: change pre employ checks, revalidation (introduced 2012)DH: ROs, Trust must tell CQC stds of Agency; Additional Fentanyl guidance

26. Nurse staffingPVD Diab, RTA- ICU low GCS.Ward: No air mattress, insuffic turns– lack staffBed sores. Sepsis. Trust: Training, Modern Matron e audit, RCAs210 Air mattresses – now 300Different ward now for neuro patients20: 32 nurses/beds at time now 20: 20

27. PFD: Alcoholic 1a Lactic Acidosis 1b Cirrhosis 1c Chronic Alc abuse.Street sleeper in A&E. Lethargic, BP 110/35. Waited for Dr.Found slumped T24, BS 0.9.Assess, observe, triage of confusional statesTrust: Rapid assessment + transfer introduced, Sr Decis maker 1hr 13’ av time, urine test Alc, Mental Capacity training, Temp staff inductionSoS: CQI skilling, time to treatment target, NICE, med education

28. PFD: Inhalation of foodSex abuse alcoholic suicidal; seizure- discharge1a Inhalation of food 1b Alc intoxicationShortage residential alcohol rehab centresTrust: complex needs dual diagnosis, motivation must be high for admittancePCT: needs assessment alcoholics – service is adequate but will build more capacity

29. Housing for Borderline personality disorderHIE post respiratory arrest, ? Subdural haemorrhage from head bangingS2 MHA chronic self harm, not psychoticNo suitable housing for BPD led to deliberate self harmCollaborate on pathways and consider pilot – Redesigned direct access hostel with psychologist for BPDHas interagency work borne fruit?

30. Prevention of Community Suicide23yM, sui attempts, Family concern risk known, suicidal ideation by rail/jumpA&E CPN discharge. 10 hrs later on rail.Trust: Awareness bulletin, new care pathway MH teams, Review Clin Risk Assessment policy39yM, homeless, paedo, sui ideation; discharged with no record risk assess or FU; jumps under train Staff awareness, FU contact numbers. 500K investment in homeless

31. Physical care MH patients -antipsychotics1. 2014 DKA: Gluc not tested 1 yr. Clinics review/ new standards set2. 2014 Cardiac arryhthmia Need in-reach DVs by physicians3. 2015 HONK D: Decomposed 1/12 after discharge. Neglect.GP reg, community review, audit, spvsn, Physical HC lead, commissioners, D liaison4. HONK Olanzapine. BS 57 no insulin/fluids. 2hrs transfer A&E Physician attend MH (impossible). MEWs, new protocol; London /NCEPOD work; Need more gen nursing in RMN course

32. PFD: Asthma44 yr 1a RDS 1b LRTI 1c Sleep apnoea, asthmaPost dent op tachypnoea R Diazepam ‘anxiety’Vital obs not recorded, only 1 PEFR in GP recordsGP: clinical changes, practice meeting, prescribing and CDM system changesNHS E investigate: limited applicatn/reflection, medical records review; MDU: now bought equipment, awareness and real change

33. Subjects of PFD Reports LIS 2020Need for systematic system of measuring wt in hospital; Individual Dr appraisal - not recognizing GI bleed and Hb drop was acute riskPolice links with NHS MH teams when facing suicide riskEnsuring GP informed of acute deterioration in disabled child medicated with antibiotics from hospital by parentsFailure to contact NOK in MHA assessment; dismissal of GP concerns of psychosis; Inadequate RCA process by TrustNeed for national register of food allergy deaths;Availability of auto-injector devices

34. Subjects of PFD Reports LIS 2021Prison sui 34y: Immediate needs form not completed. New system checks.Prison suspension 30y: ACCT closure, HC participation. National review.35y ABD police restraint. Lack engagement paramedic. MPS scenario training; LAS senior assignment, digital support. Separate refer back IOPC.63y drunk left in bus bay. Failures in risk assessment. First aid training for police in assessing breathing and consciousnessNon escalation post-op deterioration 59y with sepsis. Clinical review.Delay in antibiotics for septic shock in 72y. Review of practices in Trust.33y domestic murder. Fail info share and intervention coercive behaviour. Police review MASH processes. DWP review CMS support.17y DV. MPS workload CSUs. Vio v F strategy. Public Protection Review

35. Kissi-Debra 20219 yr severe asthma; episodes of arrest and frequent emergency admissions:1a) Acute respiratory failure 1b) Severe asthma 1c) Air pollution exposure Failure to reduce the NO2 to within EU domestic law limits; possibly contributed to her death from exposure to traffic 2010-13 Thousands of premature avoidable deaths every year in the UK.National limits for Particulate Matter are set far higher than the WHO guidelines. Defra, DoT and DHSC Low public awareness of sources of information about pollution. More air quality sensors. Defra, DoT, DHSC Mayor, LBLAdverse effects of air pollution poor communication to patients and carers. GMC HEC NMC; Royal Colleges, NICE, BTS

36. Preventing Future Deaths in E&WE&W coroners obligation to report but cannot report unless statutory criteria metAddressees must respond - and sharedTargetted reports in E&W have beneficial effects especially when augmenting other initiativesNo enforcement nor brought before Assembly but high media profile facilitates changeNo follow up or or analysis of trendsFamilies hugely appreciative especially in NHS

37. Preventing Future Deaths in AustraliaDo not need unnatural or unknown death to - May open inquest if public interest PFD (s28)Coroner may make recommendations about public health, safety, admin justice (Cor Acts: Vic s72, Q s46 SA s25, Tas s30)C must state if public safety etc (ACT s52)W and NSW Recommendations can become statutoryActions if report to AG, goes to Assemblies(SA s25, ACT s57 (in fire “may”; in disaster “must”)My view: lack of academic study what is effective in PFD

38. Justice Select Committee Report 2021Recommendations to MoJ June 2021. Govt: HC can amend Record, remote inquests, written inquests.Rejected: National Coroners Service, rights to Legal aid for families, fee increase for autopsy pathologistsDefer: independent office/inspectorate, Charter of Rights, Appeals, PFD Re PFD reports: provide funds for information about the risks to public safety from inquests being freely available and accessible onlineset up an independent office to report on emerging issues raised by coroners; and liaise with regulators, eg HSE CQC Air and Rail safety bodies, to follow up on actions promised to coroners and to report publicly where insufficient action.

39. ConclusionsMedical Examiners huge help in certification and advice to coroner, reducing unnecessary notifications to coroner.Variation in coroner practice in investigation post operative complications reflects lack of clarity in law. Family submissions keyClinicians being criticized have same rights as IPs as familyHigh level of credibility and reliance on evidence of clinical witnesses. Should answer questions as to events and reasons for decisions, but inquest should be non adversarial. Anonymous Record, ‘neglect” v rare.Investigations/ inquests give closure to families and opportunity for prevention future death reports