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Inquests - An Insight for Care Providers

on Tuesday, 03 April 2018.

Inquests can be a difficult and stressful experience for all concerned, requiring careful preparation and a considered approach throughout. In this article, we set out some useful guidance for care providers.

Deaths that occur within care homes can often give rise to suspicion concerning the conduct or misconduct of care providers and their employees.

Inquests can be a difficult and stressful experience for all concerned, requiring careful preparation and a considered approach throughout. In this article, we set out some useful guidance for care providers.

Overview

  1. What is an Inquest?
  2. Preparing for an Inquest
  3. Inquest Conclusions
  4. Preventing Future Deaths (PFD) Reports

What is an Inquest?

A coroner can require an investigation into a person’s death if they have reason to believe that the deceased died a violent or unnatural death, the cause of death is unknown or where the deceased died in custody or otherwise in state detention.

An inquest is a public court hearing held by the coroner, to establish who died, how they died and when and where the death occurred. The function of an inquest is to seek out and record as many of the facts concerning the death as the public interest requires. It is inquisitorial in nature and is not a forum for apportioning blame or liability.

The coroner, who is an independent judicial office holder, usually has a legal background but may sometimes be a doctor. They will usually sit alone but the law requires certain inquests to be held by the coroner sitting with a jury. The coroner will set the parameters of their inquiry, having regard to the function of the inquest and the public interest requirement.

A pre-inquest review hearing may be held for complex cases, allowing for effective case management. It enables the coroner to identify the issues and concerns of the interested persons, any outstanding disclosure and the availability of witnesses requested to give evidence. This ensures that the final inquest can then proceed with focusing upon the pertinent issues with minimal delay.  The majority of inquests are heard in less than a day.

An inquest must usually be completed within six months of the date on which the coroner is made aware of the death, or as soon as is reasonably practicable after that date. The coroner is required to report to the chief coroner any inquests that have not been concluded within a year.

Preparing for an Inquest

Care providers and their staff are often requested to attend the inquest as a properly interested person (PIP) and/or as a witness.

The coroner determines who should be afforded the status of a PIP, which is usually  the immediate family of the deceased and any other person who the coroner thinks has a sufficient interest. Where the coroner believes that the acts or omissions of the care provider or their staff may have caused or contributed to the death, they will be deemed a PIP. The PIP is entitled to disclosure of all evidence deemed to be relevant by the coroner and can participate in the inquest through the questioning of witnesses and addressing the coroner.

Where a care provider has not been designated a PIP and considers that they should be, representations can be made to the coroner for them to be named as such. Each case will depend on its individual circumstances and whilst there may be merit to being a PIP within certain inquests, it could be disadvantageous for others. Careful consideration is required, with regard given to the potential publicity and wider reputational risks.

The care provider may be required to assist the coroner with the gathering and disclosure of documentation. Unless any requested material is privileged, it would likely need to be provided to the coroner. Assistance may also be requested with obtaining statements from members of staff and securing their attendance as witnesses at the inquest.

The care provider must notify the Care Quality Commission (CQC) if the person's death took place while a regulated activity was being provided or may have been a result of the regulated activity or how it was provided. Unexplained deaths, as well as being reported to the CQC, may also require reporting to the Health and Safety Executive (HSE). The regulators may then commence their own investigation to establish whether there have been any regulatory breaches, which might give rise to enforcement action being taken.

There should be careful consideration of the risks; potential conclusions, supporting members of staff required to give evidence and to the steps that could be taken to protect the reputation of the care provider and reassure residents and their families, staff and the general public.

Inquest Conclusions

Once all of the evidence has been heard at the inquest, the coroner (or jury) is required to decide the medical cause of death and arrive at a conclusion by making findings of fact, based upon the evidence.

The conclusion will need to establish the answers to the four questions of: who the deceased was; when their death occurred, where the death took place and how the deceased came by their death.

When recording the cause of death the coroner or jury may use one of the following terms:

  • accident or misadventure
  • alcohol/drug related
  • industrial disease
  • lawful killing/unlawful killing
  • natural causes
  • open
  • still birth
  • suicide

The coroner may also provide a narrative conclusion, which will set out a more detailed narrative of the facts surrounding the death and their reasons for reaching their conclusion.

Preventing Future Deaths (PFD) Reports

Coroners have a duty to investigate and make reports to a person, organisation, local authority or government department or agency, where they believe that action should be taken to prevent future deaths.

Care providers who are the subject of such reports are required to give the coroner a written response within 56 days of the report being sent. The coroner is then required to send the response to the chief coroner, any interested persons who the coroner considers should receive it and to anyone else the coroner believes may find it useful or of interest. This may include the CQC or HSE, who might utilise the PFD report and any response to inform their respective investigation.

Any perceived risk of future deaths, which might give rise to a PFD report, should therefore, insofar as possible, be identified and addressed in advance of the inquest.

We provide advice, support and representation to care providers, throughout the inquest process.


For more information or questions on inquests, please contact Andrew Andrews in our Regulatory Compliance team on 020 7665 0864.

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