Recommendation F274: Information to coroners

All medical practitioners must adhere to the GMC Good medical practice and to applicable information governance law and policies. It is not anticipated that such requirements will impede medical examiners passing on feedback and referring concerns as appropriate, but if in doubt in a given case, advice should be sought (for example, from the appointing NHS body’s Caldicott Guardian) where appropriate.

Medical examiners have now been introduced as set out in Recommendation 45. The National Medical Examiner favours an assumption of transparency and openness to empower bereaved families. When a bereaved person who spoke with the medical examiner office about causes of death makes a reasonable request to see records of medical examiner scrutiny, these records should be shared where possible.

Medical Examiners are subject to statutory Duty of Candour as set out in Recommendation 21.

Recommendation 274 was in line with the government’s commitment to greater openness and transparency across the National Health Service, particularly when things go wrong.

The Coroners and Justice Act 2009 gives coroners powers to require a person or organisation in England and Wales to provide evidence and to require a witness in England and Wales to give evidence at an inquest. The 2009 Act makes it, “an offence for a person to do anything that is intended to have the effect of (a) distorting or otherwise altering any evidence, document or other things that is given, produced or provided for the purpose of an investigation…. (b) preventing any evidence, document or other thing from being given produced or provided for the purposes of such an investigation or to do anything that the person knows or believes is likely to have that effect.” This offence is limited to actions where there is “intention” to distort or alter evidence, and is punishable by a fine and / or imprisonment. The Ministry of Justice is currently conducting a post-implementation review of the 2013 coroner reforms in the Coroners and Justice Act 2009, which includes the reforms’ provisions on disclosure of information. The call for evidence and survey element of the review finished at the end of 2015, and the Ministry of Justice is now considering the responses received. The Department of Health understands that it hopes to publish a response document in the spring.

In response to the Mid Staffordshire NHS Foundation Trust Public Inquiry the Government introduced a statutory duty of candour which came into force on 27 November 2014 for NHS Trusts, Foundation Trusts and some special health authorities that provide care and treatment to people that is regulated by the Care Quality Commission (CQC) and for all other providers registered with CQC on 1 April 2015. The statutory duty of candour applies to organisations, rather than to individual members of staff. However, it is designed to foster an open culture throughout the organisation, and providers are accountable to CQC for meeting the duty of candour. CQC are able to take enforcement action against the provider, and in certain circumstances its board and senior management, where breaches of the duty of candour have been found. Providers of care will therefore be expected to implement the new duty of candour through staff across their organisations - including educating, training and, if needs be, disciplining their staff appropriately.

In addition, The NHS Serious Incident Framework published in 2015 provides advice on provision of information regarding serious incidents to coroners, patients and their families. It is available at

https://www.england.nhs.uk/patientsafety/serious-incident/

CQC will look at how safe care is for patients as part of the inspection of NHS Trusts.