Information for and from inquests
Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the death of a patient. This should include contact with the patient's family.
- The Chief Coroner has issued a comprehensive series of numbered guidance notes covering various aspects of coroner practice, many of which have been consolidated into "Guidance for Coroners on the Bench" (a comprehensive bench book). This guidance covers whom to approach in gathering information about whether to hold an inquest, including contact with the deceased's family (Chief Coroner's Guidance, Judiciary).
- The Coroners and Justice Act 2009 establishes a general duty on the senior coroner to investigate deaths where the coroner has reason to suspect that the death was violent or unnatural, or the cause of death is unknown. The investigation process includes gathering information from medical professionals, employers, and the deceased's family.
- The Chief Coroner's Guide to the Coroners and Justice Act 2009 (published September 2013) provides detailed guidance on the Act's provisions including information-gathering procedures.
- The statutory medical examiner system (from September 2024) complements this by providing a formal channel through which concerns identified during medical examiner scrutiny — including family concerns — can be referred to the coroner.
How was this evidence gathered?
Response
Accepted
Response
AcceptedThe government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
Medical Examiner system became statutory from 9 September 2024 under Coroners and Justice Act 2009 (as amended by Health and Care Act 2022). Independent medical examiners must scrutinise all deaths not referred to a coroner. Full national rollout achieved, implementing Francis recommendations on death certification.
Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS.
Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year.
Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted.