Inquest

The Health and Social Care ('HSCB') should be notified promptly of all forthcoming healthcare related inquests by the Chief Executive of the Trust(s) involved.

Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.

Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.

In the event of a Trust asserting entitlement to legal privilege in respect of an expert report or other document relevant to the proceedings of an inquest, it should inform …

A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the …

Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.

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 …

The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.