Inquest
Recommendations related to inquest
8
Recommendations
100% accepted
Government Response
Accepted (7)Accepted in Part (1)
Recommendations in This Theme
recommendation across 3 inquiries
Across 3 inquiries
Tagged Recommendations
8 total
IHRD-50
Accepted
Hyponatraemia Inquiry
HSCB Notification of Inquests
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.
- HSC Trusts reported that procedures for engagement with the coronial process had been updated (IHRD Implementation Programme, Department of Health NI, March 2018). - …
HSC Trusts
IHRD-51
Accepted
Hyponatraemia Inquiry
Independence of Coroner Witness Statements
Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.
- HSC Trusts reported that training for clinical staff on coronial and inquest procedures had been provided (IHRD Implementation Programme, Department of Health NI, March …
HSC Trusts
IHRD-52
Accepted
Hyponatraemia Inquiry
Inquest Duties Protocol
Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.
- HSC Trusts reported that arrangements for supporting families through inquest proceedings had been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - …
HSC Trusts
IHRD-53
Accepted
Hyponatraemia Inquiry
Legal Privilege Disclosure to Coroner
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 …
- HSC Trusts reported that processes for implementing recommendations arising from inquests had been formalised (IHRD Implementation Programme, Department of Health NI, March 2018). - …
HSC Trusts
30
Accepted
Morecambe Bay Investigation
National protocol on duties relating to inquests
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 …
- In July 2015, the government stated: "We accept this recommendation in principle" and said it would "give further thought, with the Ministry of Justice …
NHS England
F282
Accepted
Mid Staffs Inquiry
Information for and from inquests
Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
- NHS England stated in April 2025 that Regulation 28 reports (formerly Rule 43) are shared with the CQC when it is a named respondent …
Coroners
F283
Accepted
Mid Staffs Inquiry
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 …
- DHSC and NHS England stated in April 2025 that the Judicial College provides induction and annual training for coroners and their officers, and the …
F45
Accepted in Part
Mid Staffs Inquiry
Use of information about compliance by regulator from: Inquests
The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation was superseded by the statutory medical examiner …
CQC