Coroner family information gaps
Lack of clear guidance for coroners' offices on whom to approach for information regarding patient deaths, specifically families.
80 items
1 source
14 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
99match
F283 - 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.
Matched on
terms: coroner, family, information
Inquiry recommendation
95match
F274 - Information to coroners
There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to the priority to be given to openness over any perceived material interest.
Matched on
terms: coroner, information
Inquiry recommendation
87match
F273 - Information to coroners
The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a director is personally satisfied that withholding the information is justified in the public interest.
Matched on
terms: coroner, information
Inquiry recommendation
74match
42 - Information for next of kin
Clinicians shall give the following basic information to the next of kin when a Coroner’s post mortem examination is to be performed. – The nature of the examination, including the need to open the body and to remove and weigh organs. – The need for samples and possible retention of organs.
Matched on
terms: coroner, information
Inquiry recommendation
69match
F282 - Information for and from inquests
Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
Matched on
terms: coroner, information
Inquiry recommendation
66match
79 - Information packs for relatives
Developing and using information packs for relatives on all aspects of death in hospital.
Matched on
terms: information
Inquiry recommendation
65match
1 - Chief Coroner guidance on coroners' records
The Panel considers that the implementation of the Coroners and Justice Act 2009 should bring about a more consistent approach to the archiving and availability of transferred records and encourages the newly appointed Chief Coroner of England and Wales to issue guidance in consultation with the Keeper of Public Records.
Matched on
terms: coroner
Inquiry recommendation
64match
12 - Review and update medical records
The Chief Executive and the Trust Board shall review and update medical and pathology records to include, preferably on computer and cross-referenced, the following information: – name, medical record reference number and date of birth; – date, place of death and death certificate; – name and address of next of kin; – whether Coroner’s or hospital post mortem...
Matched on
terms: coroner, information
Inquiry recommendation
62match
74 - Explain consent after Coroner examination
Explaining that consent is necessary for the retention of organs following a Coroner’s post mortem examination (CPM) and that the consent must be obtained before the CPM is undertaken.
Matched on
terms: coroner
Inquiry recommendation
62match
50 - Introduce Coroner to next of kin
Coroners shall be introduced, their function and procedures explained and the next of kin invited to express any specific concerns and requests.
Matched on
terms: coroner
Inquiry recommendation
62match
46 - Explain Coroner post mortem report
Clinicians shall explain the contents and implications of a Coroner’s post mortem report to the next of kin as if the examination had been carried out as a hospital post mortem examination on their own recommendation.
Matched on
terms: coroner
Inquiry recommendation
61match
IHRD-51 - 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.
Matched on
terms: coroner
Inquiry recommendation
61match
80 - Practical help for relatives
Assisting relatives in the following practical matters: – collecting the deceased’s personal belongings and arranging return to relatives; – ensuring provision of certificate of death and the formal notice; – explaining the procedure to register the death; – providing support in attending the registry office if requested; – arranging contact with funeral director; – arranging contact with hospital...
Matched on
terms: coroner
Inquiry recommendation
60match
IHRD-47 - Post-Mortem Reporting Standards
In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy and completeness of the information briefed them. (ii) Work in liaison with the clinicians involved. (iii) Provide preliminary and final reports with expedition. (iv) Sign the post-mortem report. (v) Forward a copy of the post-mortem report...
Matched on
terms: family, information
Inquiry recommendation
57match
IHRD-53 - 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 the Coroner as to the existence and nature of the document for which privilege is claimed.
Matched on
terms: coroner
Inquiry recommendation
57match
45 - No compulsion for hospital examination
Clinicians requesting a hospital post mortem examination after the Coroner has declined to authorise an examination shall make it clear to the next of kin that there is no compulsion remaining for such an examination.
Matched on
terms: coroner
Inquiry recommendation
53match
83 - Translation and accessibility services
Accessing translation/interpreting services including services for people with hearing or visual impairment and providing appropriate written/taped information.
Matched on
terms: information
Inquiry recommendation
53match
81 - Discuss counselling and support
Discussing counselling or long-term support needs with relatives, including the needs of wider family members and making contact with appropriate counselling/support agencies if requested.
Matched on
terms: family
Inquiry recommendation
53match
55 - Specify retained material in reports
Coroners shall ensure that all existing retained organs, tissue, blocks, slides, photographs and X-rays are specified within any preliminary and final post mortem reports.
Matched on
terms: coroner
Inquiry recommendation
53match
52 - Reasons if examination not authorised
If a decision is made not to authorise a post mortem examination, Coroners shall notify the next of kin of that decision and give sufficient reasons for the decision.
Matched on
terms: coroner
Inquiry recommendation
53match
51 - Advice to next of kin on examination
If a decision is made to authorise a post mortem examination Coroners shall ensure that the next of kin are advised of: – the reasons for authorising the post mortem examination; – their right to ask the Coroner that the examination be carried out by a pathologist independent of the hospital in which the deceased died; – the...
Matched on
terms: coroner
Inquiry recommendation
53match
18 - Keep parents fully informed
parents must never again be drip-fed information but should be kept fully informed.
Matched on
terms: information
Inquiry recommendation
52match
IHRD-43 - GP Notification of Death Circumstances
A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.
Matched on
terms: family
Inquiry recommendation
48match
MACP-42 - Ensure advance disclosure of evidence to parties appearing at inquests.
That there should be advance disclosure of evidence and documents as of right to parties who have leave from a Coroner to appear at an Inquest.
Matched on
terms: coroner
Inquiry recommendation
48match
R69 - Explanation to relatives on CDI death
Health Boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation of the role played by CDI in the patient’s death.
Matched on
classifier match
Inquiry recommendation
48match
IHRD-44 - Post-Mortem Limitation Authorisation
Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of the family.
Matched on
terms: family
Inquiry recommendation
45match
84 - Assist with other problems
Assisting with any other individual problem presented by relatives in consequence of death.
Matched on
classifier match
Inquiry recommendation
45match
71 - Meeting with treating clinician
Encouraging a meeting between relatives and the treating clinician to explain the clinical circumstances of death and if requested arranging and attending the meeting.
Matched on
classifier match
Inquiry recommendation
45match
70 - Meeting with those present at death
Arranging and attending a meeting for relatives with anyone who was present at the death if requested.
Matched on
classifier match
Inquiry recommendation
45match
69 - Explain circumstances of death
Explaining the circumstances of death, identifying when, where and who was present.
Matched on
classifier match
Inquiry recommendation
45match
58 - Amend Act for informed consent
The Human Tissue Act 1961 shall be amended to provide a test of fully informed consent for the lawful post mortem examination and retention of parts of the bodies of deceased persons. While we have concluded that there has been little difference between ‘lack of objection’ and ‘informed consent’ in practical terms for the next of kin, it...
Matched on
classifier match
Inquiry recommendation
41match
85 - General liaison duties
Undertaking general liaison duties.
Matched on
classifier match
Inquiry recommendation
41match
82 - Awareness of support resources
Ensuring that relatives are aware of the full range of counselling/support resources available including those external to the hospital and bringing these matters to the attention of the relatives.
Matched on
classifier match
Inquiry recommendation
41match
78 - Record and share discussions
Noting discussions between relatives, clinicians and pathologists and providing a copy to each party involved.
Matched on
classifier match
Inquiry recommendation
41match
77 - Meetings with clinician and pathologist
Facilitating meetings between parents, clinician and pathologist as appropriate.
Matched on
classifier match
Inquiry recommendation
41match
76 - Clinician attendance at examination
Ascertaining whether the clinician will attend post mortem examination.
Matched on
classifier match
Inquiry recommendation
41match
73 - Explain need for hospital consent
Explaining the need for consent to carry out a hospital post mortem examination (HPM) and the retention of organs.
Matched on
classifier match
Inquiry recommendation
41match
72 - Explain reasons for post mortem
Ensuring that relatives have a full explanation of the reasons for post mortem examination including therapeutic, medical education and research.
Matched on
classifier match
Inquiry recommendation
41match
66 - Meeting and genetic counselling
Following examination of the retained organs or tissue, there should be a meeting between the clinician and parents and referral for genetic counselling or other specialist advice if appropriate.
Matched on
classifier match
Inquiry recommendation
41match
62 - Training in informed consent
The Department of Health, the Royal Colleges and medical schools shall provide training for all those involved in obtaining fully informed consent.
Matched on
classifier match
Inquiry recommendation
41match
61 - Public health education programme
There shall be a programme of health education for the public relevant to the medical need for continued post mortem examination and access to organs and samples for therapeutic, educational and research purposes.
Matched on
classifier match
Inquiry recommendation
41match
60 - Remove surviving relative class
The class of ‘any surviving relative’ shall no longer be relevant to post mortem examination.
Matched on
classifier match
Inquiry recommendation
41match
59 - Define next of kin
The class of persons relevant to the obtaining of fully informed consent shall be defined as the ‘next of kin’.
Matched on
classifier match
Inquiry recommendation
40match
CLAR-Jury Recommendations - Inform victim families of post-mortem rights and viewing opportunities with caution
I would also reiterate the recommendations which the inquest jury, although not strictly empowered to do so, made in a letter delivered to Dr Burton with their verdict on 7thApril 1995: 1. Families of victims must always be informed of their rights to attend or elect medical representatives to attend post mortems. With appropriate counselling, they should be...
Matched on
classifier match
Inquiry recommendation
36match
IHRD-52 - Inquest Duties Protocol
Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.
Matched on
classifier match
Inquiry recommendation
36match
IHRD-50 - 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.
Matched on
classifier match
Inquiry recommendation
36match
56 - Pathologists limit retention
The Royal College of Pathologists shall instruct all practising histopathologists that they shall not retain samples and organs beyond those reasonably incidental to establishing the cause of death unless there is also written consent properly obtained under the Human Tissue Act 1961.
Matched on
classifier match
Inquiry recommendation
32match
75 - Time and privacy to reflect
Ensuring relatives have sufficient time, privacy and support to reflect upon the request for consent to an HPM or the retention of organs following a CPM or an HPM.
Matched on
classifier match
Inquiry recommendation
32match
67 - Research possession and ethics approval
Once fully informed consent is obtained for research purposes, the researchers are entitled to remain in possession of the material retained while research continues. We recommend this extends to accessing archives and DNA analysis. All research remains subject to ethics committee approval.
Matched on
classifier match
Inquiry recommendation
32match
57 - Instruct doctors on Human Tissue Act
The Department of Health, the Royal Colleges and medical schools shall instruct members of the medical profession in the precise terms and provisions of the Human Tissue Act 1961, on the basis of our analysis, and the need for strict compliance.
Matched on
classifier match