Coroner family information gaps
Lack of clear guidance for coroners' offices on whom to approach for information regarding patient deaths, specifically families.
246 items
9 sources
12 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
Committee recommendation
74match
#7 - Address concerns about the Bill’s narrow definition of “close family member” and case exclusions.
The Government must address concerns about the Bill’s narrow definition of “close family member,” which may exclude relatives who often play a key role in pursuing information decades after incidents occurred. Ministers must also consider the merits of ensuring that a person’s severe physical or mental harm does not preclude their case being referred to the commission. (Recommendation,...
Matched on
terms: family, information
Committee recommendation
73match
#21 - Restrict sharing of administrative investigation information; agree MoU with the Chief Coroner.
We recommend that information obtained by the administrative body in its investigations should not be shared with any other professional or system regulator unless it constitutes unlawful activity or identifies an immediate danger to patients. We also recommend that the administrative body should agree a memorandum of NHS litigation reform 59 understanding with the Office of the Chief...
Matched on
terms: coroner, information
LGO / SPSO decision
72match
21-011-373 - Essex County Council
Summary: Mr X complains the Council has not dealt with his father’s death properly. The Council is at fault because it did not provide information, took too long to allocate a Coroner’s Officer and did not offer the opportunity to view the body. The Council has agreed to apologise to Mr X, pay Mr X £100, provide information...
Matched on
terms: coroner, information
Committee recommendation
70match
#9 - 1st Report - The Coroner Service
Bereaved people are at a disadvantage when they do not have access to the evidence. It is important that the process for obtaining evidence is explained clearly to them as this is important for the fairness of the inquest. We encourage the new Chief Coroner to strengthen guidance and training on disclosure and pre-inquest reviews, emphasising to coroners...
Matched on
terms: coroner
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
LGO / SPSO decision
69match
21-016-380 - Sandwell Metropolitan Borough Council
Summary: Mr X complains the Coroner’s office failed to tell him his sister’s brain had been removed at a post-mortem. This caused him and his family distress and financial loss. We find fault with the Council. We have made some recommendations to remedy the injustice caused.
Matched on
terms: coroner, family
IMB recommendation
68match
Lowdham Grange (2022)
In its 2020-2021 report, the Board requested priority be given to holding coroners’ inquests for deaths in custody to provide bereaved families with an understanding of the circumstances of the deaths of their relatives. No inquests into deaths in custody at HMP Lowdham Grange have been held in the reporting period and this means that some families have...
Matched on
terms: coroner, family
Committee recommendation
68match
#26 - Sixth Report - Stolen years: combatting state hostage diplomacy
We recommend that unless the detainee expressly withholds consent to do so, the families of any vulnerable or arbitrary detainee receiving consular assistance be provided by a senior manager or minister in the FCDO at the soonest possible time with a clear description of the Government’s plan of engagement. Briefings should be frequent and include as much detail...
Matched on
terms: family, information
Inquiry recommendation
65match
1 - Chief Coroner guidance on coroners' records
We recommend that the Lord Chancellor and Secretary of State for Justice invite the Chief Coroner to prepare guidance for all coroners on the appropriate retention and archiving of documents in coroners' records. Particular care should be taken to safeguard records relating to inquests arising from mass fatalities, whether attributable to natural or civil disasters or to unlawful...
Matched on
terms: coroner
Inquiry recommendation
65match
IHRD-37 - Family Involvement in SAI Investigations
Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the opportunity to become involved in setting the terms of reference for an investigation. (iii) Families should, if they...
Matched on
terms: family
Inquiry recommendation
65match
F45 - 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.
Matched on
terms: coroner, information
Inquiry recommendation
64match
IHRD-60 - Coroner Communication Training
There should be training in the communication of appropriate information and documentation to the Coroner's office.
Matched on
terms: coroner, information
Committee recommendation
62match
#8 - 1st Report - The Coroner Service
Bereaved people deserve a charter of rights setting out the standards of service they are entitled to receive from the Coroner Service. Setting out the standards they can ‘expect’ in the Guide to Coroner Services is inadequate. The Ministry of Justice should implement a statutory Charter of Rights for bereaved people, modelled on the criminal justice system’s victims’...
Matched on
terms: coroner
Committee recommendation
62match
#7 - 1st Report - The Coroner Service
We encourage Senior Coroners to make sure that bereaved people are made aware by their staff of the specialist support organisations that are available to them both locally and nationally.
Matched on
terms: coroner
Committee recommendation
62match
#6 - 1st Report - The Coroner Service
Help and support for bereaved people depend on the priorities, capacity and skills of the local Coroner Service and local volunteers in the Coroners’ Courts Support Service. The Ministry of Justice should as a matter of urgency provide funding for 58 The Coroner Service support services for bereaved people at inquests, (such as those provided by the Coroners’...
Matched on
terms: coroner
Committee recommendation
62match
#5 - 1st Report - The Coroner Service
The Ministry of Justice’s Guide to Coroner Services is good first step but more needs to be done to make sure that bereaved people know of its existence. We encourage all Senior Coroners to make sure that the updated Guide to the Coroner Service for Bereaved People is freely available both online and, where requested, in hard copy...
Matched on
terms: coroner
PFD report
61match
Christopher Seal
Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training issues and limited communication options.
Matched on
terms: information
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
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
Article 2 learning point
60match
AA — HMP & YOI Holloway - LP 4
We recommend that stronger efforts are made to assemble and substantiate basic information about prisoners’ next of kin and family situation, particularly where young offenders are concerned.
Matched on
terms: family, information
LGO / SPSO decision
60match
21-018-329 - Surrey County Council
Summary: Mr X complains a Coroner did not do her job properly. He says wrong information was read out in court and the hearing was not recorded. We cannot investigate the actions of the Coroner or what happened in court. The Council has apologised for failing to record the hearing. Further investigation on this point will not lead...
Matched on
terms: coroner, information
Committee recommendation
60match
#28 - 1st Report - The Coroner Service
We encourage the Chief Coroner to collect information from each Coroner Service Area on the challenges they face because of the pandemic and communicate the overall picture to the Ministry of Justice. (Paragraph 222) 62 The Coroner Service
Matched on
terms: coroner, information
Inquiry recommendation
60match
IHRD-54 - Bereavement Counselling Services
Professional bereavement counselling for families should be made available and should fully co-ordinate bereavement information, follow-up service and facilitated access to family support groups.
Matched on
terms: family, information
PFD report
57match
Geoff Gray
There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of suicide risk cursory investigations, potentially leading to undetected homicides.
Matched on
classifier match
PFD report
57match
Keith Whetton
The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Matched on
terms: family
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
Committee recommendation
57match
#20 - 1st Report - The Coroner Service
The majority of witnesses to our inquiry, two Chief Coroners, and almost everyone who has been commissioned to review aspects of the Coroner Service sees the need for a unified service for England and Wales. There is unacceptable variation in the standard of service between Coroner areas. The quality of each local coroner service should not have to...
Matched on
terms: coroner
Committee recommendation
57match
#15 - 1st Report - The Coroner Service
The Government consultation on coronial investigation of stillbirths was welcome but it is disappointing that it appears to have stalled. The Ministry of Justice should revive the consultation on coronial investigation of stillbirths and publish proposals for reform. (Paragraph 118) Shortage of pathology services
Matched on
terms: coroner
Committee recommendation
57match
#2 - 1st Report - The Coroner Service
Reducing the number of coronial areas has helped increase consistency across the Coroner Service. The Ministry of Justice should amend the Coroners and Justice Act 2009 (as requested by the outgoing Chief Coroner) to make it easier to merge areas.
Matched on
terms: coroner
LGO / SPSO decision
57match
21-009-310 - Surrey County Council
Summary: Mrs X complained about how the Council managed the Coroner’s inquest into her father’s death. The Council was at fault when it both failed to invite Mrs X to the inquest and provide her with important documents prior to it. It meant Mrs X did not attend the inquest into her father’s death and lost the opportunity...
Matched on
terms: coroner
Inquiry recommendation
57match
IHRD-42 - Sharing New Investigation Information
In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.
Matched on
terms: information
Committee recommendation
57match
#4 - 1st Report - The Coroner Service
The Chief Coroner’s guidance on when and how to expedite a case to meet with the requirements of the beliefs of the deceased is welcome, but whether the needs of faith communities will be met or not depends on how the Coroner Service responds locally. We encourage the new Chief Coroner to continue the work of his predecessor...
Matched on
terms: coroner
IMB recommendation
56match
Oakwood (2022)
Can the Minister ask the Chief Coroner to issue guidance about the importance of notifying the IMB of inquests concerning prisoners (para 4.2) as referred to in the IMB reference book guidance in relation to deaths in custody?
Matched on
terms: coroner
IMB recommendation
56match
Lowdham Grange (2023)
The Board continues to request that priority be given to holding coroners’ inquests for deaths in custody to provide bereaved families with an understanding of the circumstances of the deaths of their relatives.
Matched on
terms: coroner
LGO / SPSO decision
56match
21-010-162 - Sefton Metropolitan Borough Council
Summary: Mrs Y complains about how the coroner’s office handled the inquest into the death of her late sister. We cannot investigate some of the matters complained about because they are outside of our jurisdiction. However, we found the coroner’s office failed to make an audible recording of the hearing, but this did not cause significant injustice to...
Matched on
terms: coroner
LGO / SPSO decision
56match
23-005-209 - London Borough of Camden
Summary: Ms X complained about the way the coroner’s office handled the investigation of the death of her son. Most of the complaint is not within our jurisdiction but there was fault by the Council in how it responded to the complaint.
Matched on
terms: coroner
Inquiry recommendation
56match
F280 - Appropriate and sensitive contact with bereaved families
Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given to hospital staff encouraging them to raise any concerns they may have with the independent medical examiner.
Matched on
terms: family
PHSO casework decision
56match
P-002455 - A practice in the Lancashire area
Mrs H complains the Practice did not complete a referral to a specialist quickly enough for her father and did not complete a home visit the day he died. She also complains it gave incorrect information to the coroner.
Matched on
terms: coroner, information
PHSO casework decision
55match
P-003456 - Hertfordshire Community NHS Trust
Mrs J complains about the care and treatment her brother, Mr P, received during admissions at East and North Hertfordshire NHS Trust and Hertfordshire Community NHS Trust between 21 December 2019 and 5 January 2020. She complains the failings the safeguarding team and coroner identified may have contributed to or caused Mr P’s death. She also complains staff...
Matched on
terms: coroner, family
LGO / SPSO decision
55match
21-005-802 - Cambridgeshire County Council
Summary: Mrs B complained about her contact with the Council’s coroner’s office. She said the staff were unprofessional and lied to her family. We did not find fault.
Matched on
terms: coroner, family
LGO / SPSO decision
53match
21-013-351 - Nottingham City Council
Summary: We will not investigate this complaint that the coroner’s service failed to inform the complainants of the date of his daughter’s inquest. This is because the complaint is made late and because further investigation would not lead to a different outcome.
Matched on
terms: coroner
LGO / SPSO decision
53match
21-011-697 - Surrey County Council
Summary: Mr X says the Coroner failed to keep him informed of the post-mortem process involving his deceased child. The Council accepted fault and apologised to Mr X. The Council agreed to a financial remedy to reflect the distress caused to Mr X.
Matched on
terms: coroner
Committee recommendation
53match
#21 - 1st Report - The Coroner Service
As with calls for a national service for England and Wales, there is an overwhelming and long-standing view that the Coroner Service would benefit from the presence of an inspectorate overseeing its work. As with those calls, we are merely repeating what others have repeatedly said by recommending that the Ministry of Justice should establish a Coroner Service...
Matched on
terms: coroner
Committee recommendation
53match
#14 - 1st Report - The Coroner Service
There may be circumstances where with the consent of the bereaved people concerned, it would be sensible for the High Court to be able to direct that the particulars of the Record of the Inquest be amended as appropriate without ordering a fresh inquest. The Government should consider adopting the Chief Coroner’s proposed amendment to Section 13 with...
Matched on
terms: coroner
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
IMB recommendation
52match
Altcourse (2020)
Delays in scheduling Coroner inquests have caused anxiety for staff attending as witnesses and families awaiting closure.
Matched on
terms: coroner
Article 2 learning point
52match
Mr Everest — HMP Altcourse - LP 15
This is the gold standard approach to family involvement. Prisons vary in the quality of family involvement and HMP Altcourse is sadly not unusual in how it approaches this important area. There should be improved across all prisons.
Matched on
terms: family