Coroner family information gaps
Lack of clear guidance for coroners' offices on whom to approach for information regarding patient deaths, specifically families.
39 items
1 source
13 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
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
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
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
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
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
R92 - Time frame and financial information for families
Families should be provided by the relevant Trust with a time frame for resettlement and relevant financial information. Families should also be afforded an appropriate amount of time to consider resettlement options.
Matched on
terms: information
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
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
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.
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
48match
BRIS-21 - Require every trust to provide a professional bereavement service and online information
Every trust should have a professional bereavement service. (We also reiterate what was recommended in the Inquiry’s Interim Report: ‘Recommendation 13: As hospitals develop websites, a domain should be created concerned with bereavement in which all the relevant information concerning post-mortems can be set out in an appropriate manner.’)
Matched on
terms: information
Inquiry recommendation
48match
R99 - Key individual for resettlement communication
Communication between the HSCTs and/or resettlement service providers and families and people with learning disabilities should be more open and transparent. Each service user/family should have appointed to them a key individual who is responsible for ensuring both the family and the service user are consulted and kept informed in relation to considerations of resettlement, including the staff...
Matched on
terms: family
Inquiry recommendation
44match
R70 - COPFS death reporting guidance review
Crown Office and the Procurator Fiscal service (COPFS) should review its guidance on the reporting of deaths regularly and at least every two years.
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
40match
F281 - Appropriate and sensitive contact with bereaved families
It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how to undertake this sensitive task in a manner least likely to cause additional and unnecessary distress.
Matched on
classifier match
Inquiry recommendation
39match
AC-2b - Share Clinical Assessor Advice
In respect of any case in which the advice of a clinical assessor has been given, in relation to the person concerned (and no more widely except with the consent of that person): that person should be told the factual basis on which that advice has been given; and the reasons for that advice. Such information must be...
Matched on
terms: information
Inquiry recommendation
39match
FENN-151 - Avoid duplication between public inquiries and coroner's inquests
The duplication involved in holding both a public inquiry and a coroner's inquest should be avoided.
Matched on
terms: coroner
Inquiry recommendation
39match
P2-52 - Share mortuary reports with coroner service
All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service (and the Senior Coroner if they wish to see these reports). Local authorities that are not the lead authority for the coroner service must also share these reports and incidents with the coroner service lead in...
Matched on
terms: coroner
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
MACP-43 - Provide Legal Aid for victims' families for representation at appropriate inquests.
That consideration be given to the provision of Legal Aid to victims or the families of victims to cover representation at an Inquest in appropriate cases.
Matched on
classifier match
Inquiry recommendation
36match
CLAR-12.33 - Keep post mortem procedures under review, including body part removal and consent
In any event, I recommend that post mortem procedures be kept under review. Those procedures include the removal of body parts generally, the recording of any decisions to remove body parts and the reasons for such decisions, issues of consent with regard to removal of body parts and permission to attend a post mortem and also issues regarding...
Matched on
classifier match
Inquiry recommendation
36match
CLAR-12.29 - Advise officers to consider alternatives before removing body parts for identification
Further, I would also recommend that strong advice be given, both in the manual and in any training course which officers are required to undergo, that requests for the removal of body parts only be made after consideration on a case by case basis, taking into account all other available means of identification.
Matched on
classifier match
Inquiry recommendation
35match
R68 - Consultant involvement in death certificates
Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patients care is involved in completion of the death certificate wherever practicable.
Matched on
classifier match
Inquiry recommendation
35match
IHRD-62 - Adverse Incident Communication Training
Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.
Matched on
classifier match
Inquiry recommendation
32match
IHRD-46 - Clinician Attendance at Post-Mortem Discussions
Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.
Matched on
classifier match
Inquiry recommendation
32match
IHRD-45 - Post-Mortem Documentation Checklist
Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.
Matched on
classifier match
Inquiry recommendation
31match
SHI-1 - Communication strategy for patients and families
Health boards must ensure that in the event of any adverse situation that could affect the wellbeing of patients and their families, there is a communication strategy in place to liaise with this crucially important group. The Scottish Government should ensure that this liaison is supported in any overarching communication strategy it may wish to introduce.
Matched on
classifier match
Inquiry recommendation
27match
HIDD-75 - Require police forces to adopt Metropolitan Police arrangements for bereaved relatives
Police Forces shall study and follow the excellent arrangements made by the Metropolitan Police for the bereaved and relatives of the seriously injured.
Matched on
classifier match
Inquiry recommendation
27match
IHRD-59 - Post-Mortem Request Form Training
There should be training in the completion of the post-mortem examination request form.
Matched on
classifier match