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
Source spread
Where this theme appears
Coroner family information gaps has been flagged across 1 independent accountability source:
80 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (80) — showing 50 strongest matches
85 — General liaison duties
Recommendation: Undertaking general liaison duties.
Unknown
84 — Assist with other problems
Recommendation: Assisting with any other individual problem presented by relatives in consequence of death.
Unknown
83 — Translation and accessibility services
Recommendation: Accessing translation/interpreting services including services for people with hearing or visual impairment and providing appropriate written/taped information.
Unknown
82 — Awareness of support resources
Recommendation: 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.
Unknown
81 — Discuss counselling and support
Recommendation: 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.
Unknown
80 — Practical help for relatives
Recommendation: 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 …
Unknown
79 — Information packs for relatives
Recommendation: Developing and using information packs for relatives on all aspects of death in hospital.
Unknown
78 — Record and share discussions
Recommendation: Noting discussions between relatives, clinicians and pathologists and providing a copy to each party involved.
Unknown
77 — Meetings with clinician and pathologist
Recommendation: Facilitating meetings between parents, clinician and pathologist as appropriate.
Unknown
76 — Clinician attendance at examination
Recommendation: Ascertaining whether the clinician will attend post mortem examination.
Unknown
74 — Explain consent after Coroner examination
Recommendation: 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.
Unknown
73 — Explain need for hospital consent
Recommendation: Explaining the need for consent to carry out a hospital post mortem examination (HPM) and the retention of organs.
Unknown
72 — Explain reasons for post mortem
Recommendation: Ensuring that relatives have a full explanation of the reasons for post mortem examination including therapeutic, medical education and research.
Unknown
71 — Meeting with treating clinician
Recommendation: Encouraging a meeting between relatives and the treating clinician to explain the clinical circumstances of death and if requested arranging and attending the meeting.
Unknown
70 — Meeting with those present at death
Recommendation: Arranging and attending a meeting for relatives with anyone who was present at the death if requested.
Unknown
69 — Explain circumstances of death
Recommendation: Explaining the circumstances of death, identifying when, where and who was present.
Unknown
66 — Meeting and genetic counselling
Recommendation: 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.
Unknown
62 — Training in informed consent
Recommendation: The Department of Health, the Royal Colleges and medical schools shall provide training for all those involved in obtaining fully informed consent.
Unknown
61 — Public health education programme
Recommendation: 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.
Unknown
60 — Remove surviving relative class
Recommendation: The class of ‘any surviving relative’ shall no longer be relevant to post mortem examination.
Unknown
59 — Define next of kin
Recommendation: The class of persons relevant to the obtaining of fully informed consent shall be defined as the ‘next of kin’.
Unknown
58 — Amend Act for informed consent
Recommendation: 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 …
Unknown
55 — Specify retained material in reports
Recommendation: 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.
Unknown
52 — Reasons if examination not authorised
Recommendation: 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.
Unknown
51 — Advice to next of kin on examination
Recommendation: 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 …
Unknown
50 — Introduce Coroner to next of kin
Recommendation: Coroners shall be introduced, their function and procedures explained and the next of kin invited to express any specific concerns and requests.
Unknown
46 — Explain Coroner post mortem report
Recommendation: 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.
Unknown
45 — No compulsion for hospital examination
Recommendation: 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.
Unknown
42 — Information for next of kin
Recommendation: 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 …
Unknown
18 — Keep parents fully informed
Recommendation: parents must never again be drip-fed information but should be kept fully informed.
Unknown
F274 — Information to coroners
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Coroners and Justice Act 2009 states that, ‘It is an offence for a person to do anything that is intended to have the effect of (a) distorting or otherwise altering any evidence, document …
Accepted
In progress
F273 — Information to coroners
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. All relevant information should be shared with coroners to ensure that they are able to perform their roles fully. The Coroners and Justice Act 2009 states that, ‘It is an offence for …
Accepted in part
12 — Review and update medical records
Recommendation: 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 …
Unknown
MACP-42 — Ensure advance disclosure of evidence to parties appearing at inquests.
Recommendation: 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.
Unknown
CLAR-Jury Recommendations — Inform victim families of post-mortem rights and viewing opportunities with caution
Recommendation: 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 …
Unknown
R69 — Explanation to relatives on CDI death
Recommendation: 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 …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
1 — Chief Coroner guidance on coroners' records
Recommendation: 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 …
No response yet
IHRD-53 — Legal Privilege Disclosure to Coroner
Recommendation: 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 …
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-52 — Inquest Duties Protocol
Recommendation: Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-51 — Independence of Coroner Witness Statements
Recommendation: Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-50 — HSCB Notification of Inquests
Recommendation: 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.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-47 — Post-Mortem Reporting Standards
Recommendation: 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 …
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-44 — Post-Mortem Limitation Authorisation
Recommendation: 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.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-43 — GP Notification of Death Circumstances
Recommendation: A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
F283 — Information for and from inquests
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Judicial College has taken responsibility for training all coroners and coroner’s officers under the remit of the Chief Coroner’s Office from July 2013. The College has already supplied training to coroners on the …
Accepted
In progress
F282 — Information for and from inquests
Recommendation: Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Coroners and Justice Act 2009 states that where a senior coroner has conducted an investigation and anything has been revealed that indicates a risk of other deaths then the coroner, ‘…must report the …
Accepted
In progress
75 — Time and privacy to reflect
Recommendation: 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.
Unknown
67 — Research possession and ethics approval
Recommendation: 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 …
Unknown
57 — Instruct doctors on Human Tissue Act
Recommendation: 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 …
Unknown
56 — Pathologists limit retention
Recommendation: 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 …
Unknown