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
Source spread
Where this theme appears
Coroner family information gaps has been flagged across 1 independent accountability source:
39 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Inquiry Recommendations (39)
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
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.
Gov response: Section 4.2 of the Scottish Government's response emphasizes person-centred care, with a key aim to ensure people have sufficient knowledge and understanding of their health care. The "Must Do with Me" elements of person-centred care …
Accepted
1 — Chief Coroner guidance on coroners' records
Recommendation: 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 …
Gov response: Implemented. The Coroners (Investigations) Regulations 2013 introduced formal requirements for coroners' record retention. Under regulation 27(1), all inquest recordings must be kept for at least 15 years. The Chief Coroner, appointed under the Coroners and …
Accepted
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 …
Gov response: Guidance issued on legal privilege assertions and disclosure obligations to Coroner.
Accepted
IHRD-52 — Inquest Duties Protocol
Recommendation: Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.
Gov response: Protocols developed detailing employee duties in relation to healthcare inquests.
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.
Gov response: Procedures updated to separate Trust involvement from Coroner witness statement management.
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.
Gov response: Inquest notification procedures established between Trusts and HSCB.
Accepted
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 …
Gov response: Post-mortem reporting standards updated in line with these requirements.
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.
Gov response: Post-mortem authorisation procedures updated to require dual sign-off with family consent.
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.
Gov response: GP notification procedures established for SAI-related deaths.
Accepted
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.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F282 — Information for and from inquests
Recommendation: Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
R99 — Key individual for resettlement communication
Recommendation: 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 …
Response Pending
R92 — Time frame and financial information for families
Recommendation: 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.
Response Pending
MACP-43 — Provide Legal Aid for victims' families for representation at appropriate inquests.
Recommendation: 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.
Unknown
CLAR-12.33 — Keep post mortem procedures under review, including body part removal and consent
Recommendation: 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 …
Unknown
CLAR-12.29 — Advise officers to consider alternatives before removing body parts for identification
Recommendation: 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 …
Unknown
R70 — COPFS death reporting guidance review
Recommendation: Crown Office and the Procurator Fiscal service (COPFS) should review its guidance on the reporting of deaths regularly and at least every two years.
Gov response: Section 5.1 of the Scottish Government's response details actions taken to implement the report's recommendations, including R70. The Government wrote to the Crown Office & Procurator Fiscal Service in December 2014, requesting an assessment of …
Accepted
IHRD-54 — Bereavement Counselling Services
Recommendation: 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.
Gov response: Bereavement support services established across Trusts.
Accepted
IHRD-46 — Clinician Attendance at Post-Mortem Discussions
Recommendation: Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.
Gov response: Guidance issued on clinician attendance at clinico-pathological discussions.
Accepted
IHRD-45 — Post-Mortem Documentation Checklist
Recommendation: Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.
Gov response: Checklist protocols developed for hospital post-mortem documentation.
Accepted
IHRD-42 — Sharing New Investigation Information
Recommendation: 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.
Gov response: Procedures established for sharing new information with families after investigation completion.
Accepted
IHRD-37 — Family Involvement in SAI Investigations
Recommendation: 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 …
Gov response: Family involvement protocols established. Guidance issued on meaningful engagement with families throughout investigation processes. Patient Advocacy Service being developed.
Accepted
No update 2+ yrs
F281 — Appropriate and sensitive contact with bereaved families
Recommendation: 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.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F280 — Appropriate and sensitive contact with bereaved families
Recommendation: 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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F45 — Use of information about compliance by regulator from: Inquests
Recommendation: The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
AC-2b — Share Clinical Assessor Advice
Recommendation: 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 …
Gov response: The remaining 11 recommendations focus on IBCA delivery. Further detail on these will be set out by IBCA in due course.
Accepted
No update 2+ yrs
BRIS-21 — Require every trust to provide a professional bereavement service and online information
Recommendation: 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 …
Unknown
HIDD-75 — Require police forces to adopt Metropolitan Police arrangements for bereaved relatives
Recommendation: Police Forces shall study and follow the excellent arrangements made by the Metropolitan Police for the bereaved and relatives of the seriously injured.
Unknown
R68 — Consultant involvement in death certificates
Recommendation: 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.
Gov response: Section 4.1 of the Scottish Government's response introduces the chapter as focusing on professional standards and measures to govern death certification, including recommendation 68. However, the "Our current position" subsections within the provided text do …
Accepted
IHRD-62 — Adverse Incident Communication Training
Recommendation: 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.
Gov response: Specific training provided on communication with families following adverse incidents.
Accepted
IHRD-60 — Coroner Communication Training
Recommendation: There should be training in the communication of appropriate information and documentation to the Coroner's office.
Gov response: Training provided on communication with the Coroner's office.
Accepted
IHRD-59 — Post-Mortem Request Form Training
Recommendation: There should be training in the completion of the post-mortem examination request form.
Gov response: Training provided on post-mortem examination request form completion.
Accepted
SHI-1 — Communication strategy for patients and families
Recommendation: 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 …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: Discussions between the Scottish Government and NHS Boards are actively taking place to identify any gaps …
Accepted
In progress
FENN-151 — Avoid duplication between public inquiries and coroner's inquests
Recommendation: The duplication involved in holding both a public inquiry and a coroner's inquest should be avoided.
Unknown
P2-52 — Share mortuary reports with coroner service
Recommendation: 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 …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress