Misleading Information to Coroner
11 items
2 sources
Concerns regarding a local council providing potentially misleading or incomplete information to a coroner about a death.
Cross-Source Insight
Misleading Information to Coroner has been flagged across 2 independent accountability sources:
5 inquiry recs
6 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (5)
ETI-20 — Prohibition on Misleading Reports from ALEOs
Recommendation: The directors, employees and consultants of the company responsible for the procurement and delivery of the project as project managers, including an arm's-length external organisation (ALEO) wholly owned by the local authority that is the promoter and owner of the …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
ETI-21 — Duty of Officials to Councillors
Recommendation: Local authority officials should be mindful at all times of the distinction in roles between them and councillors, who are solely responsible for strategic decisions, and of their duty to provide accurate reports to councillors to enable them to take …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
82 — Metropolitan Police investigation into Lambeth Council
Recommendation: The Metropolitan Police Service should consider whether there are grounds for a criminal investigation into Lambeth Council's actions when providing information to the coroner about the circumstances surrounding LA-A2's death.
Gov response: The Metropolitan Police Service informed the Inquiry that it has accepted this recommendation.
Accepted
No update 2+ yrs
30 — National protocol on duties relating to inquests
Recommendation: A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the avoidance of attempts to 'fend off' inquests, a mandatory requirement …
Gov response: 67. We accept this recommendation in principle. We will give further thought, with the Ministry of Justice and Chief Coroner’s Office, to whether an additional protocol would be helpful in guiding appropriate behaviour in relation …
Accepted
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
PFD Reports (6)
Mark Beresford
Concerns: Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.
Responded
Roy Travers
Concerns: There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal review hampered the inquest and learning process.
Responded
Darren Goddard
Concerns: Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.
Responded
Alex Blake
Concerns: Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
Responded
Marcus McGuire
Concerns: HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Overdue
Timothy Clayton
Concerns: Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
Response: Kent Police disputes the Coroner's report, claiming it contains factual inaccuracies and questions its legitimacy regarding organ viability and the number of lives lost. They state an urgent review of …
Responded