Misleading Information to Coroner

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.

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 project, should not submit to the local authority information that is deceptive or reports that are misleading either...

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 informed decisions based upon the reality of the situation. Such reports should not be misleading either by the...

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 not to coach staff or provide 'model answers', the need to avoid collusion between staff on lines to...

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.