If you have been notified that the coroner is opening an inquest into the death of a patient, and your organisation has been directed to assist with the coroner's inquiry, we hope that this checklist will be useful in setting out the process of dealing with an inquest from start to finish from your position within an in-house legal team.
- Acknowledge receipt of the coroner's request for evidence.
- What does the coroner require by way of evidence and by when?
- Notify the relevant clinician/ staff-member that they need to provide a witness statement and give them a deadline for when you need it back.
- Ensure the witness/witnesses know(s) that you will send the statement once finalised to the coroner's office on their behalf and they should not communicate directly with the coroner and/or the coroner's officer.
- Put the witness/witnesses on notice of any proposed inquest date, even if you do not yet know if they are required to attend.
- Check if the coroner requires copies of the medical records, and provide copies as required.
- It may be prudent to notify the witness's line manager or the relevant head of department so that support can be provided as necessary.
- Check if there was an incident report raised in respect of the events giving rise to the coroner's inquiry.
- If so, contact the relevant team to establish whether a full investigation is going to take place.
- Tell the coroner's officer if an investigation is taking place, and when you are likely to be able to notify the coroner of the outcome/provide them with the investigation report.
- Check whether the family have made a complaint to the trust in respect of the treatment provided to the deceased. Make sure you have copies of the complaint and any response if so.
- Make sure the family are kept informed of the complaint or investigation process.
- Make sure a duty of candour letter has been sent to the family of the deceased if appropriate.
- Cross-reference whether the family have intimated a clinical negligence claim. You don't necessarily need to take any particular steps if they have, but: it is helpful for the witnesses to know; you need to consider whether to make any admissions of liability in advance of the inquest; and it may affect your decision to obtain legal representation.
- Once the witness/witness's have sent you their statements, ensure these are disclosed to the coroner.
- Check when disclosing the statements to the coroner whether the witnesses' attendance is required.
- Request disclosure of all documents the coroner intends to rely upon in the course of their inquiry e.g. if there is a postmortem examination report.
- Confirm with the coroner who the other interested persons are and whether any of them have their own legal representation.
- Consider if this is an inquest where external legal representation is required.
- Make sure the witnesses have the dates for the inquest marked in their diary if they do have to give evidence in person. Return witness summons to the court in a timely manner.
- Offer the witnesses the opportunity to discuss the case with you or any legal representative in advance of the inquest.
- Make sure you have confirmed the arrangements to the witnesses before the inquest – including the time and venue.
- If there has been an incident investigation, send a copy of the completed or updated action plan to the coroner. Consider if you need a senior witness to attend the inquest to give evidence in respect of lessons learnt (the coroner may require this).
- After the inquest has taken place, request a copy of the record of inquest and circulate it to the relevant parties within your organisation.
- Consider any learning arising from the inquest and make sure it is disseminated within your organisation.
Remember, Hill Dickinson is happy to assist so if you are not sure about any aspect of the inquests process, please do not hesitate to contact a member of our team.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.