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The Coroner Role & Preparing for Inquest

News and presentations from today's conference looking at the role of the Coroner and preparing for a Coroner's Inquest. Chaired by Mike O'Connell, Legal Services Practitioner. 

A Family Perspective

Tony Bonser Member NHS Patient Experience Workstream
Volunteer, Hospice UK, Member, NHS EoLC Programme Management Board 
Vice-chair, Trustees, St Catherine’s Hospice Preston

• what families want from a Coroner’s Inquest
• our journey and experience
• the importance of involving bereaved people to be involved throughout the inquest process

Tony gave a powerful presentation sharing what families want from a Coroner's Inquest based on his own family experience, he finished by saying; "My hope is that inquests can help people start to get that sense of relief, understand what's happening and that they have been listened too."


The Coroner Role

Dr Andrew Harris Senior Coroner London Inner South
Professor of Coronial Law William Harvey Research Institute, Queen Mary’s University London

• notification of deaths to Coroner
• investigatory roles of Coroner
• what is unnatural death and opening an inquest
• Covid-19 deaths


Learning from Deaths and implementing Coroner recommendations at a local level

Dr Martin Farrier Clinical Director for Quality & Consultant Paediatrician
Wrightington, Wigan and Leigh NHS Foundation Trust 

• the role of the Medical Examiner
• ensuring the appropriate direction of deaths to the coroner
• understanding the root cause of avoidable deaths, ensuring independent review and correct referral to the coroner
• understanding which deaths are attributable to problems in care at a local level
• ensuring conclusions in investigations will lead to inform learning and change practice

Martin shared work on investigating and learning from deaths in Wigan.  He said it is important to understanding mortality rates, but you can't just do data, you need to go back and review case notes.  In Wigan the notes are reviewed and reports are shared to help colleagues know and understand what happened.  This also helps indentify recurring problems and agree learning. Quality Champions agree change and take it forward. A summary improvement report is sent out to keep staff updated on findings and improvements that have been put in place. 

Martin said that the review of deaths really helps with understanding dying and what's important.  He said most are predictable and unpreventable and rates are actually going up as "baby boomers" are reaching the average age of death. He said surprisingly most people are dying in hospital due to their own or family/carer wishes and not at home as you might expect. 

On attending court, the reviews Martin has written go to their Executive Scrutiny Committee so he often goes to court.  He has built a good relationship with the coroner.  He often ends up summarising the case for the coroner, and typically the coroner is then happy that the issues have been understood and appropriately addresses. Martin is also Information Governance lead so has a good understanding of information sharing.