National protocol on duties relating to inquests

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 to coroner investigations and inquests. In the meantime, we will ask Monitor and the NHS Trust Development Authority to remind Foundation Trusts and NHS Trusts of the existing legislation and guidance setting out their duties in relation to inquests. 68. Dr Kirkup's assessment of the behaviour of certain staff in relation to the inquest process is particularly concerning. There is existing legislation in relation to how public bodies and professionals should behave with respect to coronial processes, and expectations within existing professional codes. All relevant information must be shared with coroners to ensure that they are able to carry out their statutory duties to investigate relevant deaths, to ascertain who has died, where, when and how: • The Coroners and Justice Act 2009 gives coroners powers to require a person or organisation in England and Wales to provide evidence and to require a witness in England and Wales to give evidence at an inquest. The 2009 Act makes it, "an offence for a person to do anything that is intended to have the effect of (a) distorting or otherwise altering any evidence, document or other things that is given, produced or provided for the purpose of an investigation... (b) preventing any evidence, document or other thing from being given produced or provided for the purposes of such an investigation or to do anything that the person knows or believes is likely to have that effect". This offence is limited to actions where there is "intention" to distort or alter evidence, and is punishable by a fine and / or imprisonment. • The new Nursing and Midwifery Council Code requires nurses and midwives to cooperate with all investigations and audits and to be open and candid with service users about all aspects of care and treatment, including when any mistake or harm has taken place. • The General Medical Council's publication Good Medical Practice and supporting guidance includes clear requirements for medical doctors to cooperate with formal inquiries, including inquests, to be honest and trustworthy when giving evidence, and to make sure any information they give is not false or misleading.

The Government has not introduced a national protocol.

The Coroners and Justice Act 2009 and the professional codes of the GMC and the NMC fulfil this recommendation and remove the need for a specific protocol on inquests to be developed.

NHS Improvement (now NHS England) reminded NHS providers of their duties regarding coroner’s inquests in May 2016. CQC has developed a Memorandum of Understanding (MOU) with the Coroner’s Society.

NHS Resolution published guidance for health providers on supporting staff to prepare for an inquest. In 2020, NHS Resolution also produced three films to help prepare staff for giving evidence. Film two sets out the legal and professional obligations required as part of attending an inquest and giving evidence under oath.

From 9 September 2024 all deaths in any health setting that are not investigated by a coroner will be reviewed by NHS medical examiners. The purpose of the medical examiner system includes providing greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths and ensuring the appropriate direction of deaths to the coroner.

NHS Improvement, in 2016, published national compulsory guidance on the duties, and the current legislation relating to coroner inquests that National Health Service trusts, foundation trusts, and individual clinicians must follow with regards to coronial processes.

Healthcare professional regulators, the Nursing and Midwifery Council and the General Medical Council’s guidance requires nurses, midwives and doctors to cooperate with all investigations, formal inquires and inquests.

Department of Health response (July 2015):

They will give “further thought” to an additional protocol. (p. 81) However, unable to find any follow up to this.

“There is existing legislation in relation to how public bodies and professionals should behave with respect to coronial processes.” (p. 81)

“The new Nursing and Midwifery Council Code requires nurses and midwives to cooperate with all investigations and audits and to be open and candid with service users about all aspects of care and treatment, including when any mistake or harm has taken place.”

“The General Medical Council’s publication Good Medical Practice and supporting guidance includes clear requirements for medical doctors to cooperate with formal inquiries, including inquests” (p. 81)