National protocol on duties relating to inquests
Morecambe Bay Investigation · Report of the Morecambe Bay Investigation · Issued 3 March 2015 · Addressed to: NHS England
Source — verbatim from the inquiry
●Inquiry 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 not to coach staff or provide 'model answers', the need to avoid collusion between staff on lines to take, and the inappropriateness of relying on coronial processes or expert opinions provided to coroners to substitute for incident investigation. Action: NHS England, the Care Quality Commission.
Morecambe Bay Investigation, Report of the Morecambe Bay Investigation · 3 Mar 2015 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The government noted existing legislation under the Coroners and Justice Act 2009 making it an offence to distort or alter evidence for an investigation (Learning Not Blaming, Cm 9113, Department of Health, July 2015).
- No published national protocol specifically setting out NHS trust duties in relation to inquests has been identified to March 2026.
Sources
Response — verbatim from government
●NHS England
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.
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NHS England · 16 Jul 2015 Written response →
Evidence trail — what's actually happened since
- 31 Dec 2015 National guidance issued on NHS engagement with inquests and coroners. Source →
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
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Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
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