Coroner family information gaps
Lack of clear guidance for coroners' offices on whom to approach for information regarding patient deaths, specifically families.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
99match
F283 - Information for and from inquests
Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the death of a patient. This should include contact with the patient's family.
Matched on
terms: coroner, family, information
Inquiry recommendation
95match
F274 - Information to coroners
There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to the priority to be given to openness over any perceived material interest.
Matched on
terms: coroner, information
Inquiry recommendation
87match
F273 - Information to coroners
The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a director is personally satisfied that withholding the information is justified in the public interest.
Matched on
terms: coroner, information
PFD report
77match
Keith Whetton
The coroner identified a delay in seeking medical attention for Keith on 8th September and a lack of timely communication with family members regarding his fall.
Matched on
terms: coroner, family
Inquiry recommendation
74match
42 - Information for next of kin
Clinicians shall give the following basic information to the next of kin when a Coroner’s post mortem examination is to be performed. – The nature of the examination, including the need to open the body and to remove and weigh organs. – The need for samples and possible retention of organs.
Matched on
terms: coroner, information
Committee recommendation
74match
#7 - Address concerns about the Bill’s narrow definition of “close family member” and case exclusions.
The Government must address concerns about the Bill’s narrow definition of “close family member,” which may exclude relatives who often play a key role in pursuing information decades after incidents occurred. Ministers must also consider the merits of ensuring that a person’s severe physical or mental harm does not preclude their case being referred to the commission. (Recommendation,...
Matched on
terms: family, information
PFD report
73match
Terence Dooley
The coroner noted concerns regarding the inappropriate green coding of an emergency overdose call, resulting in a significant delay in ambulance response. Gaps in communication and misleading computer-generated codes were identified as contributing factors.
Matched on
terms: coroner, gaps
PFD report
73match
Christopher Seal
The coroner identified issues with the clarity of information sharing forms, the RIO system's functionality in displaying and populating data, and a lack of 'no response' and 'welfare check' policies for primary care services. Concerns also related to staff training on these systems and procedures.
Matched on
terms: coroner, information
Committee recommendation
73match
#21 - Restrict sharing of administrative investigation information; agree MoU with the Chief Coroner.
We recommend that information obtained by the administrative body in its investigations should not be shared with any other professional or system regulator unless it constitutes unlawful activity or identifies an immediate danger to patients. We also recommend that the administrative body should agree a memorandum of NHS litigation reform 59 understanding with the Office of the Chief...
Matched on
terms: coroner, information
LGO / SPSO decision
72match
21-011-373 - Essex County Council
Summary: Mr X complains the Council has not dealt with his father’s death properly. The Council is at fault because it did not provide information, took too long to allocate a Coroner’s Officer and did not offer the opportunity to view the body. The Council has agreed to apologise to Mr X, pay Mr X £100, provide information...
Matched on
terms: coroner, information
Committee recommendation
70match
#9 - 1st Report - The Coroner Service
Bereaved people are at a disadvantage when they do not have access to the evidence. It is important that the process for obtaining evidence is explained clearly to them as this is important for the fairness of the inquest. We encourage the new Chief Coroner to strengthen guidance and training on disclosure and pre-inquest reviews, emphasising to coroners...
Matched on
terms: coroner
PFD report
69match
Lillian Robinson
The coroner identified a lack of communication between the hospital and home regarding mental capacity assessments, and unqualified medical carers evaluating patient capacity. Concerns were also raised about poor note-taking and continuity of patient care records.
Matched on
terms: coroner
PFD report
69match
Geoff Gray
Insufficient specific guidance for pathologists and coroners regarding post-mortem examinations in firearms deaths, particularly for children, risks inadequate investigations and undetected homicides when suicide is assumed.
Matched on
terms: coroner
Inquiry recommendation
69match
F282 - Information for and from inquests
Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
Matched on
terms: coroner, information
LGO / SPSO decision
69match
21-016-380 - Sandwell Metropolitan Borough Council
Summary: Mr X complains the Coroner’s office failed to tell him his sister’s brain had been removed at a post-mortem. This caused him and his family distress and financial loss. We find fault with the Council. We have made some recommendations to remedy the injustice caused.
Matched on
terms: coroner, family
IMB recommendation
68match
Lowdham Grange (2022)
In its 2020-2021 report, the Board requested priority be given to holding coroners’ inquests for deaths in custody to provide bereaved families with an understanding of the circumstances of the deaths of their relatives. No inquests into deaths in custody at HMP Lowdham Grange have been held in the reporting period and this means that some families have...
Matched on
terms: coroner, family
Committee recommendation
68match
#26 - Sixth Report - Stolen years: combatting state hostage diplomacy
We recommend that unless the detainee expressly withholds consent to do so, the families of any vulnerable or arbitrary detainee receiving consular assistance be provided by a senior manager or minister in the FCDO at the soonest possible time with a clear description of the Government’s plan of engagement. Briefings should be frequent and include as much detail...
Matched on
terms: family, information
Inquiry recommendation
66match
79 - Information packs for relatives
Developing and using information packs for relatives on all aspects of death in hospital.
Matched on
terms: information
CJINI report
66match
A Follow-Up Review of the administration systems supporting bereaved families provided by the Coroners Service for Northern Ireland
Matched on
terms: coroner
Inquiry recommendation
65match
1 - Chief Coroner guidance on coroners' records
The Panel considers that the implementation of the Coroners and Justice Act 2009 should bring about a more consistent approach to the archiving and availability of transferred records and encourages the newly appointed Chief Coroner of England and Wales to issue guidance in consultation with the Keeper of Public Records.
Matched on
terms: coroner
Scottish FAI
65match
Wallace Patrick Hendry
I simply conclude by observing that medical and nursing staff must be aware of the need to ensure as best they can that critical advice and information is conveyed to, and understood by, family members in end of life situations, and that this is done in a sympathetic manner which will require to be adjusted to take account...
Matched on
terms: family, information
Inquiry recommendation
64match
12 - Review and update medical records
The Chief Executive and the Trust Board shall review and update medical and pathology records to include, preferably on computer and cross-referenced, the following information: – name, medical record reference number and date of birth; – date, place of death and death certificate; – name and address of next of kin; – whether Coroner’s or hospital post mortem...
Matched on
terms: coroner, information
PFD report
64match
Oriel Vasey
The coroner noted that an unchanged form and process for its handling could lead to a recurrence of errors. The report also highlights that a form intended for financial decisions contained an allergy section whose purpose was unclear, resulting in incorrect clinical information and suboptimal patient care.
Matched on
terms: coroner, information
PFD report
64match
Alan Tomlinson
The coroner noted a lack of guidance for physiologists on when pacemaker data should trigger cardiology review, limited knowledge of infective endocarditis, and inconsistent clinical information gathering and documentation practices within the Cardiac Device Clinic.
Matched on
terms: coroner, information
Inquiry recommendation
62match
74 - Explain consent after Coroner examination
Explaining that consent is necessary for the retention of organs following a Coroner’s post mortem examination (CPM) and that the consent must be obtained before the CPM is undertaken.
Matched on
terms: coroner
Inquiry recommendation
62match
50 - Introduce Coroner to next of kin
Coroners shall be introduced, their function and procedures explained and the next of kin invited to express any specific concerns and requests.
Matched on
terms: coroner
Inquiry recommendation
62match
46 - Explain Coroner post mortem report
Clinicians shall explain the contents and implications of a Coroner’s post mortem report to the next of kin as if the examination had been carried out as a hospital post mortem examination on their own recommendation.
Matched on
terms: coroner
Committee recommendation
62match
#8 - 1st Report - The Coroner Service
Bereaved people deserve a charter of rights setting out the standards of service they are entitled to receive from the Coroner Service. Setting out the standards they can ‘expect’ in the Guide to Coroner Services is inadequate. The Ministry of Justice should implement a statutory Charter of Rights for bereaved people, modelled on the criminal justice system’s victims’...
Matched on
terms: coroner
Committee recommendation
62match
#7 - 1st Report - The Coroner Service
We encourage Senior Coroners to make sure that bereaved people are made aware by their staff of the specialist support organisations that are available to them both locally and nationally.
Matched on
terms: coroner
Committee recommendation
62match
#6 - 1st Report - The Coroner Service
Help and support for bereaved people depend on the priorities, capacity and skills of the local Coroner Service and local volunteers in the Coroners’ Courts Support Service. The Ministry of Justice should as a matter of urgency provide funding for 58 The Coroner Service support services for bereaved people at inquests, (such as those provided by the Coroners’...
Matched on
terms: coroner
Committee recommendation
62match
#5 - 1st Report - The Coroner Service
The Ministry of Justice’s Guide to Coroner Services is good first step but more needs to be done to make sure that bereaved people know of its existence. We encourage all Senior Coroners to make sure that the updated Guide to the Coroner Service for Bereaved People is freely available both online and, where requested, in hard copy...
Matched on
terms: coroner
CJINI report
62match
An inspection of the arrangements in place in the PSNI to manage and disclose information in support of...
Matched on
terms: information
PFD report
61match
Angus West
The coroner noted the non-retention of the placenta after a baby's death hindered the pathologist's investigation into potential causes like infection or umbilical cord issues. It was recommended that placentas be retained in similar circumstances.
Matched on
terms: coroner
Inquiry recommendation
61match
IHRD-51 - Independence of Coroner Witness Statements
Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.
Matched on
terms: coroner
Inquiry recommendation
61match
80 - Practical help for relatives
Assisting relatives in the following practical matters: – collecting the deceased’s personal belongings and arranging return to relatives; – ensuring provision of certificate of death and the formal notice; – explaining the procedure to register the death; – providing support in attending the registry office if requested; – arranging contact with funeral director; – arranging contact with hospital...
Matched on
terms: coroner
Inquiry recommendation
60match
IHRD-47 - Post-Mortem Reporting Standards
In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy and completeness of the information briefed them. (ii) Work in liaison with the clinicians involved. (iii) Provide preliminary and final reports with expedition. (iv) Sign the post-mortem report. (v) Forward a copy of the post-mortem report...
Matched on
terms: family, information
Article 2 learning point
60match
AA — HMP & YOI Holloway - LP 4
We recommend that stronger efforts are made to assemble and substantiate basic information about prisoners’ next of kin and family situation, particularly where young offenders are concerned.
Matched on
terms: family, information
LGO / SPSO decision
60match
21-018-329 - Surrey County Council
Summary: Mr X complains a Coroner did not do her job properly. He says wrong information was read out in court and the hearing was not recorded. We cannot investigate the actions of the Coroner or what happened in court. The Council has apologised for failing to record the hearing. Further investigation on this point will not lead...
Matched on
terms: coroner, information
Committee recommendation
60match
#28 - 1st Report - The Coroner Service
We encourage the Chief Coroner to collect information from each Coroner Service Area on the challenges they face because of the pandemic and communicate the overall picture to the Ministry of Justice. (Paragraph 222) 62 The Coroner Service
Matched on
terms: coroner, information
PFD report
57match
James Holgate
The coroner identified an apparent anomaly in the Human Tissue Act, which prevents medical research establishments from accepting body donations when a coronial inquest is opened, even if a post-mortem examination is not required.
Matched on
terms: coroner
PFD report
57match
Terence Clark
The coroner noted liquid food in Mr Clark's airway despite a nil-by-mouth order, and an NG tube was removed and lost before autopsy, impeding investigation. This raised concerns about the Trust's ability to secure and review evidence, particularly as its own review overlooked the tube's removal.
Matched on
terms: coroner
Inquiry recommendation
57match
IHRD-53 - Legal Privilege Disclosure to Coroner
In the event of a Trust asserting entitlement to legal privilege in respect of an expert report or other document relevant to the proceedings of an inquest, it should inform the Coroner as to the existence and nature of the document for which privilege is claimed.
Matched on
terms: coroner
Committee recommendation
57match
#20 - 1st Report - The Coroner Service
The majority of witnesses to our inquiry, two Chief Coroners, and almost everyone who has been commissioned to review aspects of the Coroner Service sees the need for a unified service for England and Wales. There is unacceptable variation in the standard of service between Coroner areas. The quality of each local coroner service should not have to...
Matched on
terms: coroner
Committee recommendation
57match
#15 - 1st Report - The Coroner Service
The Government consultation on coronial investigation of stillbirths was welcome but it is disappointing that it appears to have stalled. The Ministry of Justice should revive the consultation on coronial investigation of stillbirths and publish proposals for reform. (Paragraph 118) Shortage of pathology services
Matched on
terms: coroner
Committee recommendation
57match
#2 - 1st Report - The Coroner Service
Reducing the number of coronial areas has helped increase consistency across the Coroner Service. The Ministry of Justice should amend the Coroners and Justice Act 2009 (as requested by the outgoing Chief Coroner) to make it easier to merge areas.
Matched on
terms: coroner
Inquiry recommendation
57match
45 - No compulsion for hospital examination
Clinicians requesting a hospital post mortem examination after the Coroner has declined to authorise an examination shall make it clear to the next of kin that there is no compulsion remaining for such an examination.
Matched on
terms: coroner
HSSIB recommendation
57match
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide greater clarity on the role of PSIRF investigations and other learning responses in the coronial process to help support organisations subject to a coroner’s inquest.
Matched on
terms: coroner
LGO / SPSO decision
57match
21-009-310 - Surrey County Council
Summary: Mrs X complained about how the Council managed the Coroner’s inquest into her father’s death. The Council was at fault when it both failed to invite Mrs X to the inquest and provide her with important documents prior to it. It meant Mrs X did not attend the inquest into her father’s death and lost the opportunity...
Matched on
terms: coroner
Committee recommendation
57match
#4 - 1st Report - The Coroner Service
The Chief Coroner’s guidance on when and how to expedite a case to meet with the requirements of the beliefs of the deceased is welcome, but whether the needs of faith communities will be met or not depends on how the Coroner Service responds locally. We encourage the new Chief Coroner to continue the work of his predecessor...
Matched on
terms: coroner
IMB recommendation
56match
Oakwood (2022)
Can the Minister ask the Chief Coroner to issue guidance about the importance of notifying the IMB of inquests concerning prisoners (para 4.2) as referred to in the IMB reference book guidance in relation to deaths in custody?
Matched on
terms: coroner