Coroner family information gaps
Lack of clear guidance for coroners' offices on whom to approach for information regarding patient deaths, specifically families.
Source spread
Where this theme appears
This theme appears across 16 independent accountability sources, so the source mix matters as much as the headline total.
80 inquiry recs
25 PFD reports
44 committee recs
1 HSSIB rec
1 CQC action
1 PPO rec
15 IMB recs
5 Scottish FAIs
15 Article 2 learning points
47 DHR recs
74 PHSO decisions
59 LGO/SPSO decisions
3 CJINI reports
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(80)— showing 50 strongest matches
85 — General liaison duties
Recommendation: Undertaking general liaison duties.
Unknown
84 — Assist with other problems
Recommendation: Assisting with any other individual problem presented by relatives in consequence of death.
Unknown
83 — Translation and accessibility services
Recommendation: Accessing translation/interpreting services including services for people with hearing or visual impairment and providing appropriate written/taped information.
Unknown
82 — Awareness of support resources
Recommendation: Ensuring that relatives are aware of the full range of counselling/support resources available including those external to the hospital and bringing these matters to the attention of the relatives.
Unknown
81 — Discuss counselling and support
Recommendation: Discussing counselling or long-term support needs with relatives, including the needs of wider family members and making contact with appropriate counselling/support agencies if requested.
Unknown
80 — Practical help for relatives
Recommendation: 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 …
Unknown
79 — Information packs for relatives
Recommendation: Developing and using information packs for relatives on all aspects of death in hospital.
Unknown
78 — Record and share discussions
Recommendation: Noting discussions between relatives, clinicians and pathologists and providing a copy to each party involved.
Unknown
77 — Meetings with clinician and pathologist
Recommendation: Facilitating meetings between parents, clinician and pathologist as appropriate.
Unknown
76 — Clinician attendance at examination
Recommendation: Ascertaining whether the clinician will attend post mortem examination.
Unknown
74 — Explain consent after Coroner examination
Recommendation: 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.
Unknown
73 — Explain need for hospital consent
Recommendation: Explaining the need for consent to carry out a hospital post mortem examination (HPM) and the retention of organs.
Unknown
72 — Explain reasons for post mortem
Recommendation: Ensuring that relatives have a full explanation of the reasons for post mortem examination including therapeutic, medical education and research.
Unknown
71 — Meeting with treating clinician
Recommendation: Encouraging a meeting between relatives and the treating clinician to explain the clinical circumstances of death and if requested arranging and attending the meeting.
Unknown
70 — Meeting with those present at death
Recommendation: Arranging and attending a meeting for relatives with anyone who was present at the death if requested.
Unknown
69 — Explain circumstances of death
Recommendation: Explaining the circumstances of death, identifying when, where and who was present.
Unknown
66 — Meeting and genetic counselling
Recommendation: Following examination of the retained organs or tissue, there should be a meeting between the clinician and parents and referral for genetic counselling or other specialist advice if appropriate.
Unknown
62 — Training in informed consent
Recommendation: The Department of Health, the Royal Colleges and medical schools shall provide training for all those involved in obtaining fully informed consent.
Unknown
61 — Public health education programme
Recommendation: There shall be a programme of health education for the public relevant to the medical need for continued post mortem examination and access to organs and samples for therapeutic, educational and research purposes.
Unknown
60 — Remove surviving relative class
Recommendation: The class of ‘any surviving relative’ shall no longer be relevant to post mortem examination.
Unknown
59 — Define next of kin
Recommendation: The class of persons relevant to the obtaining of fully informed consent shall be defined as the ‘next of kin’.
Unknown
58 — Amend Act for informed consent
Recommendation: The Human Tissue Act 1961 shall be amended to provide a test of fully informed consent for the lawful post mortem examination and retention of parts of the bodies of deceased persons. While we have concluded that there has been …
Unknown
55 — Specify retained material in reports
Recommendation: Coroners shall ensure that all existing retained organs, tissue, blocks, slides, photographs and X-rays are specified within any preliminary and final post mortem reports.
Unknown
52 — Reasons if examination not authorised
Recommendation: If a decision is made not to authorise a post mortem examination, Coroners shall notify the next of kin of that decision and give sufficient reasons for the decision.
Unknown
51 — Advice to next of kin on examination
Recommendation: If a decision is made to authorise a post mortem examination Coroners shall ensure that the next of kin are advised of: – the reasons for authorising the post mortem examination; – their right to ask the Coroner that the …
Unknown
50 — Introduce Coroner to next of kin
Recommendation: Coroners shall be introduced, their function and procedures explained and the next of kin invited to express any specific concerns and requests.
Unknown
46 — Explain Coroner post mortem report
Recommendation: 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.
Unknown
45 — No compulsion for hospital examination
Recommendation: 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.
Unknown
42 — Information for next of kin
Recommendation: 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 …
Unknown
18 — Keep parents fully informed
Recommendation: parents must never again be drip-fed information but should be kept fully informed.
Unknown
F274 — Information to coroners
Recommendation: 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 …
Gov response: Accepted. The Coroners and Justice Act 2009 states that, ‘It is an offence for a person to do anything that is intended to have the effect of (a) distorting or otherwise altering any evidence, document …
Accepted
F273 — Information to coroners
Recommendation: 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 …
Gov response: Accepted in principle. All relevant information should be shared with coroners to ensure that they are able to perform their roles fully. The Coroners and Justice Act 2009 states that, ‘It is an offence for …
Accepted in part
12 — Review and update medical records
Recommendation: 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 …
Unknown
MACP-42 — Ensure advance disclosure of evidence to parties appearing at inquests.
Recommendation: That there should be advance disclosure of evidence and documents as of right to parties who have leave from a Coroner to appear at an Inquest.
Unknown
CLAR-Jury Recommendations — Inform victim families of post-mortem rights and viewing opportunities with caution
Recommendation: I would also reiterate the recommendations which the inquest jury, although not strictly empowered to do so, made in a letter delivered to Dr Burton with their verdict on 7thApril 1995: 1. Families of victims must always be informed of …
Unknown
R69 — Explanation to relatives on CDI death
Recommendation: Health Boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation of the role played by CDI in the …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
1 — Chief Coroner guidance on coroners' records
Recommendation: 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 …
No response yet
IHRD-53 — Legal Privilege Disclosure to Coroner
Recommendation: 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 …
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-52 — Inquest Duties Protocol
Recommendation: Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-51 — Independence of Coroner Witness Statements
Recommendation: Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-50 — HSCB Notification of Inquests
Recommendation: The Health and Social Care ('HSCB') should be notified promptly of all forthcoming healthcare related inquests by the Chief Executive of the Trust(s) involved.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-47 — Post-Mortem Reporting Standards
Recommendation: 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 …
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-44 — Post-Mortem Limitation Authorisation
Recommendation: Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of the family.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-43 — GP Notification of Death Circumstances
Recommendation: A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F283 — Information for and from inquests
Recommendation: 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.
Gov response: Accepted. The Judicial College has taken responsibility for training all coroners and coroner’s officers under the remit of the Chief Coroner’s Office from July 2013. The College has already supplied training to coroners on the …
Accepted
F282 — Information for and from inquests
Recommendation: Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
Gov response: Accepted. The Coroners and Justice Act 2009 states that where a senior coroner has conducted an investigation and anything has been revealed that indicates a risk of other deaths then the coroner, ‘…must report the …
Accepted
75 — Time and privacy to reflect
Recommendation: Ensuring relatives have sufficient time, privacy and support to reflect upon the request for consent to an HPM or the retention of organs following a CPM or an HPM.
Unknown
67 — Research possession and ethics approval
Recommendation: Once fully informed consent is obtained for research purposes, the researchers are entitled to remain in possession of the material retained while research continues. We recommend this extends to accessing archives and DNA analysis. All research remains subject to ethics …
Unknown
57 — Instruct doctors on Human Tissue Act
Recommendation: The Department of Health, the Royal Colleges and medical schools shall instruct members of the medical profession in the precise terms and provisions of the Human Tissue Act 1961, on the basis of our analysis, and the need for strict …
Unknown
56 — Pathologists limit retention
Recommendation: The Royal College of Pathologists shall instruct all practising histopathologists that they shall not retain samples and organs beyond those reasonably incidental to establishing the cause of death unless there is also written consent properly obtained under the Human Tissue …
Unknown
Prevention of Future Deaths reports(25)
Lillian Robinson
Concerns: 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.
Overdue
Brian Kent
Concerns: The provided text indicates that concerns are set out in an enclosed letter and enclosures, but does not detail specific issues.
Overdue
Terence Dooley
Concerns: 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.
Response (North West Ambulance Service NHS Trust): • North West Ambulance Service (NWAS) confirmed that an audit of the call determined the Green 2 code was correct based on the Medical Priority Dispatch System (MPDS). • NWAS … (AI summary)
Responded
Angus West
Concerns: 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.
Response (The Royal College of Midwives): • The Royal College of Midwives (RCM) stated its agreement with the coroner's recommendations to the NHS Trust. • The RCM indicated that best practice would involve retaining and safely … (AI summary)
Response (York Teaching Hospital): • The Trust shared the notification with its Clinical Director for Obstetrics and Gynaecology and the Risk Management team. • The Trust liaised with the Royal College of Obstetrics and … (AI summary)
Responded
Christopher Seal
Concerns: 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.
Response (Avon and Wiltshire Mental Health NHS Trust): • The Trust reviewed and disseminated amended guidance for staff on recording explicit consent for information sharing and editing RiO records. • The Trust is developing technical solutions to improve … (AI summary)
Responded
Geoff Gray
Concerns: 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.
Response (Chief Coroner): • The Chief Coroner included text in forthcoming guidance advising coroners to give particular thought to the need for or scope of post-mortem examinations in deaths from stab or gunshot … (AI summary)
Overdue
Keith Whetton
Concerns: 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.
Response (Hunters Lodge Care Centre): • Staff received supervision and completed falls training. • The falls policy and procedure was updated and implemented. • Staffing levels were increased to enhance resident observation and nursing support. (AI summary)
Responded
James Holgate
Concerns: 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.
Response (Department of Health and Social Care): • The Department stated it would discuss with the Human Tissue Authority how to ensure their guidance and codes of practice provide clarity on the criteria for the storage and … (AI summary)
Responded
Terence Clark
Concerns: 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.
Response (Department of Health and Social Care): • Department officials made enquiries with NHS England and the Care Quality Commission. • The Care Quality Commission reported that the Trust had taken actions to address the concerns. • … (AI summary)
Response (Barts Health): • The Trust discussed the case at safety huddles with senior nursing and site teams to reinforce the need for discussion with the coroner's office regarding device removal. • The … (AI summary)
Responded
Stephanie Link
Concerns: The coroner notes concerns regarding the delay in finalising and implementing an agreed, documented care pathway for patients with complex acute pancreatitis, which remains unshared across different hospital sites, posing a risk of future deaths.
Response (University Hospitals Birmingham NHS Foundation Trust): • A multidisciplinary team (MDT) for complex pancreatitis patients has been developed across sites. • A Standard Operating Procedure (SOP) for patient referral and management has been formalised, shared with … (AI summary)
Responded
Scott Catton
Concerns: The coroner notes there is no requirement for electric scooter riders to wear helmets, which creates a risk of death in collisions, even at lower speeds.
Response (Department for Transport): • The Government has committed to pursuing legislative reform for micromobility vehicles, including e-scooters, when parliamentary time allows. • Future regulations, including the potential requirement for helmet-wearing, will be subject … (AI summary)
Response (Department for Transport): • The Department for Transport has committed to pursuing legislative reform for micromobility vehicles, which will include e-scooters. • Any future regulations, including the potential requirement for helmet-wearing, will be … (AI summary)
Responded
Paul Harries
Concerns: Manual coding errors and insufficient feedback to GPs on referral urgency are concerns in the GP-Consultant booking chain. Additionally, the coroner highlights unintegrated IT systems for referrals and inconsistent reporting of incidental ED findings to GPs.
Response (University Hospitals Sussex NHS Foundation Trust): • A system has been introduced in the Emergency Department to review all imaging reports, ensuring incidental findings are followed up or GPs are informed. • Education has been provided … (AI summary)
Responded
Ellie Herron
Concerns: The coroner noted the high prevalence of drug and alcohol abuse, rough sleeping, and criminal activities in Pearson Park, which places vulnerable individuals at high risk.
Response (Humberside Police): • Humberside Police implemented "Operation Vortex" in 2025, which included increased patrols, enforcement of Public Space Protection Orders, arrests, and intelligence gathering. • The force has dedicated officers to the … (AI summary)
Responded
Clare Dupree
Concerns: The coroner identifies that in-cell automatic fire detection (AFD) has not yet been implemented at Eastwood Park prison and other prisons, and that current domestic smoke detectors are a less effective mitigation. There is also a noted delay in implementing AFD across the prison estate.
Response (HM Prison Probation Service): • HM Prison and Probation Service (HMPPS) has equipped over 40,000 prison places with in-cell Automatic Fire Detection since 2009 as part of a national programme. • A programme of … (AI summary)
Overdue
John Beagley
Concerns: The coroner noted a national shortage of maxillofacial surgeons, which could impact patient care. This shortage was linked to the long training period, a significant part of which is not NHS-funded and perceived as unattractive to prospective surgeons.
Response (Department of Health and Social Care): • The Department for Education will introduce a Lifelong Learning Entitlement (LLE) system from January 2027, enabling eligible students undertaking medicine or dentistry as a second degree to access maintenance … (AI summary)
Responded
Julie Pytches
Concerns: The coroner noted the absence of a process for doctors to notify private hospital management of practice limitations. There was also confusion among consultants and staff regarding emergency protocols and roles during major events requiring ambulance assistance or transfer to another centre.
Response (Nuffield Health): • The Practising Privileges policy requires medical practitioners to notify management of practice limitations, and induction and renewal checklists will be updated to reinforce this. • A centralised policy management … (AI summary)
Responded
Charles Harper
Concerns: No specific concerns were detailed in the provided text fragment from the coroner's report.
Response (The Pipeline Industries Guild): • The Pipeline Industries Guild confirmed that a note sharing lessons learned was issued to all members in March. • The Guild stated it would hold a webinar in April … (AI summary)
Response (British Drilling Association): • The British Drilling Association has been working with Balfour Beatty Vinci Joint Venture and the Pipeline Industries Guild to understand actions taken and offer support for proposed industry safety … (AI summary)
Responded
Viviana-Ray Butnaru
Concerns: The coroner noted a lack of national guidelines for assessing paediatric heart conditions like myocarditis in A&E, delayed radiologist reporting of chest X-rays, and incomplete documentation of observations and medical handovers.
Response (Mid and South Essex NHS Foundation Trust): • The Trust will complete a review of its policy, Guide for making the best use of a Radiology Department, by 1 June 2026 to include guidance for clinical teams … (AI summary)
Response (The Royal College of Paediatrics and Child Health): • The Royal College of Paediatrics and Child Health (RCPCH) stated that its "Facing the Future: Standards for Children and Young People in Emergency Care Settings" provide a framework for … (AI summary)
Responded
Oriel Vasey
Concerns: 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.
Response (NHS North East and North Cumbria): • The ICB amended its standard Nursing Needs Assessment form to clarify its ownership and prohibit modification. • The new form was circulated to all All Age Continuing Care teams … (AI summary)
Responded
Caroline Adeyelu
Concerns: Coroner identified insufficient safeguarding training and risk assessment concerning adult child to parent domestic abuse. There were also concerns about ineffective and non-immediate operational communication between mental health services and police for dual risk cases.
Response (North East London NHS Foundation Trust): • The Trust completed a review of its Safeguarding Level 3 training, incorporating dedicated content and case studies on adult child to parent abuse (ACPA). • The Trust is updating … (AI summary)
Response (East London Foundation Trust): • The Trust strengthened its mandatory Level 3 Safeguarding Training to explicitly address the risks of adult child to parent domestic abuse, including specific data on mothers killed by sons … (AI summary)
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) undertook a comprehensive review of information-sharing pathways with Mental Health Trusts and met with two trusts to discuss improved operational information flow. • The … (AI summary)
Responded
Alan Tomlinson
Concerns: 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.
Response (Cardiff and Vale University Health Board): • A revised escalation and referral protocol has been implemented within the Cardiac Device Clinic, including a mandatory referral trigger. • A new history sheet has been developed for documenting … (AI summary)
Responded
Kay Wilson
Concerns: A breach in a stone wall near County Bridge, Barnard Castle, provides unrestricted and unguarded access from a public area to a 9-metre vertical drop onto rocks and the River Tees.
Response (Durham County Council): • Officers inspected the breach in the stone wall and reviewed the site-specific risk assessment. • A steel fencing section will be installed to close the gap in the stone … (AI summary)
Responded
Asher Blackman
Concerns: The initial assessment by District Nurses did not record Mr. Blackman's next of kin details or a plan for gaining access. The no-access policy also lacked provision for police involvement when a patient's life might be at risk.
Response (Central London Community Healthcare NHS Trust): • The Trust undertook engagement events with approximately 420 staff to review clinical practice and the 'No Access: Not Seen: Disengagement Policy'. • The Trust reviewed District Nursing referral forms … (AI summary)
Responded
Terrence Frost
Concerns: Concerns relate to the inability of a GP to promptly communicate with the Medical Assessment Unit or Accident and Emergency department regarding patient admissions. Internal hospital staff also experienced difficulty contacting the Medical Assessment Unit.
Response (East Suffolk North Essex NHS Trust): • The Trust implemented a new electronic patient record system in October 2025, enabling internal users to send secure messages. • The Medical Assessment Unit bleep is now used exclusively … (AI summary)
Responded
Darryl Johnson
Concerns: The coroner raised concerns that the East of England Ambulance Services Trust's CAD system contained an inaccurate address and map database, specifically for a property that had been established for over 11 years.
Response (Response Ordnance Survey): • Ordnance Survey's NGD Address Version 3, released in October 2025, includes unmatched Royal Mail address data. • Ordnance Survey and GeoPlace will undertake a comprehensive analysis of unmatched address … (AI summary)
Responded
Select committee recommendations(44)
#14 —
Recommendation: We also remain concerned that there may be a delay in the appointment of individual public advocates following major incidents, when it appears to remain their role to provide support directly to victims and bereaved family members. This could result …
Response attribution not verified
#12 —
Recommendation: We welcome the creation of the roles of the standing and incident specific advocates for victims of major incidents. If implemented correctly, the advocates who fulfil those roles will provide crucial help to victims navigating the often daunting maze of …
Response attribution not verified
#10 —
Recommendation: Inequality between the State and bereaved families hinders the effective involvement of families in the inquest process, as may be required by Article 2 ECHR. By leaving the process unequal, it may also damage the ability of inquests to get …
Response attribution not verified
#9 —
Recommendation: The Joint Committee on Human Rights has previously called for families involved in inquisitorial inquests to be “given non-means tested funding for legal representation at inquests where the state has separate representation for one or more interested persons”. We welcome …
Response attribution not verified
#14 —
Recommendation: Over twenty years on from some of the judgments, it is deeply regrettable that the full implementation of the judgments in the McKerr group of cases has still not taken place. The repeal and replacement of the Legacy Act is …
Response status not verified
#12 —
Recommendation: We recommend that the Government is clearer about its timetable for consultation and bringing forward primary legislation to resolve the remaining matters arising from the Re Dillon case and fulfilling its other pledges on Northern Ireland Legacy, including the restarting …
Response status not verified
#9 —
Recommendation: 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 …
Response attribution not verified
#8 —
Recommendation: 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 …
Response attribution not verified
#7 —
Recommendation: 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.
Response attribution not verified
#6 —
Recommendation: 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 …
Response attribution not verified
#5 —
Recommendation: 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 …
Response attribution not verified
#7 — Address concerns about the Bill’s narrow definition of “close family member” and case exclusions.
Recommendation: 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 …
Response attribution not verified
#13 —
Recommendation: We are particularly pleased that the Government has recognised the importance of a speedy response to any major incident and amended the Victims and Prisoners Bill to include a standing advocate. We consider it crucial that the appointment of a …
Response attribution not verified
#11 —
Recommendation: We urge the Government to take steps to ensure that families receive proportionate legal representation at inquests and inquiries whenever the state has its own representation. If a consultation on the extension of legal aid in inquests that follow public …
Response attribution not verified
#17 —
Recommendation: The government should amend the exhaustive list of Close Family Members in clause 93(2) to add an additional catch-all final category: “(g) F is the next-of-kin”. This will ensure that family members such as grandchildren, nieces and nephews of the …
Response status not verified
#7 —
Recommendation: However, it is not clear that the Legacy Commission will have the power to do so under the bill as currently drafted. There is no principled reason why the Legacy Commission should not be able to produce ‘closed’ findings. Indeed, …
Response status not verified
#6 —
Recommendation: Public inquiries and courts using the Closed Material Procedure can create documents containing ‘closed’ findings, in addition to the published ‘open’ findings. Such ‘closed’ findings are an integral part of an investigation being effective and thorough in ascertaining the facts …
Response status not verified
#20 —
Recommendation: 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 …
Response attribution not verified
#15 —
Recommendation: 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) …
Response attribution not verified
#2 —
Recommendation: 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.
Response attribution not verified
#29 —
Recommendation: We asked the Departments what feedback they had received from victims about transparency during the claim process and what it was doing to address feedback it received. DBT told us it amended the claim guidance on the Horizon Compensation Schemes, …
#28 —
Recommendation: Our survey of individuals with experience of government compensation schemes found that two-thirds of people had irregular or no communication during the claim process. Of total respondents to our survey, 53% felt 69 Q89 70 C&AG’s Report, para 14 71 …
#27 —
Recommendation: Peter Gibson from Fighting With Pride told us that the MoD initially promised victims regular updates during the claim process, but this did not come to fruition, and it also said the MoD launched the scheme without delivering its online …
#26 —
Recommendation: Representatives of victims have expressed a need for greater transparency and clarity about how long the claims process is expected to take, and have been critical about the lack of information provided to victims about how long they might wait …
#6 —
Recommendation: There remains substantial variation across schemes in how long claims take to conclude, capacity for greater transparency and clarity during the claim process and scope for more structured and consistent cross- government learning.8 The independence of schemes, and their design …
#18 —
Recommendation: Clause 67(5) should also be amended to ensure that, even if there are Close Family Members, the Legacy Commission has a discretion to allow other family members to make personal statements as well, if appropriate. (Recommendation, Paragraph 107)
Response status not verified
#16 —
Recommendation: The definition of Close Family Member in the Troubles Bill is currently drawn too narrowly. The current definition does not match Article 2 ECHR’s approach of ensuring sufficient involvement of the ‘next-of-kin’, which is not exhaustively defined. In addition, the …
Response status not verified
#8 —
Recommendation: The government should amend the bill to give the Legacy Commission an explicit power to produce a ‘closed’ final report in addition to an ‘open’ final report in appropriate cases. (Recommendation, Paragraph 51)
Response status not verified
#43 —
Recommendation: Expansion of legal aid to inquests is positive, but there may not be capacity in the system for sufficiently qualified and experienced lawyers to do this work. (Conclusion, Paragraph 127)
Response status not verified
#11 —
Recommendation: Victims, their families, and all the communities affected by the Troubles deserve greater clarity about the timetable of the Government’s plans to finally address Legacy issues. We agree that the Government is right to consult with the affected parties. However, …
Response status not verified
#13 —
Recommendation: The Government must, with some urgency, set out how its proposed information recovery mechanism will operate, including the means by which it will obtain information. The needs of victims and survivors, for truth, accountability and for reconciliation will be deeply …
Response attribution not verified
#21 —
Recommendation: As with calls for a national service for England and Wales, there is an overwhelming and long-standing view that the Coroner Service would benefit from the presence of an inspectorate overseeing its work. As with those calls, we are merely …
Response attribution not verified
#14 —
Recommendation: There may be circumstances where with the consent of the bereaved people concerned, it would be sensible for the High Court to be able to direct that the particulars of the Record of the Inquest be amended as appropriate without …
Response attribution not verified
#4 —
Recommendation: 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 …
Response attribution not verified
#26 —
Recommendation: 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 …
Response attribution not verified
#31 —
Recommendation: We also recommend that the Governments of the UK and Ireland should agree forthwith to extend the pilot of the ICIR to at least five years. This would allow for the time period in which family members can request information …
Response status not verified
#12 —
Recommendation: The Government is right to recognise the importance of providing families that seek it with as much information as possible about the death of a loved one. Many families seek not redress, but merely to be treated with respect and …
Response attribution not verified
#28 —
Recommendation: 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
Response attribution not verified
#25 —
Recommendation: The working assumption should be that families are partners who have the potential to be instrumental in the attempts to resolve the detentions. Despite Government assurances, we do not believe that sufficient progress has been made in improving communication with …
Response attribution not verified
#21 —
Recommendation: We recommend that if a family believes their case would be best served by going public, the Government should have frank, detailed and regular conversations with them on the likely impacts of their decision and advise on how to proceed …
Response attribution not verified
#55 —
Recommendation: The MacGregor Review offers the single best insight into the changes which need to be made within the FCDO to better equip it to deal with complex ‘consular cases’. We welcome the Government’s commitment to its recommendations but are concerned …
Response attribution not verified
#21 — Restrict sharing of administrative investigation information; agree MoU with the Chief Coroner.
Recommendation: 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 …
Response status not verified
#54 —
Recommendation: In 2019, the FCDO commissioned a review into the department’s handling of complex consular cases. The review was conducted by Dame Judith MacGregor and focused on how the department balances the needs of the individual with the needs of the …
Response attribution not verified
#56 —
Recommendation: In its written evidence, the FCDO made clear that the strategies employed to secure the release of detained nationals vary by case.127 The intricacies of the negotiations and representations conducted by the FCDO in the pursuit of justice for detainees …
Response attribution not verified
NCEPOD recommendations(1)
CQC inspection actions(1)
PPO death in custody recommendations(1)
IMB individual recommendations(15)
Altcourse (2020)
Delays in scheduling Coroner inquests have caused anxiety for staff attending as witnesses and families awaiting closure.
Ministry of Justice
In Progress
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?
Ministry of Justice
Rejected
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 been waiting …
Ministry of Justice
In Progress
Lowdham Grange (2023)
The Board continues to request that 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.
Ministry of Justice
Hewell (2020)
Please conclude the report into the death on 14 June 2018, so that an inquest may be carried out.
Other
In Progress
Lowdham Grange (2021)
Ensure that priority is given to holding Coroner’s inquests for deaths in custody to enable prisoners’ families to understand more of the circumstances of the deaths of their relatives.
Ministry of Justice
In Progress
Hindley (2022)
The Board queries the significant delays in holding inquests and the resultant distress to the families and staff involved – one inquest has been outstanding since 2019. Would the Minister examine what can be done to reduce this unacceptable delay?
Ministry of Justice
Stoke Heath (2024)
When will the Governor improve the system to inform the IMB about deaths in custody, so that we know as soon as possible?
Governor / Director
In Progress
Garth (2020)
These deaths, whether from natural causes or self-inflicted, have a distressing effect on staff, prisoners and, of course, the families and friends of the deceased. It is recognised that all of these deaths should be fully investigated, but it is a cause for concern that the process invariably takes so long. It would be a benefit to all if the …
Ministry of Justice
In Progress
Littlehey (2021)
With the high number of deaths in custody the Board asks whether the Governor will be focussing on the learning points from those that have occurred and, whether she will be addressing the number of trained family liaison officers (FLOs).
Governor / Director
Thameside (2025)
Will the prison review the information for prisoners’ families, both on the website and in the visitors’ centre, to ensure this is updated, clear and also consistently applied?
Governor / Director
Hollesley Bay (2024)
The Board suggests that there is a need to review the handling of prisoners’ post, in particular where healthcare appointments are concerned.
Governor / Director
Scotland and Northern Ireland short-term holding facilities (STHF) (2025)
Access to phones in holding rooms is often poor. Information provision can also be weak. For example, some people we spoke to did not recall being informed of their right to legal advice. What steps are being taken to standardise provision in line with best practice, and to properly enforce non-compliance?
Other
Maidstone (2023)
To work with the Home Office to require that prisoners sign official documentation either in their own language or in a language they understand. Many prisoners need help with translation that they are not receiving.
Home Office
Stoke Heath (2024)
The Governor should improve the system to inform the IMB about deaths in custody, so that we know as soon as possible.
Governor / Director
Health investigations(131)
An independent investigation into the care and treatment of a … — Rec Recommendation 2
NHS England (South) should ensure that all mental health provider organisations in its geographical area have a policy in place for the active involvement of carers in the care and treatment of service users. This policy should include clear guidance on how to support carers to remain involved throughout the …
south_east
An independent investigation into the care and treatment of a … — Rec R5
To ensure that all carers are actively involved in Early Intervention in Psychosis throughout the three years the service user is cared for by the service.
south_east
Independent investigation: Richard Marden, Towcester (1999) — Rec 19
That, following production of the new leaflet which it is proposed should be available to the families of victims of homicides, the Trust implements a staff training programme which takes account of the sensitive nature of providing support to bereaved families; and that the voluntary sector be involved in, or …
midlands
Independent investigation: Richard Marden, Towcester (1999) — Rec 18
That in the event of a Serious Untoward Incident, contacts with and offers of support to the victim's family, including telephone contacts, should be documented and recorded in the Serious Untoward Incident report sent to the Health Authority. Details of contacts and offers of support made subsequent to the preparation …
midlands
Independent investigation: Richard Marden, Towcester (1999) — Rec 17
That where the need for an external independent inquiry arises, the Trust should appoint a senior person to make and maintain contact with the family until that independent inquiry has been appointed. This individual should be responsible, amongst other things, for: (a) keeping the family informed and up to date …
midlands
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.14
In partnership with other Trusts, APW should establish the means of providing appropriate and acceptable bereavement counselling and support for bereaved families following a homicide perpetrated by a patient.
south_west
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 21
The panel recommends to the SHA that in future inquiries commissioned by the SHA the panel should always give serious consideration to interviewing relatives and close associates. (Paragraph 11.67)
east_of_england
Independent investigation: John Stevens, Woking (2001) — Rec 21
We recommend that the North West Surrey Mental Health Partnership Trust, when the need for an external independent inquiry arises, should appoint a senior person to make and maintain contact with the family until that independent inquiry has been appointed. This person will be responsible for: - a. Offering to …
south_east
Independent investigation: Tracey Baker, Chard (2015) — Rec 8
Somerset Partnership NHS Foundation Trust should consider recruiting a family liaison officer who would be the single point of contact and support for families throughout the course of a serious incident investigation.
south_west
Independent investigation: Tom Easton, Old St, London (2006) — Rec 8
The East London Foundation Trust should take steps to identify the family of any person murdered or injured by a patient in the care of the Trust and to offer themany help and support they feel they would like. The Trust should also be open about the Internal Investigation and …
london
Independent investigation: Robert Lewis, Sutton (2010) — Rec Four
It is recommended that for all serious incidents, such as a death of a patient, that results in the Trust setting up an internal review the family of that individual are given an opportunity to participate in the review process. The family should also have access to the final review …
london
Independent investigation: Mark Berry, Dewsbury (2005) — Rec 1.0
The Trust should ensure that the family of patients involved in serious incidents are contacted to establish their possible care and support requirements
north_east_yorkshire
Independent investigation: Keziah Flux Edmonds, East Cowes, IoW (2016) — Rec 11
Isle of Wight NHS Trust should consider recruiting a family liaison post who would be the single of point of contact and support for families throughout the Serious Incident investigation process.
south_east
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 1
The Trust should consider making further efforts to contact the victim’s and perpetrator’s families to ensure that they have had the opportunity to become involved in, or make comment upon the investigations that have been made into the care and treatment of Mr H. The Chief Executive of the Trust …
london
Independent investigation: John TaylorBeverley Taylor, Skipton (2021) — Rec 3
As Patient E’s condition deteriorated, there was an increasing lack of engagement with him and his family members, and no evidence of any attempts to provide education about the nature and course of his illness and its treatment. Patient E and his family were not provided with an opportunity to …
north_east_yorkshire
Independent investigation: John Hall, West Rainton (2013) — Rec 4.11.2
The trust should have a clear process in place to locate and engage the families of any victim’s so they have the opportunity to be supported and involved in the trust internal investigation. As a minimum the trust should ensure that the victim’s family: are provided with and consulted …
north_east_yorkshire
Independent investigation: Douglas Scott, Manor Park (2007) — Rec 4
Following the death of Mr D, an executive director of East London and the City Mental Health Trust met with the relatives of Mr D to share with them the findings and recommendations of the internal investigation. The family of Mr D found the Trust‟s representative to be insufficiently informed …
london
Independent investigation: Dorothy Shepherd, Winchcombe (2010) — Rec 3
The Trust should ensure that one of the functions of the incident co-ordination group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way and are enabled the opportunity to take part in the Trust’s internal …
south_west
Independent investigation: Carmelita Tulloch, Vauxhall, London (2006) — Rec Recommendation Numbe
The Trust should develop strategies to ensure that condolence; support and advice are offered to the families / loved ones of the victims of homicide without this endangering the police investigation and judicial processes, and that the Being Open Policy (2008) is reviewed as necessary and fully implemented.
london
Independent investigation: Christopher Ritchie, Durham (2020) — Rec 3
• As the Trust implements the PSIRF framework, policies and procedures must include identifying all persons who should be offered the opportunity to contribute to an individual case investigation. • The procedure should set out reasonable expectations for making contact with families where details are not held on patient records, …
north_east_yorkshire
Independent investigation: Aysel Djevdet, Palmers Green (2009) — Rec 1
The Trust should consider making further efforts to contact the victim‟s and perpetrator‟s families to ensure that they have had the opportunity to become involved in, or make comment upon the investigations that have been made into the care and treatment of Mr H. The Chief Executive of the Trust …
london
Independent investigation: Antonio Tommaso, New Barnet (2014) — Rec 9
In future instances of homicide by a service user in contact with mental health services, and where practicable, the Trust should offer professional support to meet any mental health needs arising from the incident and should signpost families to help with any other needs arising from the incident, such as …
london
Independent investigation: Alan Creasey, Lancing (2017) — Rec 4
The Trust needs to review the clinical care records of AC and determine if he had any relatives who may need to be informed of the findings of the internal investigation report and this assurance review.
south_east
Independent investigation: Alan Creasey, Lancing (2017) — Rec 2
The Trust/NHS England need to establish contact with the family of DH and inform them of the findings of the internal investigation report and this assurance review.
south_east
William Mead – Root Cause Analysis Investigation Report — Rec c)
That the RCA process and how relatives are involved is reviewed and improved as a result of the positive learning from this case.
south_west
Independent review of mental health treatment and care provided in … — Rec 2
Our team recommends that Dorset Healthcare should provide an opportunity for representatives from Colin’s family to meet representatives from the service to consider the circumstances of his death, understand the changes described in the report, and the ways in which recommendations will be acted upon.
south_west
Independent investigation into the death of B: September 2014 — Rec 4
The investigation team recommends that awareness is raised about the importance of family testimony. At local level for clinicians, this could be achieved via training for staff which includes representation from users, carers and family members as appropriate and/or a focus on reflective practice. We would also suggest that national …
Norfolk and Suffolk NHS Foundation Trust
east_of_england
Independent Investigation into the care and treatment of X: October … — Rec 7
The Trust should ensure that communication with families is carried out in line with the Trust’s adverse incident policy, and follows guidance in the Memorandum of Understanding5 and best practice guidance6 and there are assurance systems that evidence this concordance with policy.
South Essex University Partnership NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of Mr D … — Rec 6
The Trust should share its internal investigation report with Miss Y’s family at the earliest opportunity.
Cambridgeshire and Peterborough NHS Foundation Trust
east_of_england
An independent review of the Level 2 RCA investigation into … — Rec 4
The Trust needs to review the clinical care records of AC and determine if he had any relatives who may need to be informed of the findings of the internal investigation report and this assurance review.
south_east
An independent review of the internal investigation and associated action … — Rec 1
The Trust must ensure that a process is in place that indicates that family members have been offered the opportunity to see a copy of the report, indicating when this has been completed.
south_east
Accepted
An independent quality assurance review (published August 2021) can be … — Rec 8
RDaSH should consider the viability of recruiting a family liaison officer, who would be the single point of contact and provide support for families throughout a serious incident investigation process.
north_east_yorkshire
An independent mental health homicide investigation into the care and … — Rec 13
AWP and Cygnet Health Care should consider recruiting a family liaison officer, who would be the single point of contact and provide support for families throughout the serious incident investigation process.
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent investigation into the care and treatment of mental … — Rec 3
The Trust should ensure that its process for involving affected families in its internal investigation process includes providing an opportunity for families to submit feedback on the draft report.
Mersey Care NHS Foundation Trust
north_west
An independent investigation into the care and treatment of Darren … — Rec 11
Isle of Wight NHS Trust should consider recruiting a family liaison post who would be the single of point of contact and support for families throughout the Serious Incident investigation process.
Isle of Wight NHS Trust
south_east
An independent investigation into the care and treatment of Adult … — Rec Recommendation 7
MHA and involving the NR at detention and discharge There is no record of information being provided to the NR about Adult 1’s detention and discharge. The Council must ensure that the NR is provided with information about a patient’s detention. The Trust must ensure that the MHA Office communicates …
south_west
An independent inquiry into the care and treatment of Mr … — Rec R5
The trust should have a clear process in place to ensure that the victims of serious incidents and their families are supported and involved in the trust internal investigation. As a minimum the trust should ensure that the victim’s family: are provided with and consulted on the terms of …
Mr S . At the time of the homicide (2011) Mr S was receiving care and treatment from Somerset Partnership NHS Foundation Trust
south_west
An independent inquiry into the care and treatment of JK: … — Rec 5
The Trust should ensure that the lead for liaison with family members and carers after such a serious incident should be at executive director or equivalent level, in accordance with the NPSA good practice guidance. This director would not necessarily carry out all contacts but would make the initial contact …
Southern Health NHS Foundation Trust
south_east
Accepted
An independent inquiry into the care and treatment of JK: … — Rec 4
The Trust should develop guidance on family support and access to information after a serious incident, to include guidance on implementation of this and the Duty of Candour policy.
Southern Health NHS Foundation Trust
south_east
Accepted
A post-publication assurance review in relation to the implementation of … — Rec A8
Senior Trust officers should discuss and agree future Trust Policy in relation to involvement / information sharing with the family of a victim, when the victim is not known to mental health services in these circumstances. In relation to this case, legal advice should be sought regarding the level of …
north_east_yorkshire
A post-publication assurance review in relation to the implementation of … — Rec A3
The EIP service should review within three months, how to ensure that a carers’ needs assessment is offered and facilitated and include an audit of the ‘Getting to Know You’ documentation.
north_east_yorkshire
Joint Safeguarding Adult Review and Independent Mental Health Homicide Investigation, … — Rec 10
The Trust must ensure any engagement with families during its internal investigation process is documented. This should include instances when the family declines to be involved and whether the final report has been shared.
london
Accepted
Independent Quality Assurance Review – Norfolk and Suffolk NHS Foundation … — Rec 2
Public Health Suffolk should ensure that if a multi-agency investigation is commissioned there is a mechanism to oversee the implementation of the action plan and the involvement of family and carers; serious incident investigation policies should be updated to include this requirement.
Norfolk and Suffolk NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of patient Y: … — Rec 5
The Trust should ensure that communication with families is carried out in line with the Trust’s adverse incident policy, and follows guidance in the Memorandum of Understanding2 and best practice guidance3 and there are assurance systems that evidence this concordance with policy.
South Essex Partnership University NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of Mr M … — Rec 4
EPUT should embed a process to ensure that when a referral is accepted to their community mental health teams the care coordinator or other relevant professional working with that patient makes contact with the patient’s family/carers at the earliest opportunity to provide a point of contact for the family and …
east_of_england
*Independent investigation into the care and treatment of Mr A: … — Rec 14
West Hertfordshire Hospitals NHS trust should ensure that responses to reports from the Coroner are accurate and that procedures are in place to make sure that Rule 43 reports are identified and that information is collected and action considered within a governance process which is monitored by the trust board.
Hertfordshire Partnership NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of DO — Rec 12
The Independent Investigation Team recommends a Trust faced with a similar situation in future must treat the families of victims as individuals. As a result, the Trust must acknowledge the personal knowledge levels of the case itself. The Trust must review its ‘Being Open Policy’ with a view to include …
DO who committed a homicide in 2013. DO was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
An independent review of the care and management of Mr … — Rec 3
It is commendable that the Trust is developing the role of a family liaison officer to work with families and be a named point of contact through an incident investigation process. However, CUK recommends that the Trust ensures it embraces the principles of restorative practice after harm into the family …
Published August 2022 This is the independent quality assurance review of the care and management of Mr F . South West Yorkshire Partnership NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of patient … — Rec 3
• As the Trust implements the PSIRF framework, policies and procedures must include identifying all persons who should be offered the opportunity to contribute to an individual case investigation. • The procedure should set out reasonable expectations for making contact with families where details are not held on patient records, …
north_east_yorkshire
An independent investigation into the care and treatment of Harry … — Rec 21
We recommend that LTHT offer to meet with the families to address their unanswered questions and discuss changes that have been made following this incident, including: how staffing levels are calculated and delivered on medical wards; and, how safeguarding is practised and how the safety and security of …
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
Scottish Fatal Accident Inquiries(5)
William Sneddon, Lemond Milroy, David Brodie McFarlane and Agnes McCoull
When corresponding with patients or their relatives in relation to concerns expressed about their care in hospital the Trust should be careful to distinguish between medical treatment, nursing care and other concerns. The management of the Trust and the senior medical management at Dumfries and Galloway Royal Infirmary should carry out an urgent and thorough review of the practices and …
Jan 2004
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 of the …
Jan 2003
Sharon Harkin
My position in this specific case does not detract from a general expectation that there should be a system in place for early and sensitive notification to a deceased’s family.
Apr 2013
Edward Varey
Apr 2018
Dawn Marshall
Dec 2018
Article 2 learning points(15)
— LP 15
This is the gold standard approach to family involvement. Prisons vary in the quality of family involvement and HMP Altcourse is sadly not unusual in how it approaches this important area. There should be improved across all prisons.
HMP Altcourse and HMPPS
Accepted
— LP 14
With the prisoner’s consent, a prisoner’s relatives should be contacted to gather information as a collateral history is extremely useful. They should also be given information, again with consent, about the prisoner’s condition. They should be included in care-planning meetings and the ACCT process where appropriate.
HMP Altcourse and HMPPS
Accepted
— LP 13
There should be a clear procedure for relatives, carers and friends to contact the prison to pass on information, express concerns or inquire about their loved-one’s wellbeing. Some prisons have a telephone hotline service, with a guarantee that the appropriate department will respond. Not only should there be a point …
HMP Altcourse and HMPPS
Accepted
— 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.
HMPPS
Accepted
— LP 10
Doncaster Prison should develop a policy for relative/next of kin liaison in circumstances other than deaths in custody, including life-threatening situations.
The Governor
Accepted
— LP 2
HMP Featherstone should review its procedures so that families are informed of a prisoner’s illness with a minimum of delay.
HMP Featherstone
Accepted
— LP 9
We recommend that in conjunction with PECS, GEOAmey develops a policy for family liaison, with a senior member of staff designated as family liaison lead and with training for that role.
PECS and GEOAmey
Accepted
— LP 8
We recommend that in conjunction with PECS, GEOAmey puts in place a procedure for a senior manager to be notified whenever a serious incident of illness or other harm occurs. The designated senior manager should take immediate responsibility for ensuring that families are notified at the earliest opportunity, facilitating access …
PECS and GEOAmey
Accepted
— LP 10
Where possible, families should be encouraged to input into the ACCT process.
HMP Altcourse and HMPPS
Accepted
— LP 10
We recommend that GEOAmey and HMPPS consider how friends and families of prisoners at risk can be encouraged and enabled to pass on any concerns about risk of self-harm. Protocols may be required as to how to reconcile requirements of privacy and requirements of safe custody that may be in …
GEOAmey and HMPPS
Accepted
— LP 2
HMP Norwich should ensure that there is an awareness of the contents of property returned to prisoners next of kin, and that such returns are handled sensitively
HMP Norwich
— LP 20
The prison must ensure that when a prisoner is on a bed watch in hospital and in a poor state of health, following an incident of life threatening self-harm, they achieve a balanced risk assessment of the need to have prison officers present to protect the public and the prisoner’s …
HMP Altcourse
Accepted
— LP 5
We recommend that particular consideration is given to ensuring that CAREMAPs include reference to specific arrangements for engaging with families unless a reason is given elsewhere in the document why this is inappropriate.
HMPPS
Accepted
— LP 4
We recommend that Swansea Prison considers the selection, appointment and training of a Family Liaison Officer as a member of the Safer Custody Team, to promote engagement with families as part of the ACCT scheme, to monitor the operation of this in practice, and to report periodically to the safer …
HMPPS
Accepted
— LP G
More resources should be used to establish next of kin swiftly, especially in foreign national cases. Enquiries could be made through Police intelligence officers, the UK Border Agency and any church or community groups with whom a prisoner had been associated.
HMPPS
Accepted
Independent reviews(50)
Ockenden Review — Rec LAfL 14.12
Patient and Family Involvement The maternity governance team must work with their Maternity Voices Partnership (MVP) to improve how families are contacted, invited and encouraged to be involved in incident investigations.
Health & Social Care
Ockenden Review — Rec LAfL 14.10
Patient and Family Involvement The needs of those affected must be the primary concern during incident investigations. Patients and their families must be actively involved throughout the investigation process.
Health & Social Care
Ockenden Review — Rec LAfL 14.8
Improving Management of Patient Safety Incidents The governance team must ensure their incident investigation reports are easier for families to understand, for example ensuring any medical terms are explained in lay terms as in HSIB investigation reports.
Health & Social Care
Williams GNM Review — Rec 4.3
In the case of NHS organisations, investigations into unexpected deaths should be carried out in line with NHS Improvement's Serious Incident framework (SIF). In particular family members, carers or advocates must be involved and supported (e.g. through family liaison) from the outset and be kept informed of progress and the …
Health & Social Care
Jones: Patronising Disposition Review — Rec 20
Families told me that they felt that the way in which death certificates were issued following the fresh inquests – with no covering letter and in some cases unexpectedly – caused great pain and distress. I accept the assurance provided to me by the Home Office's that death certificates are …
Policing & Security
Jones: Patronising Disposition Review — Rec 19
Families bereaved through public tragedy too often face a vacuum in respect of information about their rights and the process of an inquest. The Ministry of Justice's Guide to Coroner Services seeks to address this vacuum, but the evidence I have seen in producing this report demonstrates that more needs …
Policing & Security
Jones: Patronising Disposition Review — Rec 18
I would encourage the Chief Coroner to ensure that all coroners are made aware of the experience of the Hillsborough families as set out in this report. Coroners should ensure that the decisions they make on toxicology – especially in respect of children – are made in a sensitive way, …
Policing & Security
Jones: Patronising Disposition Review — Rec 15
It is difficult to overstate the impact of the failures of pathology at the first inquest. The impact is deeply personal for those families who feel they will now never know how their loved one died, but it also has a wider resonance – leading as it did to the …
Policing & Security
Jones: Patronising Disposition Review — Rec 13
A great deal of excellent work has gone into producing the draft Public Authority Accountability Bill, or 'Hillsborough Law'. I agree with the Bill's aims and with the diagnosis of a culture of institutional defensiveness which underpins it. I have drawn heavily on the Bill's principles in the drafting of …
Policing & Security
Jones: Patronising Disposition Review — Rec 9iv
The use of pen portraits at the fresh Hillsborough inquests helped to put the families at the heart of proceedings. The process was vital in humanising the inquests and was both important and therapeutic for the bereaved families. In my view, the use of pen portraits is an important point …
Policing & Security
Jones: Patronising Disposition Review — Rec 9
A fundamental point of learning from the Hillsborough families' experiences is that the state must ensure 'proper participation' of bereaved families at inquests at which a public body is to be represented. This includes inquests following a disaster such as Hillsborough, but also – for example – following deaths in …
Policing & Security
Jones: Patronising Disposition Review — Rec 5
It has been submitted to me that the issue of family members being told that their loved one is the 'property of the coroner' and being prevented from seeing, touching and holding their body in part arises from a lack of clarity in law as to the rights of bereaved …
Policing & Security
Jones: Patronising Disposition Review — Rec 3
The Hillsborough families' experience demonstrates the need for the bereaved family and friends of those who have died to be questioned only as absolutely necessary in the immediate aftermath of a major incident. Minors should not be questioned in the absence of family or an appropriate adult. In presenting this …
Policing & Security
Harris Review: Deaths in Custody — Rec 87
NOMS must establish requisite monitoring and reporting systems to ensure that all custodial establishments comply with PSI 64/2011, with regard to engagement with families after a death, and to ensure the timely provision of appropriate levels of information and support and the appointment of the FLO. The FLO must not …
Justice & Legal
Harris Review: Deaths in Custody — Rec 52
All custodial establishments must produce and publish information for families and prisoners on the arrangements for contacting their relatives in properly appropriate and accessible form. Arrangements should be made for this information to be widely available, for example at Magistrates’ Courts and online.
Justice & Legal
Harris Review: Deaths in Custody — Rec 49
Assistance should be given to families/principal carers to become more involved with their relative in custody where appropriate, including providing relevant information to help them understand the CJS, how to contact the prison, how to contact the CARO, and how to contact the Visitor Centre.
Justice & Legal
IOPC Review — Rec 70
The IOPC should ensure all bereaved families are provided with its guide for families on how the IOPC investigates and supports them following a death and the deaths in or following police custody leaflet developed following the Independent Review of Deaths and Serious Incidents in Police Custody. It should routinely …
Policing & Security
Kerslake Review — Rec 41
The National Police Chiefs’ Council and the College of Policing should explore the production of an appropriate written document to be provided to bereaved families in mass fatality incidents, explaining the Disaster Victim Identification process and the amount of time needed to secure an accurate identification in every case
Policing & Security
Accepted
Kerslake Review — Rec 40
Whilst having regard to the integrity of the formal identification of the deceased victims in mass fatality incidents, those involved in the Disaster Victim Identification process should continue to take every opportunity to share emerging information with families which would indicate that their loved one is more likely than not …
Policing & Security
Accepted
Wessely Review — Rec 32
A formalised family liaison role should be developed to offer support to families of individuals who die unexpectedly in detention.
Health & Social Care
Accepted
Angiolini Review — Rec 82
The Government should consider whether there is a need for a family’s role at a misconduct hearing to be clarified, standardised and applied with more consistency, and advance disclosure of evidence to family members recognised as interested parties (subject to the harm test).
Policing & Security
Accepted
Angiolini Review — Rec 81
The IPCC should be responsible for informing all interested persons as soon as a misconduct hearing is arranged. There must be adequate notice for a family to attend, and their rights should be fully explained.
Policing & Security
Accepted
Angiolini Review — Rec 76
The Chief Coroner should issue formal guidance to Coroners to prevent inappropriate or aggressive questioning of next of kin by counsel for interested persons at Inquest hearings. Coroners should be trained to be able to identify and prevent such styles of questioning where necessary.
Policing & Security
Accepted
Angiolini Review — Rec 75
The Chief Coroner should consider issuing guidance on what constitutes disclosure of relevant information and, subject to the superintendence of the High Court, how Coroners should approach the issue.
Policing & Security
Accepted
Angiolini Review — Rec 74
The 2013 Coroners (Investigations) Regulations should be amended to allow for a second post-mortem examination as of right, paid for by the state, in circumstances where no contact has been made with the family before the first post-mortem occurred, except for exceptional circumstances where all reasonable efforts were made to …
Policing & Security
Accepted
Angiolini Review — Rec 48
The roles of the Commissioner and the lead investigator need to be made clear to families in relation to all key aspects of the investigation from the earliest opportunity.
Policing & Security
Accepted
Angiolini Review — Rec 47
IPCC staff should to be vigilant about language and communication with families and of how their conduct and communication with police officers may be perceived by next of kin. Families should be invited to express concerns about anything said by IPCC staff which may give rise to doubts about independence. …
Policing & Security
Accepted
Angiolini Review — Rec 45
Written information about sources of specialist support and legal advice should be passed to every family by the Coroner’s Officer at the very first contact. The Police and IPCC should also be subject to a legal obligation to advise the family of this right immediately on advising the family of …
Policing & Security
Accepted
Angiolini Review — Rec 44
There should be a presumption that families should have access to the body of the deceased as soon as possible, even if this has to be through a screen or CCTV. Where this is not possible, the reasons must be explained clearly to the relatives with all necessary empathy, discretion …
Policing & Security
Accepted
Angiolini Review — Rec 43
Families should be provided with a private space for the duration of an inquest and treated with respect and dignity. There should also be designated family space within the courtroom itself.
Policing & Security
Accepted
Angiolini Review — Rec 42
All state agencies who are engaged with the family, including police, IPCC, CPS and Coroners and their staff should provide both oral and written information about support services, including INQUEST, to families as early as possible when contact is established following the death. Agencies should not assume that this has …
Policing & Security
Accepted
Angiolini Review — Rec 41
The Government should ensure that families have funded access to appropriate bereavement services offering specialist counselling to families of the deceased. Those providing the services should understand the impact of a traumatic bereavement involving a protracted, intrusive investigation.
Policing & Security
Accepted
Angiolini Review — Rec 40
The Government should consider the feasibility of a scheme to pay reasonable travel and subsistence and compensation for loss of earnings for immediate family to attend the inquest in those inquests relating to deaths in police custody. Such a measure is necessary to ensure that access to the inquest hearing …
Policing & Security
Accepted
Angiolini Review — Rec 38
NHS Trusts should engage with families throughout their own investigations. There should be formal guidelines setting out the nature and expectations of family engagement.
Policing & Security
Accepted
Angiolini Review — Rec 37
Urgent consideration should be given to the mandatory video and audio recording of post-mortem examinations in contentious Article 2 deaths, with strict respect given to the control, storage and disclosure of recorded images. Wherever possible, such examinations should not take place until the family’s chosen pathologist is in attendance. The …
Policing & Security
Accepted
Angiolini Review — Rec 36
This information should be regularly repeated during the progress of the investigation if the family have not sought legal advice at the earlier stage. The Coroner should provide information to families about the post-mortem examination before it takes place – including the time and location of the examination, and their …
Policing & Security
Accepted
Angiolini Review — Rec 35
The Coroner and IPCC staff should tell families immediately following the death of their loved one of the right to independent free specialist legal advice, the benefit of securing advice from the earliest possible stage and the right to representation of a pathologist at the post mortem or to request …
Policing & Security
Accepted
Angiolini Review — Rec 34
Written information about sources of specialist support, including information about INQUEST, should be given to every family at the very first contact with an IPCC representative, as well as alternative forms of information taking into account the needs of the individual next of kin.
Policing & Security
Accepted
Angiolini Review — Rec 33
In order to facilitate their effective participation in the whole process there should be access for the immediate family to free, non-means tested legal advice, assistance and representation from the earliest point following the death and throughout the pre- inquest hearings and Inquest hearing.
Policing & Security
Accepted
Jones: Patronising Disposition Review — Rec 9iii
The concept of an inquest as an inquisitorial process has much to recommend it, but it was not the reality of the Hillsborough inquests, and it is not the reality of other inquests in which the narrative of events is contested. I accept that a complex or contentious inquest will …
Policing & Security
Jones: Patronising Disposition Review — Rec 9i
Publicly-funded legal representation should be made available to bereaved families at inquests at which a public authority is to be legally represented. This could be achieved through amendments to the Ministry of Justice's Lord Chancellor's Exceptional Funding Guidance (Inquests) and should not need primary legislation. The requirement for a means …
Policing & Security
Jones: Patronising Disposition Review — Rec 1
The experience of the Hillsborough families of 'the patronising disposition of unaccountable power' calls for a substantial change in the culture of public bodies. To help bring about that cultural change, I propose a Charter for Families Bereaved through Public Tragedy – a charter inspired by the experience of the …
Policing & Security
Harris Review: Deaths in Custody — Rec 103
The Chief Coroner should be provided with sufficient resources to enable him to report on themes emerging from prevention of death reports involving deaths in custody.
Justice & Legal
Harris Review: Deaths in Custody — Rec 88
Families of the deceased should have a right to non-means tested public funding for legal representation at an inquest. The costs of legal representation for the families should be borne by NOMS. Secondary Recommendations
Justice & Legal
Harris Review: Deaths in Custody — Rec 86
Following a death there should be a ’Duty of Candour’ upon NOMS and its staff both towards those organisations responsible for managing the post death processes (such as the PPO and the coroner) and the families and friends of the deceased young adult.
Justice & Legal
IOPC Review — Rec 7
The IOPC should consider embedding the following as core investigation principles: investigators should speak – or, even better, meet – with any complainant or bereaved family members at the outset of an investigation to understand what they want from the investigation; investigation terms of reference should not be drawn so …
Policing & Security
Angiolini Review — Rec 95
Police forces, the IPCC, CPS, Coroners offices and the College of Policing should give consideration to how family experiences can be brought into training and awareness packages. As a result of the tragic experience of the loss of a loved one in police custody many next of kin have become …
Policing & Security
Accepted
Angiolini Review — Rec 94
Families should be involved on an ongoing basis with the provision of staff training in the IPCC including training on the impact of a traumatic bereavement
Policing & Security
Accepted
Angiolini Review — Rec 72
A nationally funded National Coroner Service should be urgently considered as a means to address persistent inconsistencies of service and the inability of Coroners to pursue investigations without complete reliance on the IPCC and other agencies.
Policing & Security
Accepted
Jones: Patronising Disposition Review — Rec 11
An inquest should be an opportunity to learn the lessons of a death in order to help the living. A key tool for achieving this should be through the coroner's power to issue Prevention of Future Deaths (PFD) reports. I have been told by the legal representatives of the families …
Policing & Security
PHSO casework decisions(74)
P-001291 — West Hertfordshire Hospitals NHS Trust
Ms A complained the Trust refused to provide information about her partner's cause of death because his son was next of kin, causing her distress and inability to grieve.
NHS in England
Feb 2022
P-002593 — Croydon Health Services NHS Trust
Miss A complained the Trust failed to inform her mother's cancer was terminal and provided poor end-of-life care, specifically inadequate pain relief.
NHS in England
Partly Upheld
May 2024
P-002646 — Manchester University NHS Foundation Trust
Mrs G complained the Trust failed to notify her of her father's death, gave his property to someone else, and prevented her from seeing him on the ward.
NHS in England
Upheld
May 2024
P-002832 — United Lincolnshire Hospitals NHS Trust
Ms O complained the Trust poorly communicated, failed to provide an appropriate diet, delayed rehabilitation, and poorly coordinated her brother's discharge, which she said contributed to his death. She also cited poor ED care.
NHS in England
Upheld
Jul 2024
P-004262 — University Hospitals of Liverpool Group
Miss X complained about the University Hospitals of Liverpool Group's poor communication regarding her father's deteriorating condition, preventing her from spending valuable final moments with him.
NHS in England
Upheld
Nov 2025
P-002047 — Northumbria Healthcare NHS Foundation Trust
The Trust did not accurately autopsy her father's body, causing anxiety about organ mix-up and exacerbating her grief.
NHS in England
Jun 2023
P-002052 — County Durham and Darlington NHS Foundation Trust
Mr I complained the Trust delayed his mother's hip surgery, discussed risks without family present, restricted visits, and notified him of her death by text message.
NHS in England
Jun 2023
P-002455 — A practice in the Lancashire area
Mrs H complained the Practice gave incorrect information to the coroner, failed to chase a referral, and missed a home visit for her late father.
NHS in England
Feb 2024
P-002493 — Leeds Teaching Hospitals NHS Trust
Mrs M complained the Trust delayed contacting her about her father’s deteriorating condition and administering end-of-life medication, denying her the opportunity to be with him before he died.
NHS in England
Upheld
Mar 2024
P-002824 — University Hospitals Birmingham NHS Foundation Trust
The Trust allegedly kept Mrs G's mother in hospital unnecessarily, mismanaged her nutrition/hydration, failed to communicate deterioration, and made incorrect discharge record entries.
NHS in England
Jul 2024
P-002782 — Barts Health NHS Trust
The Trust allegedly mismanaged Miss F's mother's deterioration, prematurely withdrew treatment, and communicated poorly regarding a Do Not Attempt Resuscitation (DNAR) decision.
NHS in England
Partly Upheld
Jul 2024
P-002791 — North Middlesex University Hospital NHS Trust
Mr A alleged poor communication, a punctured artery, delayed investigations post-stroke, and inadequate monitoring of his mother's critical care, contributing to her death.
NHS in England
Jul 2024
P-003069 — The Princess Alexandra Hospital NHS Trust
Mrs W complained about a delayed CT scan, missed AF diagnosis, lack of family contact when her father deteriorated, being misled, and incorrect causes of death on his death certificate.
NHS in England
Oct 2024
P-003162 — Tameside and Glossop Integrated Care NHS Foundation Trust
Mrs N complained the Trust's account of service improvements was insufficient following missed antibiotic doses, lack of consultant input, and poor critical care decisions for her mother.
NHS in England
Nov 2024
P-003479 — Isle of Wight NHS Trust
Mrs F complained Trust A failed to inform her of her husband's sepsis and transferred him without her consent. She also stated Trust B provided inappropriate care and delayed informing her of his death.
NHS in England
Apr 2025
P-003567 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs X complained the Trust gave incorrect advice, preventing her from seeing her deceased brother before the mortuary, which caused significant distress.
NHS in England
May 2025
P-003645 — Barnsley Hospital NHS Foundation Trust
Ms G alleged her mother received inadequate basic nursing care, including cancelled procedures, delayed medication, and poor communication, leading to an undignified end of life.
NHS in England
Jul 2025
P-003667 — South Tyneside and Sunderland NHS Foundation Trust
Mrs O complained the Trust failed to inform her husband his cancer was untreatable and provided inappropriate post-operative nursing and discharge, denying them preparation time.
NHS in England
Jul 2025
P-001351 — North Middlesex University Hospital NHS Trust
Miss A complained about her aunt's cardiology appointment, including dismissed concerns and delayed blood test results, alongside inadequate hospital monitoring, treatment, and communication leading to her death.
NHS in England
Partly Upheld
Mar 2022
P-001461 — County Durham and Darlington NHS Foundation Trust
Mrs A complained the Trust provided conflicting information and redacted reports about her mother's death, preventing her from understanding what happened.
NHS in England
Jul 2022
P-001464 — Ashford and St Peter's Hospitals NHS Foundation Trust
Miss U complained about poor communication and misinformation from the Trust while her father received palliative care, causing her additional stress and sadness.
NHS in England
Jul 2022
P-001830 — Gateshead Health NHS Foundation Trust
Mrs O complained the Trust failed to communicate the severity of her mother's condition and provide updates, leading to her mother dying alone and causing family distress.
NHS in England
Nov 2022
P-001653 — University Hospitals Coventry and Warwickshire NHS Trust
The Trust failed to inform family or district nurses about L's ankle sores developed in hospital, and discharge notes were inadequate. This caused distress during L's final days.
NHS in England
Partly Upheld
Dec 2022
P-002636 — Hampshire Hospitals NHS Foundation Trust
Mrs S complained the Trust failed to inform her of scoliosis and Bertolotti's syndrome diagnoses and provided inadequate treatment for her chronic ankle pain.
NHS in England
May 2024
P-002818 — Mid and South Essex NHS Foundation Trust
Staff allegedly failed to inform Miss A's family, promptly investigate/treat her grandfather's worsening condition, and appropriately manage his pressure ulcer, fluid, and nutrition.
NHS in England
Jul 2024
P-003234 — Tameside and Glossop Integrated Care NHS Foundation Trust
Miss G complained the Trust delayed acting on Mr H's lung disease diagnosis, preventing treatment, and failed to notify his brothers of risks, contributing to his death.
NHS in England
Partly Upheld
Dec 2024
P-003456 — Hertfordshire Community NHS Trust
Mrs J complained that identified care failings may have contributed to her brother's death and that staff did not inform the family he was receiving end-of-life care, denying them precious time.
NHS in England
Upheld
Mar 2025
P-003394 — London North West University Healthcare NHS Trust
Ms E complained the Trust wrongly removed her father's cardiac monitor, failed to treat sores and provide water, and did not notify her of his death, causing profound distress.
NHS in England
Mar 2025
P-003437 — University Hospitals of Derby and Burton NHS Foundation …
Mr Z complained the Trust failed to share information about his wife's cancer progression, delaying the option for alternative treatments and contributing to her premature death.
NHS in England
Upheld
Mar 2025
P-004165 — Barking, Havering and Redbridge University Hospitals NHS Trust
His aunt was incorrectly told her cancer had spread and treated as palliative without family consultation, receiving substandard care. He also complained of poor communication and inadequate complaint handling.
NHS in England
Oct 2025
P-004144 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mr H complained the Trust failed to act on CT scan findings indicating idiopathic pulmonary fibrosis and poorly communicated aspects of his father's end-of-life care.
NHS in England
Oct 2025
P-004132 — Oxford University Hospitals NHS Foundation Trust
Dr A complained her mother choked while being fed by a nurse, leading to aspiration pneumonia and death. She also alleged no incident report was filed and the Trust's review was inadequate.
NHS in England
Upheld
Oct 2025
P-004256 — Epsom and St Helier University Hospitals NHS Trust
Mrs K complained the Trust failed to follow up a colon PET scan, ensure family support for a cancer diagnosis, and correctly consent her mother for surgery.
NHS in England
Partly Upheld
Nov 2025
P-004259 — The Royal Wolverhampton NHS Trust
Miss N complained the Trust failed to inform her mother of a cancer diagnosis with family support, and did not provide adequate pain relief, causing distress and physical pain.
NHS in England
Upheld
Nov 2025
P-004299 — Surrey and Sussex Healthcare NHS Trust
Mr C complained that Ms M's CT scans showing cancer were misread or not acted upon, leading to a significant delay in diagnosis and treatment.
NHS in England
Partly Upheld
Nov 2025
P-004304 — Royal Devon University Healthcare NHS Foundation Trust
Mrs K complained about her husband's inadequate pain management, delayed communication of his cancer's spread, and slow involvement of the Speech and Language Therapy team.
NHS in England
Partly Upheld
Nov 2025
P-004464 — University Hospitals Birmingham NHS Foundation Trust
Mrs O complained about her father's care, citing unclear DNACPR status, delayed CPR, unnecessary sedation, poor communication, and lack of dignity, believing these contributed to his death.
NHS in England
Dec 2025
P-002794 — Crown Prosecution Service
The CPS prosecuting barrister allegedly failed to read Miss C's Victim Personal Statement (VPS) in court before sentencing, causing distress and preventing closure.
UK Government
Jul 2024
P-001764 — Northampton General Hospital NHS Trust
Ms A complained Northampton General Hospital NHS Trust failed to supervise her father in the toilet, implemented a DNACPR order without her consent, and miscommunicated his death.
NHS in England
Jan 2023
P-001727 — Frimley Health NHS Foundation Trust
Mrs L complained Frimley Health NHS Foundation Trust delayed her husband's cancer diagnosis, provided inadequate palliative care, and mishandled her subsequent complaint.
NHS in England
Upheld
Jan 2023
P-002400 — Sheffield Teaching Hospitals NHS Foundation Trust
Ms J complained the Trust failed to manage her father's pain and did not inform her of his deterioration, denying the family a final visit before he died.
NHS in England
Not Upheld
Jan 2024
P-002415 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs F complained the Trust did not inform her or her husband about the risk of metastatic liver cancer during his eye cancer treatment, causing shock at diagnosis.
NHS in England
Jan 2024
P-003111 — A practice in the Thurrock area
Mr A complained the Practice delayed a cancer referral for his father, leading to a late diagnosis. He also alleged the Trust poorly managed his father's pain and communication.
NHS in England
Nov 2024
P-003374 — James Paget University Hospitals NHS Foundation Trust
Mrs A complained a consultant nephrologist failed to communicate effectively and discuss treatment options with her family during her husband's final hours, causing immense distress.
NHS in England
Feb 2025
P-003447 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mr N complained the Trust refused to investigate his complaint, ignored warnings about a falling drip stand, administered incorrect medication, and denied him access to meetings, leading to his mother's death.
NHS in England
Mar 2025
P-003536 — University Hospitals of Liverpool Group
Mrs R complained the Trust failed to detect her sister's liver cancer, delayed scans and treatment, failed to inform her of tamoxifen risks, and communicated poorly with the family.
NHS in England
Partly Upheld
Mar 2025
P-003477 — A practice in the Wiltshire area
Mr O complained the Trust failed to identify rib fractures and provide antibiotics, leading to pain and a hip infection. He also complained about poor family communication and the Practice's delayed response to his injuries.
NHS in England
Apr 2025
P-003737 — Medway NHS Foundation Trust
Mrs O complained about administrative errors during her sister's hospital admission leading to inappropriate treatment, poor communication, and delays in processing her sister's death, preventing a final viewing.
NHS in England
Aug 2025
P-003962 — Countess of Chester Hospital NHS Foundation Trust
Mrs H complained the Trust delayed diagnosis and treatment for her husband's lung disease, failed to inform him of his condition, misled him, and handled her complaint poorly.
NHS in England
Upheld
Aug 2025
P-003782 — Hull University Teaching Hospitals NHS Trust
Mr D complained his mother was wrongly assessed as having capacity and unsafely discharged without proper assessments or a care package. He also alleged delayed identification of her nearing death.
NHS in England
Aug 2025
LGO / SPSO decisions(59)
21-013-351 — Nottingham City Council
Summary: We will not investigate this complaint that the coroner’s service failed to inform the complainants of the date of his daughter’s inquest. This is because the complaint is made late and because further investigation would not lead to a different outcome.
LGO (Local Government & …
Other Categories
Feb 2022
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 …
LGO (Local Government & …
Other Categories
Upheld
Mar 2022
21-011-697 — Surrey County Council
Summary: Mr X says the Coroner failed to keep him informed of the post-mortem process involving his deceased child. The Council accepted fault and apologised to Mr X. The Council agreed to a financial remedy to reflect the distress caused to Mr X.
LGO (Local Government & …
Other Categories
Upheld
Mar 2022
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.
LGO (Local Government & …
Other Categories
Upheld
May 2022
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. …
LGO (Local Government & …
Other Categories
Upheld
Apr 2022
21-005-590 — St Helens Metropolitan Borough Council
Summary: Mrs X and Ms Y complain about the Council’s handling following their uncle’s (Mr Z) death and its failure to inform them when his funeral was taking place. The Council was at fault for not following its own policy and government good practice in this case. This meant Mrs …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-010-162 — Sefton Metropolitan Borough Council
Summary: Mrs Y complains about how the coroner’s office handled the inquest into the death of her late sister. We cannot investigate some of the matters complained about because they are outside of our jurisdiction. However, we found the coroner’s office failed to make an audible recording of the hearing, …
LGO (Local Government & …
Other Categories
Upheld
Apr 2022
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 …
LGO (Local Government & …
Other Categories
Upheld
May 2022
23-005-209 — London Borough of Camden
Summary: Ms X complained about the way the coroner’s office handled the investigation of the death of her son. Most of the complaint is not within our jurisdiction but there was fault by the Council in how it responded to the complaint.
LGO (Local Government & …
Other Categories
Upheld
Mar 2024
23-019-595 — Durham County Council
Summary: We cannot investigate Miss B’s complaint about the decision made by the coroner on the cause of death of her brother and the coroner’s alleged failure to discuss the matter with Miss B. This is because we have no power to do so.
LGO (Local Government & …
Other Categories
Apr 2024
23-014-375 — London Borough of Lambeth
Summary: We will not investigate this complaint about the actions of the coroner’s office. We have no power to do so.
LGO (Local Government & …
Other Categories
Jun 2024
25-006-935 — Westminster City Council
Summary: We cannot investigate Ms X’s complaint about the actions of the coroners’ office. We do not have the power to investigate the actions of the coroner or the coroners’ office staff who complete administrative tasks on the coroners’ behalf.
LGO (Local Government & …
Other Categories
Aug 2025
25-007-568 — Royal Borough of Kensington & Chelsea
Summary: We cannot investigate this complaint about the coroner’s service. This is because the law does not allow us to investigate the actions of the coroner and their officers.
LGO (Local Government & …
Other Categories
Sep 2025
25-013-159 — London Borough of Waltham Forest
Summary: We cannot investigate Mrs X’s complaint about a coroner because the Council is not responsible for the actions of coroners and their officers who carry out coroners' functions, and we cannot investigate the actions of other bodies. We will not investigate the Council’s complaint handling because it is not …
LGO (Local Government & …
Other Categories
Oct 2025
21-014-254 — Somerset County Council
Summary: A care home providing care on behalf of the Council, made several unsuccessful attempts to contact Ms X to notify her of her father’s deteriorating health and his subsequent death. There is no fault in the care home then notifying the second recorded contact.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
24-009-750 — London Borough of Camden
Summary: We will not investigate Miss X’s complaint about poor communication she experienced with a coroner’s officer. This is because their actions were not an administrative function of the Council.
LGO (Local Government & …
Other Categories
Oct 2024
24-012-375 — Somerset Council
Summary: We will not investigate this complaint about the Council’s decision not to share information relating to coronial proceedings. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. The issues Mrs X is complaining about are closely …
LGO (Local Government & …
Other Categories
Oct 2024
21-005-802 — Cambridgeshire County Council
Summary: Mrs B complained about her contact with the Council’s coroner’s office. She said the staff were unprofessional and lied to her family. We did not find fault.
LGO (Local Government & …
Other Categories
Not Upheld
Mar 2022
21-018-378 — Nottingham City Council
Summary: We cannot investigate this complaint about conclusions made by the coroner into the cause of death of Miss X’s partner. Coroners are not employees of the Council and therefore its actions are not administrative functions of the Council.
LGO (Local Government & …
Other Categories
Apr 2022
21-013-154 — London Borough of Ealing
Summary: We will not investigate Ms C’s complaint about the Council’s failure to inform her of the death of her brother, Mr B, at the earliest opportunity. This is because there is not enough evidence of fault to warrant an ombudsman investigation.
LGO (Local Government & …
Adult Care Services
Jul 2022
22-005-549 — Staffordshire County Council
Summary: We will not investigate Mr X’s complaint about a care provider not releasing information to him regarding what happened on the day his mother was found unresponsive by her carers. This is because there is another body better placed to consider the complaint.
LGO (Local Government & …
Adult Care Services
Sep 2022
22-001-120 — Lancashire County Council
Summary: We will not investigate this complaint about the Council’s refusal to share a deceased person’s records with their executor. There is not enough evidence of fault to justify us investigating.
LGO (Local Government & …
Adult Care Services
Sep 2022
22-008-622 — Somerset County Council
Summary: We will not investigate this complaint about the Council’s failure to put Mr X’s complaint about the Coroner’s Office through its complaints procedure. We are unlikely to add anything to the substantive matter about the location of the inquest.
LGO (Local Government & …
Other Categories
Oct 2022
22-011-184 — Surrey County Council
Summary: We will not investigate this complaint about the actions of a coroner during the inquest into the death of the complainant’s mother. This is because coroners are not employees of the Council and therefore their actions are not administrative functions of the Council. Other elements of this complaint are …
LGO (Local Government & …
Other Categories
Dec 2022
23-017-815 — Surrey County Council
Summary: We cannot investigate Miss X’s complaint about decisions a coroner’s officer made during inquest proceedings because those decisions are outside our jurisdiction. And while we could investigate how the Council considered Miss X’s complaint about these matters, we should not investigate this, because there is no worthwhile outcome we …
LGO (Local Government & …
Environment And Regulation
Not Upheld
May 2024
24-001-827 — Derbyshire County Council
Summary: We will not investigate Mr X’s complaint about the Council’s failure to keep him informed about his mother’s health, giving the keys to his mother’s property to another council without telling him, and taking away the opportunity for him to say goodbye to his mother. This is because there …
LGO (Local Government & …
Adult Care Services
Jul 2024
24-003-104 — London Borough of Croydon
Summary: We cannot investigate this complaint against the Council about the conduct of coroners involved in investigating the death of the complainant’s husband. We have no jurisdiction to investigate this complaint because the Council is not responsible for the issues.
LGO (Local Government & …
Other Categories
Jul 2024
24-006-635 — Westminster City Council
Summary: We will not investigate this complaint about a coroner. The coroner’s actions were as part of the coroner’s functions, and were not an administrative function of the Council. The matters complained about are therefore not within the Ombudsman’s jurisdiction.
LGO (Local Government & …
Other Categories
Sep 2024
24-000-751 — Gateshead Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s actions following the death of a citizen. The Council was required to arrange a funeral, which it did. The Council acted to seek the next of kin. While we appreciate the distress for the next of kin, there is not …
LGO (Local Government & …
Adult Care Services
Sep 2024
25-002-071 — London Borough of Lewisham
Summary: We will not investigate this complaint about the Council’s failure to notify the complainant of the correct date for a funeral. This is because the Council will make a symbolic payment of £500.
LGO (Local Government & …
Environment And Regulation
Upheld
Jul 2025
25-008-303 — Kent County Council
Summary: We cannot investigate this complaint about delays with coronial processes. Nor can we investigate Ms Y’s complaint about the conduct of the coroner. This is because these actions relate to coronial proceedings and are not an administrative function of the Council. Therefore, we have no power to investigate.
LGO (Local Government & …
Other Categories
Aug 2025
25-009-795 — Westminster City Council
Summary: We cannot investigate this complaint about the actions of the coroner’s office. We do not have the power to investigate the actions of the coroner or the coroner’s office staff because they are not acting under an administrative function of the Council.
LGO (Local Government & …
Other Categories
Oct 2025
24-008-373 — Birmingham City Council
Summary: We will not investigate Ms X’s complaint about what happened in the Coroner’s Court. That is because it is not an administrative function of the Council.
LGO (Local Government & …
Other Categories
Oct 2024
24-012-160 — Westminster City Council
Summary: We will not investigate this complaint about a coroner and the actions of a coroner’s office. This is because these actions are those related to a coroner’s function and are not an administrative function of the Council.
LGO (Local Government & …
Other Categories
Nov 2024
25-011-728 — Essex County Council
Summary: We will not investigate this complaint about the actions of a coroner and pathologist. Such actions are not administrative functions of the Council and are therefore not within our jurisdiction.
LGO (Local Government & …
Other Categories
Dec 2025
21-013-721 — Essex County Council
Summary: Ms X complains the Council has not dealt with her mother’s death properly. The Council is at fault because it did not provide information, delayed sending the death certificate and did not respond to Ms X’s complaint clearly. The Council has agreed to apologise to Ms X, pay Ms …
LGO (Local Government & …
Other Categories
Upheld
May 2022
23-020-441 — Herefordshire Council
Summary: We will not investigate this complaint about the alleged failure of the Council to consider a complaint about the service provided by the coroner. We do not consider it a good use of public money to investigate complaints about complaint procedures, if we cannot deal with the substantive issue.
LGO (Local Government & …
Other Categories
May 2024
23-016-755 — City of Bradford Metropolitan District Council
Summary: We cannot investigate this complaint about the actions of the coroner’s office. We do not have the power to investigate the actions of the coroner or the coroner’s office which completes administrative tasks on the coroner’s behalf.
LGO (Local Government & …
Other Categories
May 2024
24-002-429 — East Sussex County Council
Summary: Ms K complained about the way the Council communicated with her late aunt’s family when it applied for Power of Attorney, and after her death. We found some fault in the Council’s actions after Ms K’s aunt’s death. The Council has already offered a fitting remedy, so we do …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-007-208 — Liverpool City Council
Summary: We will not investigate Mr X’s complaint the Council withheld information from him about his mother’s, Mrs Q’s care. There is not enough evidence of fault to justify investigating.
LGO (Local Government & …
Adult Care Services
Oct 2024
24-002-920 — Surrey County Council
Summary: We will not investigate Miss X’s complaint about delays in a coronial process, or the actions of a coroner’s officer, because they are not an administrative function of the Council. Nor will we consider the suitability of a remedy the Council offered Miss X, because it is not a …
LGO (Local Government & …
Other Categories
Oct 2024
25-004-746 — London Borough of Barnet
Summary: We will not investigate Ms X’s complaint about the actions of the Council when she registered her father’s death. Further investigation would not lead to a different outcome.
LGO (Local Government & …
Other Categories
Upheld
Jun 2025
24-012-225 — Cornwall Council
Summary: We will not investigate Ms X’s complaint about the Council’s handling of the registration of her relative’s death. It is unlikely we could add to the Council’s investigation or achieve a different outcome.
LGO (Local Government & …
Other Categories
Nov 2024
25-011-044 — Hertfordshire County Council
Summary: We will not investigate a complaint about a failure to tell a woman’s family when she died. Services provided coherent explanations for why they did not contact anyone. It is unlikely that an investigation would be able to find evidence of fault.
LGO (Local Government & …
Adult Care Services
Dec 2025
NIPSO-201916450 — South Eastern Health and Social Care Trust
The South Eastern Health Trust failed to tell a man about changes to his mother’s nutritional plan and the process of her palliative care.
NIPSO (NI Public Service…
Health & Social Care
Feb 2023
21-007-638 — Bournemouth, Christchurch and Poole Council
Summary: We cannot investigate this complaint about the verdict of a Coroner because we have no jurisdiction over the decisions of coroner’s. We will not investigate comments made by staff working for the coroners service, because we could not add to the Council’s investigation or achieve the outcome she wants.
LGO (Local Government & …
Other Categories
Jan 2022
21-018-069 — Calderdale Metropolitan Borough Council
Summary: Mr X complains about the handling of his objections made to the Council’s Bereavement Services about a cremation. He says he objected to the cremation of a deceased family member based on his beliefs and cultural reasons. We have decided to uphold Mr X’s complaint because there is evidence …
LGO (Local Government & …
Environment And Regulation
Upheld
Aug 2022
22-006-354 — London Borough of Hillingdon
Summary: We will not investigate this complaint about information not being provided about a court case (to decide where the complainant’s family member should live). This is because the case has already been decided in court, so we have no remit to intervene.
LGO (Local Government & …
Adult Care Services
Sep 2022
22-010-130 — Derbyshire County Council
Summary: We will not investigate this complaint about administrative failings by the coroner’s officer. The complainant has not suffered personal injustice from these faults alone to justify an investigation. The Information Commissioner’s Office is better placed to consider complaints about access to information. Also, complaints about the coroner’s investigation are …
LGO (Local Government & …
Other Categories
Upheld
Dec 2022
24-002-184 — Surrey County Council
Summary: We cannot investigate this complaint about the actions of the coroner’s office. We have no power to do so.
LGO (Local Government & …
Other Categories
Jun 2024
Domestic Homicide Reviews(47)
Gloucester — recommendation 3
Safer Gloucestershire to share the action plan created from this DHR and report to Scott’s family every six months on the progress being made.
Safer Gloucestershire
Enfield — recommendation 7
The victim's mother and daughter had a number of questions they wanted answered about the chain of events following the victim's death (see section 2.2.1.). The Metropolitan Police Service should consider how best to address those questions
Metropolitan Police Service
Metropolitan Police Service
Pembrokeshire — recommendation 9
All Family Liaison Officers to receive training in relation to Domestic Homicide Reviews to improve their understanding of the review process and to enable them to inform families at the appropriate time that a review will be undertaken
Dyfed Powys Police
Dyfed-Powys Police
West Berkshire — recommendation 7
The family members of the perpetrator and the victim who provided information and comments for the investigation, asked to receive a copy of the investigation report. It is suggested that consideration is given to this request and to an appropriate level of feedback. Measure of success: Family members of the …
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Bromley — recommendation National recommendat
That the Home Office work with NHS England to agree a process by which families bereaved through a domestic homicide, whose relative had mental health problems and was the victim or perpetrator of the homicide, can get information as early as possible about the diagnosis and care of their relative …
Home Office | NHS England
Home Office
Haringey — recommendation R22
Haringey CSP to share the above mentioned updates with the victim’s family
Haringey CSP
Buckinghamshire — recommendation 6
Safer Buckinghamshire Partnership to share an update with the bereaved family in 12 months’ time, concerning what has changed as a result of the domestic homicide review and subsequent action plans.
Safer Buckinghamshire Partnership
Solihull — recommendation 8
Safer Solihull Partnership to share an update with the bereaved family in 12 months’ time, concerning what has changed as a result of the domestic homicide review and subsequent action plans and the family have an opportunity to contribute to change
Safer Solihull Partnership
Norfolk — recommendation 13
The Early Intervention Team should confirm back after any meetings with the next of kin in a quick memo (email or letter) any agreed actions/key information discussed by both sides. This could be a simple copy and paste of any notes taken. (family member recommendation).
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Telford and Wrekin — recommendation 6
West Mercia Police and Telford Mind to work together to strengthen links and develop a referral route which will ensure that bereaved families are systematically offered signposting to specialist support services following police attendance at a sudden death.
West Mercia Police | Telford Mind
West Mercia Police
Telford and Wrekin — recommendation 5
Home Office to liaise with the chief coroner in respect of guidance to coroners to ensure that all coroners are part of Real Time Suspected Surveillance System
Home Office
Home Office
Telford and Wrekin — recommendation 4
Telford and Wrekin Public Health to liaise with the Coroner and encourage local sign-up with the Real Time Suspected Surveillance System
Telford and Wrekin Public Health
Kent — recommendation 14
The Home Office must produce leaflets for family members and friends that are suitable for reviews using the DHR methodology in cases where a person has taken their own life.
The Home Office
Home Office
Tower Hamlets — recommendation 1
The Tower Hamlets CSP to satisfy itself that Child A, B and C (as well as their kinship carers) are offered support in relation to the publication of the DHR.
Tower Hamlets CSP
Tower Hamlets Social Services
Somerset — recommendation 9
Safer Somerset Partnership to request the Home Office consider updating the Multi-Agency Statutory Guidance for a Conduct of a Domestic Homicide Review 2016 to include specific guidance where a person may have taken their own life. This review to include recommended terminology to replace the DHR use of homicide/victim/perpetrator to …
Safer Somerset Partnership
Somerset Partnership NHS Foundation …
Somerset — recommendation 8
Safer Somerset Partnership to review how it informs families of the deceased that a Domestic Homicide Review will take place. This will include protocols for homicides and unexpected deaths.
Safer Somerset partnership
Bexley — recommendation 11
Bexley Community Safety Partnership provide regular updates to Andrea’s family on the completion of this review’s action plan.
Bexley Community Safety Partnership
Doncaster — recommendation 4
The Community Safety Partnership should review the process of communicating with and interviewing procedure for the family of homicide victims particularly at the time of the death of the individual to provide consistency, support and compassion.
Doncaster Community Safety Partnership
Chiltern — recommendation National - Recommend
The Home Office’s preferred support agency for families of domestic homicides, Advocacy After Fatal Domestic Abuse (AAFDA) should be recommended by the Home Office Domestic Homicide Review Quality Assurance Panel, to amend their leaflet to cover suicide or to add an additional leaflet. The current leaflet only refers to homicide …
Home Office | Advocacy After Fatal …
Home Office
Milton Keynes — recommendation 7
Hertfordshire Domestic Abuse Partnership should facilitate a meeting between Debra's sisters and managers from the multi-agency safeguarding hub (MASH) and the multi-agency risk assessment conference (MARAC). This should ensure that Debra's sisters understand the changes that have been made since their sister's death and are reassured that positive improvements have …
Hertfordshire Domestic Abuse Partnership
Rochdale — recommendation 13
When the learning from this case is disseminated, that Rochdale Borough Safeguarding Adults Board and Rochdale Safer Communities Partnership arrange to further promote awareness of the service provided by the Coronial Bereavement Nurse.
Rochdale Borough Safeguarding Adults Board | …
Welwyn Hatfield — recommendation R12
In the case of an unexpected parental death Hertfordshire Domestic Abuse Partnership should consider mirroring the Bereavement Planning meeting and review process in use for the Rapid Response to Child Death, to include identification of a single lead agency.
Hertfordshire Domestic Abuse Partnership
Bexley — recommendation 10
Home Office to develop and make available a leaflet about Domestic Homicide Reviews for friends and family of those deceased through suicide.
Home Office
Home Office
Cornwall — recommendation 21.2
As this review is not unique in finding that the families of the deceased and her partner were confused by the title of this review “Domestic Homicide Review” resulting in missed opportunities for the safety of future partners; it is recommended that consideration should also be given to changing the …
Home Office
Home Office
Cumbria — recommendation 14
Trust and Adult Social Care staff must consider how best to communicate information to Nearest Relatives, so they can be assured that the Nearest Relative clearly understands their role and rights under the Mental Health Act. Simplified versions of written materials are recommended, where they are not already in use.
Trust | Adult Social Care
Adult Social Services
Northumberland — recommendation 8
NTW should review their position relating to post incident contact with family members following homicide with immediate effect to ensure consideration and decisions on a case by case basis. This should have regard for the police support framework provided through Police liaison officers.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
Norfolk — recommendation 2
That the Ministry of Justice ensures processes are in place to ensure that families of victims of homicide are provided with a written record of the Judge’s sentencing comments after a trial. (To be monitored by Norfolk CSP)
Ministry of Justice
Ministry of Justice
Haringey — recommendation 15.1
Upon receiving permission to publish, Haringey Safer Communities Partnership should attach a full and unredacted copy of this report to the victim's son's Social Care Records should he later wish to find out more information about his mother’s death.
Haringey Safer Communities Partnership
Kent — recommendation 4
That the process of Mental Health Tribunal Review hearing applications for Absolute Discharge be reviewed to ensure that current arrangements are adequate to provide the panel with the appropriate breadth of information needed to reach their decision. Such changes should also consider how best to receive intelligence/information from the family.
SoS
West Berkshire — recommendation 7
We recommend that NHS England and the Home Office undertake work to examine the impact of the conflicting requirements of confidentiality and the Duty of Candour in the context of the conducting of Domestic Homicide Reviews and Mental Health Homicide Reviews. This case has demonstrated how these duties conflict and …
NHS England | Home Office
NHS England
Haringey — recommendation 4
That the Victim Contact Scheme provide details of the local domestic abuse service(s) to victims and their families, and particularly when the service informs victims and their families of perpetrators’ imminent release.
National Probation Service
National Probation Service
Haringey — recommendation 3
Ensure that domestic abuse victims and their families are informed about the Victim Contact Scheme and the information it can provide when the perpetrator is sentenced to 12 months or more in prison or when the offender is detained as a mental health patient.
National Probation Service
National Probation Service
Kent — recommendation 2
Kent Police must ensure that importance of keeping domestic abuse victims informed of police action is seen as a priority.
Kent Police
Kent Police
Kent — recommendation 6
Suicide prevention team to link in with (AAFDA) to join the conversation regarding unexplained deaths.
KCC Suicide prevention team
Norfolk — recommendation 12
Mental Health Service contingency plans should take a ‘Think Family’ approach and be shared with related parties/carers having been written in plain English and avoiding professional jargon to ensure it is accessible to enable families and/or carers to fully understand the steps to take when required. This should include relevant …
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Huntingdonshire — recommendation 1
Cambridgeshire Police to communicate to frontline officers attending any death where there is domestic abuse history within the relationship, to consider the support needs of wider family members when the Next of Kin has been the potential abuser. This will enable support provisions to be offered to the family following …
Cambridgeshire Police
Cambridgeshire Constabulary
Tower Hamlets — recommendation 2
After publication of this DHR, the Tower Hamlets CSP to ensure that this report is attached to Child A, B and C’s social care records. This is so that, if they wish to read the DHR when they are older, it will be available to them. (In delivering these actions, …
Tower Hamlets CSP | Tower Hamlets …
Tower Hamlets Social Services
Monmouthshire — recommendation 11
When family members, friends or other personally interested parties appear at the scene of a homicide, a Duty Supervisor is always appointed to support them, act as an information conduit and explain crime scene procedure. They also ensure that other close relatives are promptly informed either by themselves or by …
Gwent Police
Gwent Police
Cornwall — recommendation 3
Family members should be an integral part of DHRs. Family members should be involved at the earliest opportunity and support should be provided to ensure they can remain key stakeholders throughout the process. The CSP should ensure Chairs adhere to the DHR Statutory Guidance to ensure this is the case …
Cornwall Community Safety Partnership
Sheffield — recommendation 4.1.8
That the likely support needs of families and DHR subjects are assessed by future DHR panels when creating terms of reference for future DHRs. These support needs should be actively considered through the process of completing any future DHRs with any relevant learning in relation to supporting families shared appropriately. …
Domestic Abuse Strategic Board
Northumberland — recommendation 9
The outcome of this investigation should be made available to the patient’s grandparents and an apology offered regarding shortfalls in the provision of appropriate standards of care and treatment.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
Lambeth — recommendation 4.2
Safer Lambeth are recommended not to publish this review because in the case of both incidents the young child of each relationship was present and witnessed the respective attacks. Both children are still young and the case received national publicity both at the time of the murder and attempted murder …
Safer Lambeth
Haringey — recommendation 2
That the NHS provide improved guidance to GPs on how to engage with DHRs including: (a) The legal basis for sharing information in these circumstances (b) The nature of the information needed by this process (c) The selection of an appropriate IMR writer (d) Support for staff in the surgery …
NHS England
NHS England
Norfolk — recommendation 13
The Early Intervention Team should confirm back after any meetings with the next of kin in a quick memo (email or letter) any agreed actions/key information discussed by both sides. This could be a simple copy and paste of any notes taken. (family member recommendation).
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Blackburn With Darwen — recommendation 1
The Community Nursing Service review procedures in regard to bereavement visits/family contact to ensure support for families following any death not just those receiving end of life care.
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Cumbria — recommendation 15
NHS England should share learning identified with the First Tier Tribunal (Mental Health) regarding providing guidance to families about how any confidential information they share may be used.
NHS England
NHS England
Hammersmith and Fulham — recommendation 3
The CSP to ensure that the expectations around timely and regular family contact are reflected in the local procedure for the conduct of DHRs.
CSP
CJINI inspection reports(3)
A Follow-Up Review of the administration systems supporting bereaved families provided by the Coroners Service for Northern Ireland
Prosecution and the Courts, Coroners Service
Nov 2009
An inspection of the arrangements in place in the PSNI to manage and disclose information in support of the Coronial process in Northern Ireland
Policing, Police Internal Operations
Dec 2016
Report published on the State Pathologist’s Department
State Pathologist's Department, Forensic Services
Aug 2014