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May 2008

Inquests

It was hoped that the Coroner’s Reform Bill would have been before Parliament by now but it has been delayed and the proposed date is unknown. We take this opportunity to look at issues that Thompsons have dealt with in relation to an important but little used power called Rule 43.

Firstly a reminder of what an Inquest is and its purpose.

An inquest is a public hearing headed by a coroner or deputy. The coroner may sit alone or with a Jury, although a Jury hearing will only be conducted if the death
- occurred in prison
- occurred as a result of an accident, poisoning or disease
- occurred in police custody
- has implications for the health and safety of the general public

A Coroner is usually either a medically or legally qualified person.

A Coroner will become involved if he is informed that there is a body of a dead person lying within his district and there is reasonable cause to suspect that the person has died either a violent or unnatural death, or has died a sudden death of which the cause is unknown or that such a person died in a prison. The initial investigation is conducted by the Coroner’s officer who decides whether there should be a referral to the Coroner. The Coroner will conduct an initial investigation and decide if there should be an inquest.

The purpose of the Inquest is to examine the facts and circumstances of the death and to reach a verdict as to the cause of that death. The Coroner has no interest in blame but is a court of inquisition to examine the facts. The Coroner is required to reach a verdict as to the cause of death or to assist the Jury in reaching that verdict.

There are 13 prescribed verdicts i.e death by natural causes, by industrial disease etc, which can be given although more frequently we are finding that a “narrative” verdict is being given because the death does not fit one of the prescribed verdicts.

In clinical negligence cases Inquests are helpful as they enable evidence to be heard at an early stage as to the treatment and what might have caused or contributed to the death. The Coroner has powers to call medical evidence not only of those who treated the deceased but also of other medical experts who the Coroner feels might be able to shed some light on complex medical issues.

Whilst the Coroner’s role is to examine the facts and for a verdict to be reached as to the cause of death, the Coroner has a power known as Rule 43 to make reports to prevent future deaths.

The rule states as follows : “A coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly”.

More frequently Coroners are making use of this Rule and reports have been sent on a number of important cases that Thompsons have recently been involved in:

a) where the deaths have involved Firefighters, making a number of recommendations including concern over the use of tea lights, the procedures for tackling high rise fires and training generally. Importantly the Coroner provided in full, copies of the extensive reports, compiled by the Union and Legal teams on behalf of the deceased.

b) In a Clinical negligence case run by our Newcastle office recommending a “root and branch review” in the Trusts procedures including the surgical referral system , observation chart completion procedures and nursing note keeping systems, highlighting the Coroner ‘s concerns from the evidence given at the Inquest.

One of the anticipated reforms will be a strengthening of the Coroner’s powers under this Rule and a discussion paper has been issued. At the moment the Rule allows the Coroner to complete a report and send it to either a government department or other such body. They are currently required to respond within a time limit, but there is no sanction for non compliance and it is hoped that the reforms will improve on the position for Rule 43. This could have important implications for clinical negligence. Where the Coroner finds failings in the Trust that could and should have been prevented, that caused or contributed to the death, the Coroner should be encouraged to make more use of Rule 43 and require the parties concerned to respond.