Preparing for an inquest

Guidance for families and carers

Coping with the death of a loved one is difcult enough without having to worry about an inquest. This leaet sets out what is involved in the inquest process and provides some useful contact numbers for families and friends who would like support or more information.

The inquest
The inquest process is a fact-nding rather than fault-nding process to help the coroner establish the cause of death and the appropriate verdict. Essentially, the four questions the coroner considers are who, where, when and how. There are no parties in an inquest, no prosecution or defence counsel as in a criminal court, no indictment, no prosecution, no defence and no trial. However, in light of the requirement for fairness under the Human Rights Act, the coroner may consider it necessary to have a jury present. You will be advised if that decision is made. Depending on the circumstances, or if the patients family decides to appoint counsel, the hospital trust will seek legal advice and may appoint counsel. It is not within the role of the coroner to enquire into potential issues regarding a possibility of medical negligence. The court is open to the public and members of the media, and it is usual for any journalists to approach the coroners ofcer to obtain the names of the witnesses and family attending the hearing. Local newspapers such as the Southern Daily Echo are often represented. Broadcast media and news agencies may also be present if there are likely to be issues raised that will have widespread interest. Patients families may visit the coroners court in advance of the inquest. Please contact the coroners ofcer to arrange a mutually convenient time if you would like to do this. Your mobile phone must be silenced during the hearing and you are asked to
2 Preparing for an inquest

remain in court until released by the coroner. The coroners ofcer will be able to advise on the order in which the witnesses are to be called. The inquest hearing is recorded on tape and a copy of this can be requested. Witnesses will be called to the stand to be sworn in by the coroners ofcer before giving their evidence, usually seated. The coroner usually asks the witness to summarise events in their own words before asking them questions to clarify any points. Usually, coroners are lawyers and have limited understanding of medical terms and conditions, so will seek clear jargon-free explanations on behalf of both themselves and the patients family. The pathologist often provides his or her evidence early in the proceedings and will highlight the main ndings along with any important points, before answering any questions from the coroner. Members of the patients family are also given the opportunity to ask questions. If you have anything to ask, you should direct your questions to the witness or through counsel if you have legal representation. The coroner may step in if he or she feels that questioning is inappropriate. The verdict is read out at the closure of proceedings. In some circumstances, there may be a need to adjourn for the coroner to consider all the evidence and return on another date to announce the verdict. A narrative verdict is usually offered verbally and a copy in writing is then supplied to all in attendance at the hearing.

Verdicts
The verdicts more commonly assigned to hospital deaths are natural causes, accidental death, misadventure, open and narrative. A narrative verdict is a commentary of the events leading to the death of the patient, where more detail is felt to be needed to clarify the cause of death.
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Other verdicts include industrial disease, drug-related, stillbirth, lawful killing, unlawful killing and manslaughter.

The coroner
The coroner is an independent judicial ofcer acting on behalf of the Crown who is appointed to establish the cause of death and the circumstances leading up to a persons death. He or she may be either a lawyer, with or without a medical qualication, or a medical professional who has undergone training in law to full the requirements of the role.

The coroners ofcer

The coroners ofcer provides a point of contact for the deceaseds family and our hospital, as well as carrying out the day-to-day administration of the inquest investigation on behalf of the coroner. Contact with the family usually includes home visits to ensure any concerns are claried so relevant information can be sought in advance of the inquest hearing. The coroners ofcer will then remain in regular contact with our patient safety team.

The Coroners Act 1988/2009

The inquest procedure has undergone signicant change in recent years, giving the deceaseds family greater involvement and providing the coroner with more powers to ensure a thorough investigation takes place. A coroner is required to conduct an inquest where it is suspected the person has died a violent or unnatural death, has died suddenly without a clear reason or has died in prison or in uncertain circumstances.

Preparing for an inquest

Referral to the coroner

The death of a person in a healthcare setting such as a hospital is referred to the coroner when the circumstances full certain criteria. This criteria lists in more detail what situations are required to be reported to the coroner. If a full inquest is needed, the death will be investigated by the coroners ofce in conjunction with a liaison ofcer from our patient safety team. In cases where an inquest hearing is not required, a death certicate will be issued and support for the deceaseds family is co-ordinated by the hospitals bereavement team.

Post-mortem
In most cases of deaths reported to the coroner, a post-mortem, also known as an autopsy, will be carried out. This is the examination of a body after death. Post-mortems are carried out by pathologists, who are doctors specialising in the diagnosis of disease and the identication of the cause of death. Post-mortems are carried out for two reasons: If the death has been referred to the coroner and he or she feels that a post-mortem is necessary to determine the cause of death At the request of a hospital in order to provide information about an illness or cause of death, and to further medical research. If a post-mortem is ordered by a coroner, it must take place by law - whether the deceaseds next of kin has given their agreement or not. If the post-mortem is requested by a hospital, written consent from the deceaseds next of kin is required. In some circumstances, such as a public health emergency, the Secretary of State for Health can override the wishes of the next of kin and order a post-mortem to go ahead. Relatives of the deceased can also ask a hospital to carry out a post-mortem in order to learn more about the reasons why a partner or relative died.

Preparing for an inquest

As part of a post-mortem carried out by a hospital, the pathologist may wish to take samples of human tissue or remove organs for further study and research. This can only be done if the persons next of kin gives their consent.

Preparing for the inquest

The coroners ofce will contact the inquest liaison ofcer in our patient safety team when a case has been accepted for inquest, in order to establish communication links and ensure all paperwork is prepared effectively. Case review All cases accepted for inquest will require a review by the hospital department in which the deceased was receiving treatment. This will result in a written report, providing clear information about patient care preceding the death, any areas of concern and, most importantly, any lessons that can be learnt. Some patient deaths reported to and accepted by the coroner will need little input from the hospital for example, if the deceased had a history of asbestos exposure or the majority of care took place in a different part of the country. Statements A review of the patients notes will identify all relevant staff who have been involved in the care of the deceased before his or her death. These members of staff will each provide their own detailed information in a statement to help the coroner identify any key issues. Usually, the statements are factual but in some cases it may be appropriate for clinicians to offer an opinion on an event or issue. The statement will be shared with the patients family as well as the coroner. Close family members will also be able to see other relevant information such as copies of the case notes, post mortem report, hospital investigation report, and, in some cases, additional technical reports or details about drugs and/or treatment. After receiving the hospitals investigation report and statements, the coroner decides whether or not any staff are required to attend as witnesses.

Preparing for an inquest

After the verdict

A hospital liaison ofcer will attend the inquest in order to support Trust witnesses and make notes on the proceedings. He or she will also be available on the day if you have any outstanding issues or concerns.

Support
Support is available throughout the case review process through to the preparation for the inquest. Please contact any of the following: The bereavement care team at Southampton University Hospitals NHS Trust: 023 8079 4587 The coroners ofcer (if you have questions or concerns about the inquest process): 023 8067 4267 or 023 8067 4266 Your GP Chaplaincy at your local church CRUSE Bereavement Care (a national charitable organisation which helps bereaved people): 023 8023 2500 (local ofce) or 0870 167 1677 (national ofce) Eastleigh Bereavement Service: 023 8057 8844 Childhood Bereavement Network: 020 7837 6309 Victim Support: 0845 30 30 900

More information about inquests and the role of the coroner can be found at www.coronersociety.org.uk

Preparing for an inquest

Patient safety team Southampton University Hospitals NHS Trust Southampton General Hospital Tremona Road Southampton Hampshire SO16 6YD Telephone: 023 8079 4428

For a translation of this document, an interpreter or a version in large print, Braille or on audio tape, please telephone 023 8079 4688.

www.suht.nhs.uk
Version 1, published December 2010, review date December 2013