Inquests – Social Care – Investigations by The Coroner’s Office

Working in social care with the elderly is likely to mean that there will be occasions when you will be  required to assist the coroner. Deaths will inevitably occur whilst providing care in residential and nursing homes and in domiciliary care in circumstances where the Coroner may need to investigate.

For example, the coroner will likely investigate any death arising from a fall.  Similarly, pressure sores are a topical and emotive issue and where the existence and/or management of pressure sores falls within the clinical cause of death, it is highly likely that the coroner will investigate and hold a substantive inquest.

The key question is – how to manage the coroner and these inquests?
The answer is preparation. 

The coroner’s role is to investigate who, where, when and how the deceased came by his/her death, and also to investigate the prevention of future deaths.  Whilst it will greatly assist the coroner if the factual position is clearly presented, the main work to be undertaken when an issue arises relates to the second strand of the coroner’s role, i.e. the prevention of future death reports.


In the context of these types of care providers there is likely to be frequent interaction with one particular coroner/coroner’s office.  It is important to build a good relationship with your local coroner.  Whilst work has been undertaken in attempting to homogenize and unify the different coronial jurisdictions, the fact still remains that each coroner (and coroner’s office) will deal with matters in a particular way.  It is therefore helpful for a care provider falling within a particular coroner’s jurisdiction to seek to understand their local coroner, and similarly, where deaths are repeatedly falling to a particular coroner, it makes sense to take time to explain to the coroner the particular challenges facing your organisation, for example, relating to the formatting and collating of records, or where the GP notes are held.

When contacted by the coroner’s office, usually the first request is for a report.  In many instances, if the report is thorough and comprehensive, it may obviate the need for oral evidence in respect of the home and/or the particular witness.

An overview report

There are essentially two types of reports requested by the coroner.  One is an overview report, usually prepared by a home manager but could be any senior person within the care provider, who will review the records and speak to the relevant members of staff and provide a report on this basis.  In these reports the coroner would like to see the following:

  • Details of the author of the report, including qualifications and experience.
  • Background to the deceased, including how long he/she has been in care, a summary of any important clinical conditions and any significant history.
  • An overview of the events leading up to the death. For example, if this was a fall, it would be necessary to detail any history of falls, and then move on to deal with the details of the particular fall leading to the death.
  • Details of risk assessments and any precautionary measures taken.
  • A detailed account of any matters directly relating to the death.
  • If there is an issue of concern and it is clear upon investigation that there has been negligence, neglect or other untoward behaviour, it is best to address this head on to avoid a prevention of future deaths report. You will need to do the following:
    • Set out the factual position honestly and accurately;
    • Apologise for the error;
    • Set out what has been done to ensure that this situation does not rise again. This could be by tackling employment issues/taking disciplinary action or on a corporate level, in relation to policies procedures, staffing levels etc.

A Statement

The second type of report is provided by someone who witnessed the incident and/or background that led to the death.  Whilst they will also need to give details of their personal background and qualifications, they are essentially providing a statement to set out specifically what happened at the time and what they witnessed.

You should also ensure that any documentation referred to is evidenced, for example, by attaching sections of the care plan.

The more preparation that is put into these reports and into preparing for an inquest the less likely witnesses will be called to a hearing.  Furthermore in the event these witnesses are called to the hearing, they will be well prepared and the coroner will have fewer questions, as the information is  set out in the report.

Preparation – what does this mean for you?

I have briefly summarised above the work that can and should be carried out to prepare for an inquest, however, the real preparation happens before the incident even occurs in making sure that policies, procedures and training is up to date, all critical matters are documented and the care plan and accompanying risk assessments are up to date and fully evidenced, documented and in order.  Where this is in place, it is straightforward to rely upon the relevant information and demonstrate that the correct procedures were in place at the time of the inquest, making everyone’s job significantly less complex.

Partner_E-1-web Written by Ella Partner, an Associate in the BLM Healthcare team.

The team has produced a series of podcasts about healthcare issues, click here to listen.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.