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1 February 2018 0 Comments
Posted in Health & Social Care, Opinion

Chief Coroner’s Annual Report – what does it mean for care providers?

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At the end of 2017, the Chief Coroner published his annual report on inquests over the preceding year. The report provides useful insights for care providers on the common pitfalls in care provision that have been identified during inquests and how to avoid similar incidents being repeated.

Key findings

The report identifies key issues or trends, and makes a number of recommendations for good practice:

  • Communication – Too frequently, coroners were seeing missed incidents arise due to poor verbal and written communication, notably between agencies, shift staff and with relatives.It is important to ensure that there are robust handover procedures in place (both external and internal) and that notes of key decisions/actions are clearly documented and assigned to an appropriate staff member or team.
  • Procedural awareness – there were repeated concerns raised about a lack of adequate procedures in place. The report notes that even when appropriate procedures are in place there is often inconsistent application by staff, leading to failures in the care provided.Care providers ought to regularly ensure that procedures are up to date and that staff are familiar with them. Where appropriate, refresher training should be provided to ensure all staff are aware of all policies which apply to their role.
  • Emergency responses – The Chief Coroner notes that there were too many occasions where staff failed to request an emergency response promptly, causing or contributing to the death of a service user.This has two main aspects: awareness that an emergency response is required and knowing how to call such a response. Care providers should ensure there is a clear process in place for escalating concerns and for triggering an emergency response, and that all staff are aware of this. It may also be advisable to provide basic first aid training for all staff.
  • Adequacy of training – A running theme of the report was concern about inadequately trained staff.As with permanent staff, agency staff must be suitably trained so that they can perform their roles fully and safely. It is imperative that adequate staffing levels are maintained at all times, and that there are contingencies in place for staff sickness/absence. Thorough induction and refresher training should be provided to ensure continuing competency of all staff.

Changes on the horizon

The report considers new provision for the discontinuance of an investigation by the coroner where the cause of death is conclusively established by a post-mortem examination. This was not previously available to coroners and will allow them to bring an investigation into the death to a close without holding an inquest hearing in certain circumstances. This will be an interesting development to follow.

Another area where care providers should take note is the proposal to drastically widen the access to publicly funded representation for bereaved families. There is a concerted drive to ensure equality of arms between the Interested Parties in an inquest and to avoid situations where the family of the deceased are unrepresented, while a care provider, for instance, will have specialist legal representation on their behalf. This is likely to mean that a greater number of families will be in a position to attend an inquest with legal representation.

More generally, the report highlighted the need for increased nationalisation of the coroner service. This would result in more consistency across the coroner’s service, which could be particularly useful for care providers with operations across the UK.


Our Health & Social Care team specialises in advising care providers facing an inquest following the death of a service user. We can advise on the inquest process; assist with the preparation of your case and witness statements; provide support and guidance to those giving evidence at the hearing; and provide legal representation at the inquest hearing. For further information please contact:

01225 730 100     Email

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