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Many providers will at some point be involved in an inquest by virtue of delivery of care and services to the elderly and vulnerable. 

Initial contact from the coroner’s officer can be by telephone or in writing (e-mail or letter) and typical early requests may be for: 

  • Resident care plans and records; 
  • Incident reports. 
  • Risk assessments. 
  • Statements of staff. 

It is crucial that careful attention is paid to dealing with any or all such requests and that there is an understanding of wider implications. The purpose of this briefing is to highlight the practical steps that providers should take to minimise the impact of the inquest and to be ready to deal with any simultaneous or consequent action following the death by the regulator and/or safeguarding and/or police authorities. 



What is an inquest?  

An inquest is a fact-finding investigation into a death which appears to be due to unknown, violent or unnatural causes. A coroner and sometimes a coroner with a jury sit in a public court hearing evidence about the circumstances of the death. 

What is the purpose of the inquest? 

The coroner has to answer 4 questions: who the deceased was; and where, when and how did they die. The “how” question is usually the most difficult and is where the inquiry is focused. 

How long does the inquest process take? 

An inquest must usually be completed within six months of the date on which the coroner is notified of the death, The coroner is required to report any inquests that have not been concluded within a year to the chief coroner. Many inquests take at least a year from first notification to conclusion because of the pressure on resources in coroners’ courts.  

Will a representative from the provider have to attend the inquest?  

Staff are often required to attend the inquest in addition to providing a written statement and this includes members of the senior management team. This can cause anxiety and stress and requires careful support and management.   

Can the coroner criticise the provider and/or their staff? 

Although the inquest is not seeking to establish liability or blame, if the coroner considers that acts or omissions of the provider and/or their staff may have caused or contributed to the death they will be identified as Properly Interested Persons. Where appropriate the coroner can identify failings and missed opportunities and can record these in open court. 

Is the inquest a private matter? 

The inquest is a public hearing and members of the public and press can attend. There is a risk of publicity and reputational damage if the press/media report on the inquest either locally or nationally.      

Is the inquest the end of the investigation into the death?  

In addition to reaching a conclusion and confirming the medical cause of death, the coroner must look at whether a report should be made about action to be taken to Prevent Future Deaths (PFD report). If a provider receives such a report they must respond within  56 days. The report and response will also be shared with the chief coroner and with CQC, Safeguarding Authorities, HSE and Police as required and published on a dedicated website which is accessible to the public. 



It is very important to approach the inquest with an understanding of what it could lead to: 

  • Public criticism of staff and/or the organisation 
  • Referral by the coroner to CQC, or CQC responding to publicity or their own involvement prompting inspection /enforcement action  
  • A PFD report sent to Police CQC and LA leading to further investigations  
  • Action plan having to be created to show changes which will be monitored  
  • Local Authority decide to carry out a large-scale investigation leading to multi-agency and safeguarding meetings 
  • Police decide to investigate criminal charges of gross negligence manslaughter corporate manslaughter and wilful neglect. Concerns about the action plan not being followed. Interview of staff members. Seizure of documents and lengthy police involvement  
  • The provider and their staff are reported in the local and national media and documentary makers (such as Dispatches/Panorama) pick up the story. 


Practical steps 

As soon as there is a death of a service user the provider must notify CQC if the person died whilst a regulated activity was being provided and the person’s death may have been a result of the regulated activity or how it was provided. The death may also be reported to the coroner’s office. Following this investigations may progress very quickly and simultaneously and providers should follow a protocol or checklist to minimise disruption to the business and to enable them to respond to concerns raised swiftly.  

  • Take time to consider the wording of any notification to the regulator. There is a danger that a premature or poorly drafted notification may include admissions of liability and may undermine the rights of the organisation.   
  • As soon as practicable after the death (and subject to police/CQC intervention) the provider should undertake its own investigation into the circumstances of the death and identify the key issues, any root causes, any shortcomings and staff/potential witnesses who will be relevant. Shortcomings should be addressed early to avoid a PFD report. 
  • Information and support should be offered early on to relevant staff members as to likely involvement in the inquest and their obligations and responsibilities in that process.  
  • Doctors and nurses may wish to contact their defence unions and should be supported to do so.  
  • Any staff involved who have left the organisation should be contacted and up to date contact details recorded.  
  • Providers should carefully consider obligations under the duty of candour and be open and transparent with the service users’ family/ next of kin where appropriate.  
  • Quickly establish a communication pathway with family /next of kin and offer condolences, offer to meet and answer any queries promptly where possible.   
  • Care plans, charts and associated records should be reviewed, preserved, well-ordered and locked in a fire-proof cabinet for safekeeping.  
  • Any archived documents should be located, retrieved and securely stored.  
  • All records should be copied, ensuring that the copies are complete and legible and placed in chronological order in a bundle. 
  • Statements should be taken as soon as possible (within 24 hours)  to record first accounts from staff involved in the care of the deceased and any incident leading to death. These should be carefully reviewed, typed, signed, dated and securely stored. Badly written statements may inadvertently incriminate providers or managers or may omit materials which may exonerate them.  Legal advice on statements before they are submitted can be crucial. 
  • Consideration should be given to any conflicts between the organisation and its staff which may impact upon support and representation at the inquest and other investigations.        
  • Original records should not be released and where these are requested and are disclosable copies should be provided as per the chronological bundle.  
  • Early advice should be sought about whether documentation is privileged (and therefore not necessarily disclosable). 
  • Communications teams should consider steps to take to protect the reputation of the provider in the event of any unfavourable publicity. 
  • Resident liaison teams should take steps to reassure service users and their families about the death and the inquest.   
  • Senior management teams should provide advice and support about the inquest process to those staff members called as witnesses.   
  • Seek advice on risk management strategy. 
  • Line up specialist legal representation for the inquest to enable appropriate legal submissions to be made including any necessary submissions to the coroner relating to the evidence, case law and appropriate conclusion. 
  • Recognise where lessons can be learned and take early action to deal with any identified shortcomings to provide assurance to the coroner about the prevention of future deaths.   
  • Seek advice about any criminal proceedings which may result and the defence of any enforcement action which may be taken by the regulator following an Inquest. 
  • Consider claims for compensation flowing from fatal accidents or other injuries and notify insurers   
  • Deal with media and adverse publicity 


Julia Appleton 


T: 020 7227 6758 

E: julia.appleton@weightmans.com