Inquests serve as a crucial mechanism for investigating the circumstances surrounding sudden or unexplained deaths.
It is the role of the Coroner to gather all the relevant evidence in order to identify someone’s medical cause of death and to answer 4 key questions on the conclusion of the inquest:
- Who was the Deceased?
- When did their death occur?
- Where did their death occur?
- How did the Deceased come about their death?
At the end of an inquest, the Coroner’s or jury’s conclusion is formally documented on the Record of Inquest.
Types of inquest conclusions
An inquest conclusion can be “short form”, where just a few words are used to summarise the cause(s) of someone’s death. For example:
- Natural causes
- Accident or misadventure
- Unlawful or lawful killing
- Alcohol or drugs related
- Suicide
- Industrial disease
- Road traffic collision
- Open conclusion – this means that there is insufficient evidence to decide how someone died.
Alternatively, a Coroner may determine that a “narrative conclusion” is more suitable to describe the circumstances leading to a person’s death, having considered the evidence. This can be one or more paragraphs.
Natural causes
In the context of inquests where there are concerns regarding the Deceased’s medical treatment, natural causes may be one of the conclusions considered by the Coroner or jury.
A conclusion of natural causes refers to a death that has occurred due to the normal development of a natural illness but only where this was not significantly contributed to by human intervention. Where the inquest establishes that medical treatment, or lack thereof has caused or contributed to a person’s death, an alternative conclusion may be more suitable.
Findings of neglect
Among the most concerning inquest outcomes are findings of neglect. Neglect is not a conclusion in itself. Rather, the phrase “contributed to neglect”, can be attached to a short form or narrative conclusion at the end of an inquest.
For an inquest finding of neglect to be made, the Coroner or jury must be satisfied that there has been a gross failure to provide the person who died with basic needs or medical attention. There must also be a clear causal link between the gross failure and the person’s death. The criteria is stringent and the threshold for establishing a finding of neglect is high – a finding of neglect is therefore rare.
Neglect in the context of an inquest differs from its definition for the purposes of a civil claim for clinical negligence but where findings of neglect are made at an inquest in the context of medical treatment, this will indicate that a civil claim for clinical negligence is likely to be established.
Impact of neglect findings
Findings of neglect can be made where there are systemic failures or individual lapses which are identified as contributing factors to a person’s death. These findings often attract press attention and cast a spotlight on significant shortcomings within various sectors, including healthcare, social services, and in the prison setting.
These findings often lead to internal investigations (if not conducted already), external investigations by independent organisations such as the CQC, public inquiries, and most importantly changes to prevent deaths occurring in similar circumstances in the future. Neglect findings prompt organisations to re-evaluate their policies, practices, and procedures and can result in the implementation of more robust procedures.
On conclusion of the inquest, and often where findings of neglect are made, a Coroner may also make a report called a Prevention of Future Deaths (PFD) or Regulation 28 Report. Coroners are under a duty to issue Reports to Prevent Future Deaths where they identify circumstances or practices that, if left unaddressed, could lead to similar deaths in the future.
Comment
Coroners evidently play a vital role in bringing to light systemic issues that have caused or contributed to otherwise preventable deaths. The duty of a Coroner is clearly not only confined to determining the cause of someone’s death but also focuses on accountability and preventing future deaths in similar circumstances.
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