Navigating the Inquest Process

Case Study background

Jane is 40 years old and lives in residential care. She has moderate life-long learning and physical disabilities. She has very limited ability to express herself and relied on others for her daily care. She is visited regularly by her parents Sue and Dave, who are her appointees as she lacks capacity to make decisions for herself. On a Tuesday afternoon, Jane suddenly fell ill and was taken to hospital. Sue and Dave attended immediately, and she was treated and discharged on the same day with a gastric bug.

Sue and Dave phoned the residential home on both Wednesday and Thursday to check how Jane was recovering, and they were told that Jane was getting better but that they were unable to visit as she was still too unwell. The staff were generally reassuring and told Sue and Dave that there were no reasons for them to be concerned.

On Friday morning, Sue and Dave received a call that they needed to go to the hospital immediately, as Jane had been rushed back in an ambulance. The ambulance staff had diagnosed peritonitis, which they were told was caused by a perforation (or hole) in the bowels that had caused an infection in the abdomen. The hospital said due to Jane’s learning disability they would not operate, and she would be made comfortable. She died of the infection 2 days later.

Sue and Dave are devastated by the loss of their daughter, and feel that they were not included in the decisions and the care and treatment Jane received when she became ill. They feel that the care at both the hospital and residential home was inadequate, and that decisions about her care pathways were made on the basis of her having learning disabilities and judgements about her quality of life. They believed that if she had received the care she needed she would still be alive, and have questions about why the peritonitis was not identified by care staff sooner.

Sue and Dave gather their documents together to make a referral via the Mencap helpline. They get put in touch with Annie, a solicitor from Fieldfisher. At this stage, Sue and Dave know that the hospital has referred Jane’s death to the coroner, and they have had some correspondence with the Coroner’s Clerk. The most recent contact they have had is confirmation that the Coroner will be opening an inquest into Jane’s death.

Advice for when a death has been referred to a Coroner

Obtaining representation

Annie explains to Sue and Dave that the person they deal with the entire time is coroner’s clerk –  they will only meet coroner when doing the inquest. The clerk may ask them for information they have, and also may send the family information which is sent in from other parties. The clerk has also told them in an email that they may want to consider legal representation. The parties for the inquest include the NHS Trust where Jane was treated, the Care Home where she lived and was discharged from hospital to, and the Ambulance service. They are told that all these parties are likely to have legal representation from a barrister at the inquest.

 Annie tells Sue and Dave the options for legal representation which may be available to them. She says that the Rachel’s Voice team sometimes represent families in certain circumstances, and that she would be able to take their case on. Annie says that she will write to the coroner’s clerk on Sue and Dave’s behalf to let them know that she will be representing them.

If Annie were advising a family who Rachel’s voice were unable to represent, she would tell the family that lawyers may take on cases such as this for a fee. It may be that if the lawyer thinks that a civil claim could arise following the findings of the inquest, that representation may be an option as they would be able to recover costs from the claim. Annie would however make it clear that it can sometimes be difficult to get representation, and that not everyone wants to make a civil claim after losing a family member. She would say that the best thing the family could do was to seek advice from a lawyer or an advice organisation as soon as possible following the death of a family member.

If you are a family member involved in the inquest of a person with a learning disability and are struggling to obtain advice, please contact the Mencap helpline.

Early stages of the inquest

Annie explains to Sue and Dave that at this stage, it is important to set out in writing to the coroner the concerns that they have about the treatment Jane received. This letter would include:

  • A history of the care Jane received, including where they think things went wrong and any evidence of care/treatment that they thought was good

  • Where the family feel that Jane’s learning disability needs were not accommodated for or contributed to failings

  • The questions they have about the care Jane received and why they believe Jane’s death occurred.

  • What aspects of the care given to Jane that the family would like the coroner to consider including into the scope of the inquest

Annie advises Sue and Dave that there are concerns that the Rachel’s Voice team see across many cases which they may like to consider whether are relevant to the care Jane received. This may include:

  • Lack of accommodation for learning disability needs, such as communication, healthcare adjustments or diet.

  • Decisions that were made without consulting family members, such as issuing a DNACPR

  • Poor communication with family members about the care that the person received and poor updates

  • Family members being advised that a person with a learning disability is unable for a certain course of treatment or surgery

  • Needs detailed in the person’s hospital passport not being considered or accommodated for

  • Lack of notification to the learning disability team when a person first attends hospital

  • Lack of communication between care teams

  • Lack of consideration for how multiple care needs or co-morbidities interact to create additional need or need for adjustment in care

The Rachel’s Voice team have also been campaigning on issues relating to death certification and inclusion of learning disability. If you have had any documentation that learning disability has been included as a cause of death on the certificate, please alert this to a Mencap caseworker or a Rachel’s Voice team member.

The Inquest process

Scope of the inquest

Annie tells Sue and Dave that the coroner has a limited scope in what it is that they are there to investigate, and that their job is to try determine who the deceased was and where and when they died; how they came about their death and why. In other words, the role of the coroner is to determine when Jane died, the place she died at and what her cause of death was.

Annie says to Sue and Dave that it is important to remember that the coroner looks at these questions at the inquest in a narrow way, and is unlikely to consider any bigger questions or look at evidence that may indicate a past failing if it does not directly relate to the cause of death. This is what is effectively referred to as the scope of the inquest.

The scope of the inquest can include:

-       Whether there are any relevant witnesses who may be able to give evidence, such as a key doctor or nurse.

-       Whether they think an independent or specialist expert is needed to give evidence

-       If there are other people other than family members who should be listed as an interested party. This could be someone who was involved in the care of the person who has died. In Jane’s case, an interested party would be the hospital where she was receiving treatment or the care home where she lived beforehand. In some cases where there are concerns around the social care given to someone who has died, CQC can be registered as an interested party as they are interested in the care standards which may be found to not have been upheld.

Pre-Inquest Review Hearing

Annie tells Sue and Dave that there may be multiple meetings which are like this one before the inquest occurs. She explains to them that the purpose of the PIR is to: 

  • Make decisions about the practical arrangements of the inquest, such as order of witnesses  

  • Determine the scope of the inquest and the lines of inquiry 

Annie has prepared her argument as to why there should be some independent expert evidence heard, in case this is not suggested by the coroner. Even if one wasn’t arranged, Sue and Dave would be able to request the coroner to hold one.  

Even though Sue and Dave are glad that Annie is there, as she is removed from the emotion surrounding Jane’s death, they choose to attend the PIR because they want to have their voices heard in the meeting if necessary.  

How the pre-inquest Review hearing proceeds  

Annie tells Sue and Dave that the coroner should have provided them with their initial view of any issues they have identified so far. This will be a starting point for how wide of a scope the inquest will have, what information they are considering and if they require further information from any of the interested persons, or other agencies which may be involved.  

Annie explains that this is any evidence which the coroner receives which is relevant to the inquest. As an interested person, Sue and Dave have the right to have sight of disclosure. Some of it may have already been shared with them in advance of the PIR. The coroner will also set deadlines for any outstanding documentation to be received by the coroner’s office. Annie tells Sue and Dave that they can ask the coroner when they can expect disclosure to be shared with them if it hasn’t been already.  

Annie also explains that, in addition to the scope of the inquest, the coroner will provide them with a provisional list of witnesses that they intend to call to give evidence in person and witnesses whose evidence will be read/ summarised by the coroner. If there is anyone that they would prefer to give evidence in person, then either they or Annie will need to make this known to the coroner. Annie says that while the coroner does have quite a wide discretion to decide on witnesses, there is no harm in making the family’s views known.  

Annie lets Sue and Dave know that the coroner may decide that an independent expert is needed to assist them with particular points of evidence. They can instruct an independent expert, but this would be subject to funding. Annie also explains to Sue and Dave that they can also make representations to the coroner if they think an independent expert is necessary. As with witnesses, the coroner has a wide discretion. Annie advises Sue and Dave to, if possible, ask for a copy of the letter of instruction as this is the letter which the coroner will send to the expert asking for their services and giving them terms of reference.  

The coroner will establish when the final inquest hearing will be and/ or if any further pre-inquest reviews are necessary. They will note when it will be held, where it will be held (if a different location to the ordinary coroner’s court) and how long for.