Recommendation 45

Care Quality Commission notified of upcoming healthcare-related inquests

Accepted in principle
The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.

Coroners’ investigations and inquests can provide useful information on the quality of services delivered by care providers and any risk of future deaths.  As a result, the Care Quality Commission already receives Reports to Prevent Future Deaths and disclosure in inquests where they have interested person status.

Since 25 July, coroners are under a statutory duty to make details of the date, time and place of all inquests available before hearings commence.  However, in order to support its new inspection model, the Care Quality Commission may require further details regarding upcoming inquests.

To this end, the Care Quality Commission will undertake an analysis of the information available from coroners’ investigations and inquests, along with other information it already receives relating to expected and unexpected deaths.  It will consider the findings of that analysis, including how it could target requests for information from coroners and any burden that collecting this data might impose, working with the Coroners’ Society of England and Wales, the Office of the Chief Coroner, the Ministry of Justice and the Department of Health.  Together, they will develop an appropriate way forward.

In addition, the Care Quality Commission is also working with the Coroners’ Society of England and Wales and the Office of the Chief Coroner in establishing a Memorandum of Understanding with the aim of achieving better working relationships and the sharing of information between the Care Quality Commission and coroners.

Update

The Care Quality Commission is undertaking an analysis of the information available from coroners’ investigations and inquests, along with other information it already receives relating to expected and unexpected deaths. It will consider the findings of that analysis, including how it could target requests for information from coroners and any burden that collecting this data might impose, working with the Coroners’ Society of England and Wales, the Office of the Chief Coroner, the Ministry of Justice and the Department of Health.

In addition, the Care Quality Commission is also working with the Coroners’ Society of England and Wales and the Office of the Chief Coroner in establishing a Memorandum of Understanding with the aim of achieving better working relationships and the sharing of information. The Care Quality Commission continues to receive prevention of future death reports, and received 127 notices between August 2013 and August 2014.

The Care Quality Commission now has a single point within the Care Quality Commission where all Regulation 28 notices from Coroners are received. There is a central record to enable tracking of the regulations from receipt through to response and the Care Quality Commission has created detailed guidance on internal processes to facilitate earlier involvement in inquests including the provision of information. In the future there is the potential for a reporting capacity.