Coroners and inquests
The inquiry highlighted the tension and misunderstanding between doctors and coroners’ offices over the certification of the cause of death.
It recommended improvements in the accuracy of the cause of death certified and the identification of cases to be referred to the coroner.
The sharing and collecting of information with coroners, and by coroners, is key to taking this forward.
The Coroners and Justice Act 2009 states that it is an offence to distort, alter or prevent evidence being provided for the purposes of an investigation. It is vital that those responsible for disclosing information locally to coroners prioritise openness in sharing such information to support investigations into deaths.
To support the use of information, the chief coroner’s office has issued further guidance to coroners regarding sharing ‘reports to prevent future deaths’, previously referred to as ‘rule 43’ reports, with the Care Quality Commission.
The Judicial College will continue to develop training to support coroners’ officers in undertaking their roles, including how to involve the bereaved when gathering information.
In addition, we expect to consult on the role of medical examiners and death certification, including on the draft regulations that will underpin many of the changes needed to support the inquiry’s recommendations in these areas.
The role of the medical examiner, where deployed in sufficient numbers by the local authorities and supported by appropriate guidance and training, will improve the accuracy of death certification and the consistency in collecting information about a death, including from the bereaved.