Procedure for inquest arrangements

Trust Policy and Procedure Procedure for inquest arrangements Document ref. no: PP(15)135 For use in (clinical areas): For use by (staff groups): For use for: Document owner: Status: All areas of the Trust Clinical, operational and governance staff All inquests within the Trust Richard Jones Approved CONTENTS 1. Purpose of document 2. Aims 3. Background 4. Immediate action 5. Inquest with a Jury 6. Action to be taken 7. Review of associated adverse events 8. Preparation for inquest 9. Outcome of inquest 10. Media interest 11. Governance 12. Record keeping 13. Conclusion of inquest 14. Document summary Appendix A: Process Flow Chart Appendix B: Checklist/Documentation required Appendix C: Contact list Appendix D: Statement invitation Appendix E: Guidance and template for statement writing 2 2 2 2 2 3 5 5 6 6 7 7 8 8 9-19 Source: Governance Manager Status: Approved Page 1 of 19

1. Purpose of this Document To co-ordinate the staff and documentation required to support the West Suffolk Hospital Trust s representation at an Inquest and to formulate an action plan for addressing issues arising from the Inquest. 2. Aims To retrieve all relevant documentation; brief and support staff involved and respond to the Coroner s enquiries within an acceptable time frame. To ensure that clinical and non-clinical practice is appropriately reviewed and improved where appropriate. 3. Background An Inquest is arranged when the Coroner is requested to identify the cause of death of a patient who has died whilst on the Trust s premises or after recent care at the hospital. This may be required for a number of reasons, including: Sudden death of unknown cause; Reasonable cause to suspect person has died a violent or unnatural death. An Inquest may be requested by a representative of the Trust; by the family or legal representative of the deceased; or at the Coroner s direction. 4. Immediate action If a doctor at the Trust is required to notify the Coroner of a death at the Trust, this must be done as soon as practicable within working hours, normally by 10.00 am on the next working day. In certain circumstances (e.g. death in custody) the Coroner s officer should be contacted immediately. Relatives should be informed as soon as possible that the death has been referred to the Coroner for consideration. If a letter is required, ideally the Consultant in charge of the patient will write to the Coroner (see Appendix C for contact address). This should contain brief, factual details about the patient s last illness and death, and should not offer any opinion or unsubstantiated information. The reasons for requesting an Inquest should be stated. The Coroner may wish to know if the relatives have any strong feelings about an inquest or post-mortem. 5. Inquest with a jury A jury may be engaged for Inquests where the death has occurred in prison, in custody, at work or where further deaths may occur in similar circumstances. In these cases, the Coroner decides matters of law and the jury decide the verdict. Source: Governance Manager Status: Approved Page 2 of 19

6. Action to be taken (as summarised in Flow Chart Appendix A) 6.1 Notification (by Coroner) that Inquest is to be held. 6.2 An Inquest Co-ordinator usually the General Manager for the area concerned (i.e. Medicine; Surgical; Women and Children or Clinical Support Services) will take responsibility to ensure: (i) A Start-up meeting is arranged by the Inquest Co-ordinator (General Manager) to include the Inquest Administrator and Head of Patient Safety and Clinical Effectiveness. Where the inquest is likely to involve media interest the Communications Manager should be involved in all stages of the inquest preparation. This includes neonatal mortality and inquests in which infection contributed to the death or for which concerns exist regarding the provision of clinical care. (ii) (iii) The appropriate Director is notified, who will take responsibility for keeping the Trust Board informed of developments. The lead director will be identified based on the predominant nature of the issues identified - service, medical or nursing (Director of Operations, Medical Director or Director of Nursing respectively). The Inquest is registered on Datix. (iv) The Inquest Co-ordinator will arrange for ALL records relating to care of patient to be retrieved, including medical, nursing, physiotherapy, ITU as appropriate; as well as any documentation relating to a complaint about the episode of care. The Inquest Coordinator retains these until the Inquest has taken place and no records should be removed until that time (*unless needed by the Information Governance & Legal Services Manager for a legal claim, which may run consecutively). The Trust may already have carried out its own root cause analysis (RCA) investigation and it is imperative that all records and statements taken at that time are retrieved and retained securely. Staff may have access to the notes for the preparation of statements, etc. but they MUST NOT be removed from the Co-ordinator s office.* 6.3 The purpose of the start-up meeting is to: Identify who should provide statements Identify sources of information Source: Governance Manager Status: Approved Page 3 of 19

Review who has been invited to provide statements by the Coroner and consider whether any other statements would support the Inquest process. Consider the need for PR and communications involvement (see (iv) above. Determine whether a complaint or claim is ongoing for the case Consider the need for legal representation at the Inquest Identify and assess any adverse events associated with the patient s care (see section 7) Identify who should attend the Inquest as Trust representative in addition to the Inquest Co-ordinator who will normally attend 6.4 Statements The Inquest Co-ordinator will arrange for statements to be obtained from the staff concerned (to be supplied within one week See Appendix D). The Inquest Co-ordinator will collate these to forward to the Coroner. It is important that staff providing statements do not respond directly to the Coroner so that the Trust is able to maintain a full record of information for use at the Inquest. However, the statements should be addressed to the Coroner and not the General Manager. Guidance for statement writing, together with an example statement is provided in Appendix E. 6.5 Legal Representation Depending on the level of involvement by Trust staff and the nature of the Coroner s enquiries, consideration will need to be given to: 1) Whether statements need to be checked by the Trust s solicitor. 2) Whether legal representation is required at the Inquest. The solicitor appointed by the Trust will depend on whether or not a Legal Claim is likely to follow the Inquest. The Trust s Inquest Co-ordinator will arrange the checking of statements and the appropriate legal representation. Occasionally, a legal claim may already have been initiated and, in these circumstances, close co-operation is required between the Information Governance & Legal Services Manager and Inquest Co-ordinator and likewise with the Governance Lead if the Inquest has been graded as a SIRI. Similarly, if a general complaint has been raised, the Complaints Manager will need to be appraised of the Inquest outcome. Source: Governance Manager Status: Approved Page 4 of 19

7 Review of associated adverse events As part of the inquest pre-meeting, the patient s care will be reviewed to identify any adverse events that took place. This will include a review of any details previously reported via the Trust s incident reporting system. Where adverse events are identified which have previously not been reported an incident form will be completed retrospectively according to the Trust s policy (PP105 - Incidents policy and procedures). The inquest start up meeting will review the grading of all incident forms associated with the patient s care to determine whether the appropriate level of investigation is/was undertaken. Where a root cause analysis (RCA) is determined to be the appropriate level of investigation the Trust s Incident Reporting policy will be followed. N.B. Consideration must be given to the requirement to inform NHS Suffolk of the inquest through the SIRI procedure based on any adverse events associated with the care or potential/actual media interest for the inquest itself. 8 Preparation for inquest An Inquest is a Court of Law that seeks to ascertain the cause of death but is not allowed to couch the verdict in a way that apportions blame to an individual. Statements are made under oath and the inquest is a public hearing. Statements are obtained from the staff concerned (to be supplied within one week, see Appendix D), and sent to the Inquest co-ordinator who will forward them to the Coroner. Statements from hospital staff should not be sent directly to the Coroner but a copy should be retained for use at the Inquest. Staff involved are identified by the Coroner and asked when they are not available to attend an Inquest. Following the inquest start up meeting it may be appropriate to suggest further individuals provide statements to the Coroner. Staff are subsequently notified of date of Inquest and who is required to attend; or whose statement will suffice without personal representation. Staff who have left the Trust may also need to be contacted and attend the Inquest. Certain expenses will be paid by the Coroner s office. Support for Staff Individual staff may feel apprehensive about attending an Inquest. Line Managers should give moral and professional support to the individuals Source: Governance Manager Status: Approved Page 5 of 19

concerned; and attend the Inquest with their staff. Support and counselling for staff is available through the Trust s Occupational Health Services. A bundle containing all pertinent information will be circulated to all witnesses a week prior to the Inquest for information and a pre meeting for the Inquest will be arranged on the morning of the Inquest to go through the process and answer any queries staff may have. Arrangements should also be made for staff attending an Inquest for the first time to be buddied with colleagues who already have such experience. It would also be appropriate for the Role of the Coroner and what is expected at an Inquest to be presented to all concerned (see Appendix F). If legal representation has been arranged, the solicitor will arrange to meet the individuals prior to the Inquest to provide advice. Although the Trust has vicarious liability for its employees, an individual may wish to discuss the Inquest with his/her own medical defence society or professional organisation. 9 Outcome of inquest The Coroner will usually give a verbal verdict at the conclusion of the Inquest. This information should be recorded by the Trust representative and reported to the staff concerned as soon as possible by the relevant General Manager (Inquest Co-ordinator). The Inquest Co-ordinator will be responsible for relaying the relevant details to the staff that have been involved in preparing for the Inquest as well as the Directorate s Governance Lead and Clinical Director. The Coroner may, in his verbal and subsequent written report, propose action by the Trust to change or improve practice. An action plan will need to be developed to address any such issues within a specific time frame. The Inquest Co-ordinator will lead this process. N.B. Based on the outcome of the inquest consideration must be given to the requirement to inform NHS Suffolk of the inquest through the SIRI procedure based on the inquest findings and potential/actual media interest. The Inquest Co-ordinator will arrange a post-inquest meeting to review the outcome and identify any further action required by the Trust if necessary. 10 Media interest The Press often attend Inquests. All enquiries by the Press should be directed to the Inquest Co-ordinator. Staff should not engage in any dialogue with the press. Source: Governance Manager Status: Approved Page 6 of 19

Families often find the outcome of an Inquest disappointing or upsetting as it may not answer all their questions or produce a satisfactory verdict. It is sometimes appropriate for staff to talk to the family after the Inquest but extreme caution needs to be taken with this and permission should be sought from the Trust representative before doing so. The Inquest Co-ordinator will liaise with the Trust s media consultants to make a decision on the need for a Press Statement by the Trust. Where a higher than normal level of media interest is expected, the Inquest Co-ordinator will contact the Trust s Communications Manager to discuss if their presence is needed at the Inquest. 11 Governance Following the initial notification, the Governance Department (Head of Patient Safety and Clinical Effectiveness) will be involved in the Start-up meeting. The outcome and verdict of all Inquests will be reported to the Governance Department along with any action identified as part of the post inquest review meeting. Six-monthly summaries of inquest activities will be reported to the Risk Management Executive Committee. These reports will summarise activity, themes and learning. Relevant information will also be summarised for Directorate Governance Steering Groups. A register of all inquests will be maintained. This will include key timing information, a summary of the nature of the death and an indication of the level of media interest. This will be shared with the Communication Manager and Chief Executive on a regular basis or whenever an inquest is likely to lead to significant media interest is identified. 12 Record keeping The Inquest Co-ordinator will maintain records of meetings and actions as part of the case file. A central database of Inquests will be established. In line with the recording of Incidents, Complaints and Legal Claims, a unique numerical numbering system will be established to facilitate administration and tracking of records; monitoring outcomes, actions and trends. When the Inquest and follow up action has been completed, the closed case file will be held in the Operational Directorate. N.B A check list (Appendix B) will assist with monitoring the process for Inquest arrangements. Source: Governance Manager Status: Approved Page 7 of 19

13. Conclusion of inquest The Inquest Co-ordinator will liaise closely with all the staff involved throughout the inquest and at its conclusion. A closure meeting will be held to review the process by which the inquest was managed and ensure that no new issues/risks had been identified since the original investigation if necessary. Action identified from the post inquest review will be reported to the relevant directorate Governance Steering Group. If it is anticipated there will be media interest, the staff involved will be notified immediately as well as the Trust s Chief Executive, Communications Manager and Governance Manager. A press statement will be prepared if necessary. 14. Document information Author(s): Richard Jones Other contributors: Sara Ames, Karen Sadler Approvals and endorsements: Risk Management Committee Consultation: General Managers and Governance staff Issue no: 6 File name: Inquest arrangements Supercedes: PP(13)135 Equality Assessed Yes Implementation Trust-wide circulation; Intranet Monitoring: (give brief details how this will be done) Regular reports to RMC and Directorate Governance Steering Groups; Annual review of policy Other relevant policies/documents & PP 105 references: Additional Information: Clarification of involvement of Communications Manager for Inquest likely to lead to media interest. Introduction of regular summaries of Inquests to the Communications Manager. Explicit reference to counselling support for staff. Source: Governance Manager Status: Approved Page 8 of 19

Appendix A: Process flow chart Notification from Coroner s Office Identify Inquest Co-ordinator Review associated adverse events Review existing incidents forms and/or need for forms to be completed. Ensure appropriate investigation is/was undertaken Start-up Meeting To include: Inquest Co-ordinator, SM, Clinical Director, Information Governance & Legal Services Manager, Communications Manager, Governance Co-ordinator. Log on to Datix Gather Statements If Legal Issues check with Solicitors (via Information Governance & Legal Services Manager) Submit statements and documentation to Coroner s Office Who to attend 1. Coroner s Office Indicates who to attend Inquest 2. Coroner s Office requests non availability from attendees. Pre inquest meeting Inquest Post Inquest Review Meeting Review inquest findings and identify further action action required required by Trust by if Trust necessary Source: Governance Manager Status: Approved Page 9 of 19

Appendix B: Checklist/Documentation required Documents required Action by: Date: MEDICAL RECORDS: Clinical Records Nursing Records X-Rays Physiotherapy and/or Occupational Therapy records Critical care nursing notes are computerised but can be printed off, when what is required has been decided Post Mortem Report STATEMENTS: List names of staff: OTHER DOCUMENTS: Incident form Root Cause Analysis papers Letters from Patient and/or Family outlining concerns Complaints file Source: Governance Manager Status: Approved Page 10 of 19

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Appendix C: Contact list Contact Telephone number West Suffolk Hospital 01284-713370 General Managers (Inquest Co-ordinators) Medicine 01284-7133804 Surgical 01284-7132751 Clinical Support and Women & Children Services 01284-713967 Governance Support 01284 713057 Information Governance & Legal Services Manager Coroner s Office Suffolk Constabulary Police Station Raingate Street Bury St Edmunds Suffolk IP33 2AP 01284-712781 01284-774167 Source: Governance Manager Status: Approved Page 12 of 19

Appendix D: Statement invitation Sample of letter requesting statements Dear xxx, Inquest into the Death of Xxx Deceased - CRN:- xxx The above patient died on the xxx, whilst on xxx. The Coroner advises me that there is to be an inquest, which may require you to appear in Court as a witness. In preparation of this, please provide me with a statement of your involvement in xxx s care. Statements must be provided to the Coroner within a timely manner of the request and therefore, your statement must be with me by xxx. Points to note when preparing your statement: - The Coroner has the power to issue a summons in the event that this timescale is not complied with, requiring the witness to explain him/herself - Statements should be addressed to the Coroner (address provided above) - Return statement to Karen Sadler who will submit all evidence to the Coroner, once the statements have been approved by the Trust Solicitor - Please address the points raised in the correspondence attached, if applicable to you - Please be aware your statement will be seen by the family, so consider terminology used **delete as appropriate **The patient s records are tracked to Karen Sadler, and you are very welcome to come up to the office to view these but, as per Trust policy, the records and supporting documents cannot be removed from the Operational Directorate. This is purely to maintain access to all necessary parties, ensure they are not misplaced around the Trust and to preserve the integrity of the notes themselves. Karen, however, is very happy to make copies of any documentation that you may require. **The patient s records have been scanned to Evolve. Should you require any assistance in accessing these records please do not hesitate to contact Karen Sadler on extension 3370. If you receive a Coronial summons, you are required to attend by law. The inquest process is a lengthy one and therefore, it is possible that you may have left the Trust, so please complete the attached contact form, returning it to Karen Sadler. An example statement is attached for your reference. For further information on inquests, please refer to the Inquest Arrangements Policy on the Trust Intranet site. Should you require any further clarification or assistance please do not hesitate to contact Karen Sadler or myself. Source: Governance Manager Status: Approved Page 13 of 19

Appendix E: Guidance and template for statement writing 1. Purpose A statement may be requested in connection with an incident at work and may form part of the investigation into an Inquest, formal complaint or legal claim. Statements will be used to help explore the facts and establish the course of events associated with incident, complaint or claim. 2. Helping to write statements The inquest co-ordinator, your manager or Trade Union Representative will normally be willing to help in preparing a statement and if appropriate, you may wish to involve a professional organisation such as the RCN, RCM, MDU, MPS or IHSM. If this statement is needed for the investigation of an incident, complaint or legal action against the Trust, the Governance Department will be happy to advise. 3. Background Writing a statement can often appear a daunting task. This guidance aims to make it as easy as possible. The purpose of writing a statement is so that you can provide a detailed chronological step by step account of your involvement. A statement is not a list. It should explain your involvement in a particular incident and based on factual evidence obtained from the notes. It is not something to be rushed and it is often easier to write down everything first and then put into chronological order for the statement. It is important to remember that although your statement will be used to assist in the investigation into the cause of death,it is not something that should cause you any concern, rather it reinforces the importance of taking care in compiling it. 3. How to write a statement Before providing a written statement, particularly if it relates to an incident that occurred some time ago, make sure that you have access to any relevant records. The Trust has a template for statement writing available on the Intranet as part of the Incident reporting and management policy (PP(05)105) or alternatively typed on Trust letterhead. The statement should: 1. Begin with your full name, position, grade and area of work. 2. Indicate who has requested the statement and sources of information/records used to prepare the statement. 3. Confirm the date, time and location of the incident. 4. Give the full name of any person(s) referrred to in your statement (patient, visitor, staff, public, etc). 5. Describe your period of duty and specific responsibilities at the time. 6. Give a full description of the sequence of events. This should be written in the first person ( I ) and include what you saw, the actions of others involved andwhat you did,. Include actual or approximate times where you know them and details of where the events took place. This must fully document any information given to the individual(s) affected by the incident or their relatives. 7. Be signed and dated at the end. Your account must be as accurate as possible and, above all, factual. Do not express opinions and avoid using hearsay (i.e. someone else's view or version of events). Source: Governance Manager Status: Approved Page 14 of 19

State whether what you have described is your actual memory of the incident or whether you have relied entirely on records made at the time, or a combination of the two. This is when good record-keeping will prove invaluable. The text should be concise, whilst containing all the relevant details. Highlight anything unusual, e.g. a departure from normal practice for whatever reason. Avoid jargon, clichés, and abbreviations (unless you have already explained the meaning and the need to use a particular abbreviation frequently). Statements should be legible, typed, and carefully checked before being signed. Remember to keep a copy in a safe place. Source: Governance Manager Status: Approved Page 15 of 19

West Suffolk Hospitals NHS Trust Statement template Title: First Name: Surname: Job Title/Grade: Person requesting statement: Ward/Department/Speciality: Records used to prepare statement: Incident Date: Incident time: Incident Form Number: (if known) Incident location: Person(s) involved in incident Description of period of duty and responsibilities at the time Description of the sequence of events (include time of events if possible) This statement reflects a true and accurate account of the events as witnessed by me: Signed: Page 1 of Date: Source: Governance Manager Status: Approved Page 16 of 19

Description of the sequence of events (continued) This statement reflects a true and accurate account of the events as witnessed by me: Signed: Page of Date: Source: Governance Manager Status: Approved Page 17 of 19

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