Practice Guidance for supporting staff preparation and appearance as witnesses within Coroner s inquests This practice guidance describes the process for supporting staff called as witnesses within coroner s inquests, following the death of a child or adult. It describes media preparation and management Key Words: Version: 1 Adopted by: Coroner s Inquests, preparation of witnesses, management of media interest Adopted document (13.11.2012) Safeguarding Committee Date adopted: 13.11.2012 Name of Jackie Wilkinson & Vicky McDonnell originator/author: Name of Safeguarding Committee responsible committee: Date issued for February 2013 publication: Review date: 13.01.2015 Expiry date: 13.04.2015 Target audience: All service areas Type of Policy (tick appropriate box) Clinical NHSLA Risk Management Standards if applicable: State Relevant CQC Standards: Standard 7 Non Clinical Page 1 of 17
CONTRIBUTION LIST Key individuals involved in developing the document Name Jackie Wilkinson Vicky McDonnell Carolyn Corbett Jimmy Endicott Vicki Spencer Designation Trust Lead for Safeguarding Trust Lead for Quality and Patient safety Named nurse Communications lead FYPC Divisional Safeguarding Lead Circulated to the following individuals for comments Name Sue Troy Pauline Blake Jo Read Roma Boobyer Claire Silcott Mary Barrett Oliver Lord Jackie Ardley Lynn Moore Bernadine Green Designation Named Nurse Named Nurse Health Visitor Named Nurse Named Nurse Named Doctor Consultant Psychiatrist Consultant Psychiatrist Chief Nurse Practice Lead / LD Human Resources Page 2 of 17
Contents Definitions 5 Equality statement 6 1. Summary 6 2. Introduction 6 3. Purpose of Inquest 7 4. Duties within the organisation 7 5. Witness statement content 10 6. Preparation for Inquest 11 7. The Inquest 12 8. Juries 13 9. Verdict 13 10. Media 13 11. References 13 Appendices 1 When a death will be reported to the coroner 15 2 A guide for jurors: Ministry of Justice 16 Page 3 of 17
Version Control and Summary of Changes Version number Date Comments (description change and amendments) 1 6.11.2012 New practice guidance All LPT Practice Guidance can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them. For further information contact: Vicky McDonnell (Trust Lead for Quality and Patient safety) Jackie Wilkinson (Trust lead for safeguarding) Page 4 of 17
Definitions that apply to this Policy Coroner Inquest The Coroner: is an independent judicial officer of the crown whose responsibility it is to investigate the circumstance and cause of death in certain cases The purpose of the inquest is to determine: a. Who the deceased was b. When, where and how the deceased came by their death c. In what circumstance the deceased came by their death Witness Inquest Serious Case Review A witness is someone called to provide evidence at a Coroner s Inquest who had clinical involvement with the patient prior to death, or is considered an expert witness; the purpose of the witness evidence is to support the coroner to determine the facts and circumstances around the death. Local Safeguarding Children Boards; under chapter 8 arrangements of Working Together To Safeguard Children DH 2010 are required to carry out multi-agency investigations into the deaths or significant harm of children from abuse or neglect, where there are identified areas for learning on local partnership arrangements. Local Safeguarding Adult Boards; within local multi-agency procedures can commission similar multi-agency investigations into the death or serious harm to a vulnerable adult, where local safeguarding procedures have failed. Due Regard Having due regard for advancing equality involves: Removing or minimising disadvantages suffered by people due to their protected characteristics. Taking steps to meet the needs of people from protected groups where these are different from the needs of other people. Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Page 5 of 17
Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development, review and implementation. 1.0 Summary The Trust is committed to an effective and timely response to any request by the coroner for assistance with his / her investigations in to the death of any service user / patient where an inquest has been opened. This guidance describes how we support staff and managers with this process. 2.0 Introduction The Coroner is an independent judicial officer of the crown whose responsibility it is to investigate the circumstance and cause of death in certain cases (See Appendix 1) Locally there are two coroners who have jurisdiction across Leicester City, Leicestershire and Rutland; the following websites explain their divisional areas and responsibilities: Rutland and Leicestershire North Coroner Leicester City & South Coroner On occasion staff may be asked to provide evidence to inquests held in neighbouring areas. The coroner is obliged by law to hold an inquest in certain circumstances where initial enquires give reasonable cause to suspect that the death: a. Was violent or unnatural b. Was a sudden death of unknown cause c. Occurred in custody Page 6 of 17
d. Was in such a place or circumstances as to require an inquest under any other act The purpose of the inquest is to determine: d. Who the deceased was e. When, where and how the deceased came by their death f. In what circumstance the deceased came by their death The inquest is not concerned with matters of civil or criminal liability. Once the Coroner has decided to hold an inquest he will contact the Trust Lead for Quality and Patient safety to inform her of forth coming inquests which relate to the trust, when services have been involved in patient care prior to a death that meets their jurisdiction. The coroners office will identify staff that will be called as witnesses relevant to the care and treatment of the deceased child / adult. 3.0 Purpose 3.1 The aim of the guidance is to advise staff and managers of good practice and processes to support preparation for attendance at coroner s Inquests. The guidance deals with only the handling of a coroner s inquest cases. 3.2 The practice guidance describes the communication and media preparation to be followed for high profile inquest cases. 3.3 The Local Safeguarding Children Board (LSCB) and Local Safeguarding Adult Board (LSAB) commission Serious Case Reviews (SCR) following the deaths or serious injury of children or adults locally as a consequence of abuse or neglect, to determine the learning to improve local safeguarding practice across local agencies. These cases attract high level of media interest when they go through local inquests; in these cases it is usual for the LSCB or LSAB to co-ordinate a media response on behalf of local agencies. 4.0 Duties within the Organisation 4.1 The Trust Board has a responsibility to ensure that guidance and procedures are in place, which support organisational representation at Coroner Inquests and adequately support staff through this process. 4.2. The Quality Assurance Committee (QAC) receives Serious Incident (SI) Investigation reports and actions, including Serious Case Reviews and Serious Incident Learning Process reports commissioned externally where the trust has had previous clinical involvement. The Safeguarding Committee provide a highlight report to Quality Assurance Committee on Serious Case Reviews and Serious Incident Learning Process investigations which report on high profile inquest dates. Page 7 of 17
4.3 Trust Lead for Quality and Patient safety: is responsible for ensuring that managers and staff are supported through Inquest processes. They receive regular communication from the coroner s offices where LPT services were involved in patient care, prior to deaths where an inquest will be called. The Trust Lead for Quality and Patient safety will ensure that: Our staff members receive advice and support for providing inquest statements or appearing as a witness at an inquest. The trust provides legal representation for staff appearing as witnesses for inpatient deaths, or following a serious case review of a child or adult death where the organisation has supported an Independent Management Review; or family concerned have commissioned legal representation. Appropriate legal advice on inquest matters is sought where appropriate Staff are supported through the Inquest process Ensure that media preparation is in place on high profile cases Ensure that the Chief Nurse and Director for Quality, Performance is informed of high profile cases. 4.4 Managers and Team leaders: are responsible for: ensuring that staff called to provide a statement or called as witnesses within a Coroner s Inquest receive: Adequate support within the Trust to support preparation and attendance at Coroner s Inquest Protected time away from clinical practice to support inquest preparation and attendance Information on the Trust Supporting staff after serious incidents policy and ensure that staff have information on AMICA counselling services, as a means of supporting staff following a child/ adult death or through the developing investigation processes both internal and external. Regular management contact and support through all stages of the Inquest process this will vary according to practitioner s wishes, but at a minimum will be telephone support. An opportunity for staff following the inquest process, to debrief with the manager on their experiences. 4.5 Responsibility of staff: They must inform their line manager as soon as they receive a request from an external agency, (police, or coroner s office) to provide a police statement for an inquest or are requested to attend an inquest as a witness. All members of staff are required to fully co-operate in the preparation of evidence for submission to Page 8 of 17
the coroner in a manner consistent with the guidance in the Trust Policy on Being Open. The General Medical Council and Nursing Midwifery Council recognise that practitioners have a professional duty to co-operate with the Coroner in their investigation of deaths. Staff should: Prioritise requests for statements or appearance as a witness in an inquest over other clinical work priorities. Keep their manager and Trust Lead for Quality and Patient safety or Named Professional (if death subject to safeguarding investigation) informed of all developments. Ensure that they confirm with the coroner s office their attendance at inquest dates Meet with the Trust Lead for Quality and Patient Safety and any legal representative (if required) prior to the inquest to support preparation Visit the coroners court with the Trust Lead for Quality and Patient Safety prior to the inquest to familiarise themselves with the court arrangements. Ensure that they do not speak independently on any media enquiry, but direct these to the Divisional Communication Lead.. 4.6 Divisional Communication Lead: will support effective communication with relevant stakeholders on high profile inquest cases, this is likely to include the Chief Nurse and Director of Quality, Performance and Innovation, Divisional Director, relevant service managers, Trust & Divisional Safeguarding Lead (if case relates to a previous safeguarding investigation), Trust Lead for Quality and Patient Safety. The communication lead for the division will: Represent the organisation at the large publications group meetings coordinated through the LSCB and LSAB offices, to support media preparation across agencies on high profile cases going through inquest or court processes, to support media preparation. Maintain communication with other agency communication leads in respect to individual cases, to support preparation. Where the case is subject to Serious Case Review under LSCB or LSAB areas, work with Trust & Divisional Safeguarding Leads on trust media preparation around the internal management reports (IMR) completed. Ensure that all communication sent to relevant people are timely, proportionate and succinct identifying the basic details of the case (anonymous), the implications for the service / trust and inquest / court dates. Have regard to any ongoing criminal or police processes on cases, ensure that information sharing does not jeopardise any future coronial processes. Page 9 of 17
4.7 Named Professionals: will support internal trust media preparation for high profile inquests on cases where deaths have been investigated through Serious Case Review safeguarding processes, working closely with the Divisional Communication Lead. The Named Professional will: Review the IMR report they authored in response to the SCR processes and identify key learning areas. Collate the documentation required to support the preparation including the IMR report, over-view report (health and executive summary (if published), clinical records. Meet with the Trust Lead Quality and Patient Safety, Incidents and Barrister (if appointed) to prepare for the inquest. Work with the Divisional Communications lead and Trust & Divisional Lead for Safeguarding to prepare media statements on behalf of service areas. Work with the Trust Lead for Quality and Patient Safety and Locality Service Managers to ensure that staff called as witnesses are appropriately prepared. Keep the Divisional & Trust Lead for Safeguarding briefed of any new developments within the coroner s inquest processes 4.8 Training training and guidance on inquest processes is available from the Trust Lead for Quality and Patient safety 5.0 Process: Witness statement content: 5.1 Should be prepared in accordance with the trust s current guidance on the preparation of statements and contain dates and times of all treatment provided by the staff preparing the statement. The police acting on behalf of the coroner will seek statements for inquests from staff. Staff should notify their manager when contacted for a witness statement. 5.2 The police statement should be chronological and be a factual account of a witness s involvement with the child/adult. It should not contain expressions of personal opinion outside of their field of expertise. Support with inquest statements is provided by the Incident Manager, or where there have been previous safeguarding processes within the case, by contacting Named Nurses (children or adult safeguarding). 5.3 It is important to note that delays in the provision of statements can lead to public scrutiny. It is essential that statements are provided within agreed timescales. 5.4 Once the coroner is satisfied that he/she has all the necessary evidence the date for inquest will be agreed the office will then send a summons to all those he/she requires to attend the inquest for the purpose of providing evidence. The coroner has the power to call anyone as a witness if they are able to provide any information that will assist him/her to establish how the deceased came by his or her death. Page 10 of 17
5.5 If a witness is unable to attend on the designated day they must inform the coroner immediately and provide the reasons why. A coroner may reschedule an inquest but does have the power to insist on a witness s presence not withstanding any other commitments they might have, including illness. 5.6 Attendance at the inquest, once summoned, is mandatory. Failure to attend an inquest may render a witness liable to a fine not exceeding 4,000 and/or imprisonment. 6. Preparation: Before the inquest a briefing session will be held with the trust s solicitors for any witnesses required by the coroner to attend the inquest. The primary purpose of this is to explain the inquest process, to prepare witnesses as fully as possible for the anticipated questions the coroner, the family or their legal representatives may ask and to agree a strategy for presenting their evidence. 6.1 On high profile inquest cases where there have been a previous SCR or SILP safeguarding investigations into the death of a child or adult agencies should consider holding a pre-inquest briefing session jointly with the local CCG; to support preparation across health agencies on the content of the health overview report (which is developed from single agency reports IMR). 6.2 Coroner s locally may require LSCB s or LSAB to provide independent reports arising from SCR or SILP investigations or single agency reports to support the inquest process. Locally agreements have been reached with coroner s that these documents are only viewed by the coroner and not released into open court proceedings. LSAB and LSCB make the final decision as to whether a SCR or SILP report will be published on website areas. 6.3 The LSCB or LSCB are data controllers of SCR or SILP overview report and executive summaries, the information is provided by all agencies involved in the case, these MUST NOT be shared with any third party without they explicit agreement of the board in question. 7. The Inquest: The inquest is held in open court and in addition to the coroner the following individuals may be present: Coroners officer Pathologist Witnesses Family/friends Legal Representatives Page 11 of 17
Press Public 7.1 Evidence is given under oath. It is also tape-recorded so when speaking witnesses should do so as clearly as possible 7.2 The Coroner will go through the report or statement provided by the witness and may ask certain questions to elaborate on any particular aspect. It is important that witnesses have a copy of their statement and the original clinical records and are familiar with the entries they have made. If witnesses are unable to answer any particular question they should say so and never attempt to guess. It is permissible, and advisable, to refer to the clinical records regarding details of medical treatment. 7.3 Once the coroner has completed his /her questioning the family or their legal representatives will then have the opportunity to ask questions followed by legal representatives for the trust. 8. Juries 8.1 Medical inquests are held with the coroner sitting alone though the Coroners Act does specify a number of instances where a jury must be called. The coroner is required to hold the inquest before a jury if: The death occurred in custody The death occurred whilst the deceased was in police custody or resulted from an injury caused by a police offer in the purported execution of his duty The death was caused by an accident, poisoning or disease which must be notified to a government or department inspector e.g. Health & Safety Executive under RIDDOR. Where a death concerns public safety (where there is evidence to suggest system neglect within the meaning of Article 2 of the Human Rights Act or a systematic failure contributing to the death might reoccur. Where the deceased is detained under the Mental Health Act. The coroner may also summon a jury in cases other than those listed at his/her discretion. 8.2 Staff may be called as a Juror for Inquest purposes; Appendix 2 provides guidance on the role. Page 12 of 17
9 Verdict 9.1 Only in very exceptional circumstances will the Coroner retire to consider their verdict. On occasion the Coroner may adjourn the inquest to a later date if further witnesses are required but he normally delivers his/her verdict once all the evidence has been heard. 9.2 There are several verdicts that the coroner may return depending on the evidence presented to him / her but for medical inquests those most frequently used are: Accidental Death- where the death occurred as an unintended consequence of an action (this will include for example, death resulting from complications of medical treatment or surgery) Open Verdict where the coroner is unable to decide between one or more verdicts Neglect/ Lack of Care where the Coroner believes there has been a gross failure to provide medical care to a patient Suicide- where the deceased took his or her own life and intended to do so Natural causes- where the death was caused by an underlying disease or illness 9.3 The Coroner may also give a narrative verdict which involves a descriptive account of how the deceased came by their death. 9.4 The Coroner has the power under rule 43 of the Coroners Rules 1984 to issue a report where the evidence at the inquest gives rise to a concern that a similar death may occur in the future. 9.5 The Coroner may issue a rule 43 where he/ she feels action should be taken to reduce the risk of future deaths. If a rule 43 letter is sent to the trust they must respond to the coroner within 56 days (or longer period if agreed by the coroner). 10 Media 10.1 Members of the press may be present at the inquest. For high profile inquest cases it is also possible that television crews will be present outside of the court. 10.2 If it is the case that any staff are approached by any member of the media for any comment regarding the inquest they should refer any such request to the Communications Team who are responsible for dealing with all such Page 13 of 17
approaches. 10.3 As part of media preparation, the divisional communication lead will ensure that lead directors are kept informed of inquest preparation; it is clearly communicated across agencies that are leading media statements on behalf of the health community.. 11.0 References Equality Act 2010 http://www.homeoffice.gov.uk/equalities/equality-act/ General Medical Council http://www.gmc-uk.org/ HM 2010 Working Together to Safeguard Children https://www.education.gov.uk/publications/eorderingdownload/00305-2010dom-en-v3.pdf Ministry of Justice 2008 : Jury Service at an Inquest (leaflet) Nursing Midwifery Council http://www.nmc-uk.org/ Page 14 of 17
Appendix 1 When a death will be reported to the coroner If death occurs in any of the following circumstances, the doctor may report it to the coroner: after an accident or injury following an industrial disease during a surgical operation before recovery from an anaesthetic if the cause of death is unknown if the death was violent or unnatural - for example, suicide, accident or drug or alcohol overdose if the death was sudden and unexplained - for instance, a sudden infant death (cot death) In addition to this, if the deceased was not seen by the doctor issuing the medical certificate after he or she died, or during the 14 days before the death, the death must be reported to the coroner. Anyone who is concerned about the cause of a death can inform a coroner about it, but in most cases a death will be reported to the coroner by a doctor or the police. Page 15 of 17
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