SH NCP 9 Version: 3 Summary: Keywords (minimum of 5): (To assist policy search engine) This document outlines the roles and responsibilities of different clinical and corporate services in the management of inquests to ensure a standardised approach and appropriate information sharing between clinical and corporate services. Inquest, Coroner, Management, Legal Inquiry, Findings, Coronial Target Audience: Area Managers and their administrators, Clinical Service Directors, Directors of Integrated Services, Medical Director, Professional Leads and Communications Team Next Review Date: October 2018 Approved and ratified by: Quality & Safety Committee (virtually) Date of meeting: Date issued: Author: Head of Legal & Insurance Services Sponsor: Julie Dawes, Director of Nursing & Quality 1
Version Control Change Record August 2014 August 2014 August 2014 Date Author Version Page Reason for Change C Goodyer 2 4 Background, Purpose and Roles and Responsibilities: updated in line with new Coronial Rules. Eg Verdict now referred to as Finding. C Goodyer 2 5 Pre-Inquest Responsibilities added to ref Communications Team being informed and briefed adequately. L Béga 2 8-10 Appendix 7 Inquest Planning Meeting Terms of Reference updated to those approved in at the meeting held in November 2013. July 2016 S Pearson 3 5, 12 & throughout Amended on call number for Comms, frequency of meetings, change of title for Legal Services Officer July 2016 L Béga 3 3, 8-10 Roles and responsibilities to reflect updated process followed by Legal Services Officer since the introduction of Ulysses module. Additional explanation of Case A and B s. Amendment to Appendix A to clearly define that the SOP applies to AMH (as opposed to all of MH) and that the SOP in Appendix 2 is the model followed by the rest of the Trust (previously detailed as ISD Southampton & West only). September 2016 L Béga 3 2-3, 10-11 Flowchart regarding the rest of the Trust (non-amh) reflected to make clear that it encompasses the whole Trust and not just the Integrated Service Division West. Flowchart regarding the Adult Mental Health Division amended to remove area names as these are subject to change (North & West due to split 2016 end). Flowchart to include that any actions identified are shared as learning with the Trust. 13/8/18 3 Review date extended from Sept to Oct 2018 Reviewers/contributors Feedback received from: Name Position Version Reviewed & Date John Stagg Interim Lead Nurse (LD) Version 1.0 draft Amy Hobson Divisional Director (LD/Specialised Services) Version 1.0 draft Jane Bray Area Manger (OMPH) Version 1.0 draft Jude Diggins Interim Director of Nursing and AHP Version 1.0 draft Helen McCormack Interim Medical Director Version 1.0 draft Paul Warren Consultant Psychiatrist (AMH) Version 1.0 draft Amanda Horsman Divisional Director (OMPH) Version 1.0 draft Lesley Stevens Clinical Director (AMH) Version 1.0 draft Paul Hopper Interim Clinical Director (OPMH) Version 1.0 draft Kate Brooker-Corcoran Area Manager (AMH) Version 1.0 draft Karen Guy Area Manager (AMH) Version 1.0 draft Trevor Abbotts Area Manager (AMH) Version 1.0 draft Kerry Beakes Area Manager (AMH) Version 1.0 draft Catherine Goodyer Interim Head of Legal & Insurance Services Version 2 Sarah Pearson Head of Legal & Insurance Services Liz Béga Legal Services Officer (LSO) Theresa Lewis Lead Nurse Infection Prevention and Control Kathy Jackson Head of Nursing Inpatients (ISD East) Carole Adcock Associate Director of Nursing Adult Mental Health Briony Cooper Head of Quality Performance and Quality Contracts Patrick Carroll East ISD Integration and AHP Lead 2
CONTENTS 1. Background 4 2. Purpose and Scope of the Protocol 4 Page 3. Roles and Responsibilities Roles and responsibilities for clinical services Roles and responsibilities for corporate services 4 5 7 Appendices Individual Flowcharts/Standard Operating Procedures for each Division A1 Mental Health 8 A2 Rest of the Trust 9 A3 Inquest Planning Meeting Terms of Reference 10. 3
1. Background An inquest is a legal inquiry into the medical cause and circumstances of a death. It is a fact-finding inquiry to establish who has died, and how, when and where the death occurred. It is not about determining blame. It is held in public - sometimes with a jury - by a coroner, in cases where the death was: violent or unnatural took place in custody or state detention (eg whilst in prison, police custody or detained as a formal inpatient under the Mental Health Act and/or possible under Deprivation of Liberty Safeguards via the Mental Capacity Act) or when the cause of death is still uncertain after a post-mortem Possible findings (formerly known as verdicts) include: natural causes accident or misadventure he or she killed him/herself (i.e. suicide) unlawful killing lawful killing industrial disease open verdict (where there is insufficient evidence for any other verdict). The Coroner is not required to return a finding in one of the above set formats. It is sufficient to produce a short, factual statement setting out the circumstances of the death if this more fairly and accurately reflects how the deceased came to his or her death and this is known as a narrative verdict. More information about Inquests and the role of the coroner can be found in the Ministry of Justice publication A Guide to Coroners and Inquests which is readily available online. 2. Purpose and scope of the Protocol Since 2011 Southern Health has been involved in approximately 100 inquests per year. The majority of the inquest process is devolved to divisions in most areas of the Trust. The purpose of this protocol is therefore twofold: 1. To aim for a standardised approach to the management of inquests by the different divisions 2. To allow for information to be shared between divisions and corporate services so that support can be offered by corporate services as necessary. 3. Roles and Responsibilities The following tables outline the roles and responsibilities of both clinical and corporate services at various stages of the inquest process. Note: Due to the small numbers of inquests held in any one year for TQtwentyone and the Learning Disabilities Division, the Head of Legal & Insurance Services will normally 4
lead on inquest management and will liaise directly with the Coroner. Any roles and responsibilities for these services will be delegated on an individual basis and will be agreed at the outset when the death occurs and the Coroner confirms an inquest will be held. Roles and Responsibilities for Clinical Services Pre Inquest Area Manager / Head of Nursing and Allied Health Professions (or their administrator) to liaise with relevant Coroner s Office on an ongoing basis to determine the following: Date of inquest Names of witnesses to be called Whether family are to have legal representation Area Manager / Head of Nursing and Allied Health Professions (or their administrator) to inform the Clinical Service Director, Divisional Director, Associate Director of Nursing and Legal Services Officer (via hp-tr.legalservices@nhs.net)) of the above and also whether the family have any specific concerns and whether there has been any media interest Area Manager / Head of Nursing and Allied Health Professions to ensure any high profile inquest (*see overleaf for definition) is considered at an early Inquest Planning Meeting by liaising with the Legal Services Officer to add to the next agenda and ensuring that a representative of the Division will be in attendance and able to brief colleagues. Area Manager / Head of Nursing and Allied Health Professions to carry out witness preparation session with witnesses called ensuring they review and are familiar with their relevant clinical entries Area Manager / Head of Nursing and Allied Health Professions to liaise with HR if there are simultaneous disciplinary proceedings underway Clinical Service Director to quality assure reports and witness statements that are sent to the Coroner Area Manager / Head of Nursing and Allied Health Professions to notify the Communications Team to ensure they are briefed and have sufficient information in order to prepare a Press Statement at the time of the inquest. During Inquest Area Manager / Head of Nursing and Allied Health Professions to attend inquest to support staff or to arrange for a suitably senior deputy to carry out this function Area Manager (or their deputy) to inform Communications Team by telephone (02380 874666 or 07017 029238) of any press interest that becomes apparent as the day progresses Post Inquest Area Manager / Head of Nursing and Allied Health Professions to arrange for any staff who were called as witnesses to be debriefed as soon 5
as is practicably possible after the inquest Area Manager / Head of Nursing and Allied Health Professions (or their administrator) to notify the Clinical Service Director, Divisional Director, Clinical Director and Legal Services Officer (via hp-tr.legalservices@nhs.net) of the inquest finding within 48 hrs of this being known (or immediately if finding is not what was expected). This should include the full text if the finding is a narrative one Clinical Director to determine whether any issues raised at inquest require a part 2 Critical Incident Report (CIR) to be done It is recommended that this table is used as a basis for a checklist for all inquests to ensure standardisation of the process across services. 6
Roles and Responsibilities for Corporate Services Pre-Inquest Legal Services Officer to populate the central inquest database when they first become aware of a death that might go to inquest (via automated incident notification), to maintain the central Inquest database and to liaise weekly with the Area Managers administrators for updates and at a frequency identified by each local Coroner (e.g. fortnightly, monthly). Arrange and administer bi-monthly Inquest Planning Meetings, including populating agenda in conjunction with HoLS and the divisional representatives. To provide weekly raw data reports of upcoming/open inquests to Lead Investigation Officers, Communications and Trust Board. Head of Legal & Insurance Services to assist the Area Managers with witness preparation as and when requested. Head of Legal & Insurance Services to co-ordinate the involvement of external legal support for the Trust if legal representation is required (*see below for definition). Head of Legal & Insurance Services to chair the Inquest Planning Meeting (held every 2 months). Agenda to be populated by both HoL&IS and Divisional representatives who attend meetings. This meeting facilitates the exchange of information between clinical and corporate services and allows the roles and responsibilities of clinical and corporate services to dovetail as appropriate. (See Appendix 7 for Terms of Reference) Head of Legal & Insurance Services to notify the NHSLA of the inquest if subsequent litigation seems likely. External Communications Manager to prepare press statements and issue Board briefings as necessary During Inquest Head of Legal & Insurance Services and/or External Communications Manager to only attend high profile inquests as necessary following liaison with the Area Manager. External Communications Manager to organise delivery of statement to the press, whether this is done remotely (via email) or televised. Post Inquest Head of Legal & Insurance Services to report findings of inquest to the NHSLA where litigation is ongoing or is deemed likely. Legal Services Officer to update the inquest database and corresponding incident report with inquest findings (or *Form A/B cases). To notify the sign off manager/s of the incident report of the outcome. To note findings in the monthly Governance report to the Chief Operating Officer. 7
*High Profile Inquests: The criteria for high profile cases is worked out by reviewing the nature of the death combined with evidence of significantly compromised care, where substantial media and social media attention has been generated and with a claim anticipated post inquest. Each of these criterion alone would not necessarily make it high profile, nor warrant major legal input. Each inquest should be considered on a case-by-case basis to determine whether it comes under the banner high profile. As a general rule, external legal representation at inquests will only be requested when it is known that the family plan to be legally represented themselves. It is not considered appropriate for the Trust to be represented when the family is not. *Form A/B cases: A Form A case indicates that a certificate was issued in first instance and the cause of death has been agreed by the Coroner. These are cases where the Doctor has to report to the Coroner (for example a death involving alcohol or following a fall) but it has been agreed by the Coroner that no Post Mortem is required and the Doctor can issue the death certificate. The Coroner's involvement ends here. A Form B case indicates that the cause of death remained unclear and a Post Mortem was carried out with the cause of death being found to be natural. The Coroner's involvement ends here. 8
Appendix 1: Mental Health Division Standard Operating Procedure Adult Mental Health Division Inquest Process Database populated & updated by LSO following receipt of death notification and as a result of weekly area updates Death requiring inquest Legal Services Officer (LSO) contacts each MH area administrator, once weekly, with names listed for the respective area Coroner notified via Registrar of Births and Deaths or police or Trust staff Area administrators contact the relevant Coroners for each case and request a weekly update of: anticipated media attention, if the family have legal representation/concerns, the date and finally the findings. The Coroner provides updates to each individual area administrator, who will then feed these back to the LSO. NB: Highest profile cases are listed on the Trust inquest planning meeting agenda. Decided by Legal Services in conjunction with division. Division follow local preparation procedures including staff witness support, providing statements to the Coroner etc. and ensure investigation actions are agreed and complete. Division attend inquest, witnesses supported by area or other relevant senior manager. Feedback from attending staff to LSO immediately post inquest. Legal Services/Solicitor attends only in the event that the family have instructed legal representation and are involved in pre-inquest procedures of a high profile nature only. On completion of any actions identified during statement preparation, the division should share this learning with the Trust where this is applicable. 9
Appendix 2: Integrated Services Division, OPMH, LD, TQtwentyone and Specialised Services Standard Operating Procedure Inquest Process for the Trust (non-adult Mental Health) Database populated & updated by LSO following receipt of death notification and as a result of weekly area updates Death requiring inquest Coroner notified via Registrar of Births and Deaths or police or Trust staff Coroner notifies Legal Services Team Legal Services Team notifies: Senior Team member, CD, HoS & HoP Division notifies: Senior Team member, Q&G team, CD, HoS & HoP Coroner notifies Division/ specific staff member LSO updates central tracker NB: Legal Representation (Q&G Team or Solicitor) at inquest is only deemed necessary if the family have instructed and are bringing Legal Representation to the inquest. 1. If unsure, Division decides with Legal Team input if inquest is likely to be high profile 2. Divisional preparatory pre-meet (Legal Team involved if high profile only), including staff witness support. 3. Division to prepare statements and/or ensure investigation actions are agreed and complete. 4. On completion of any actions identified during statement preparation, the division should share this learning with the Trust where this is applicable. 10
Appendix 3: Inquest Planning Meeting Terms of Reference Inquest Planning Meeting Terms of Reference 1. TITLE The name of this regular meeting shall be Inquest Planning Meeting. 2. PURPOSE To provide a consultative forum that can effectively plan for upcoming inquests arising for Southern Health NHS Foundation Trust with particular reference to those which are higher profile and for which the Divisions require support from Corporate services. The forum can also be used to discuss criminal trials, serious case reviews and domestic homicide reviews on an ad-hoc basis as and when they arise. 3. CORE ATTENDEES (Members) 3.1 The attendees required at every meeting are as follows: An Executive Director (Deputy Chair) or nominated deputy Senior Divisional or area representatives who can speak to cases on the agenda. Head of Legal & Insurance Services (Chair) Representative from the Safeguarding Team Representative from the Communications Team Minute Taker 3.2 In addition to the above, internal or external persons may be invited to attend the meetings at the request of the Chair to provide advice and assistance where necessary. These may include but are not limited to: Specialist Clinical Leads Head of Organisational Learning or Serious Incident Manager External solicitors 3.3 A quorum of members must be present before a meeting can proceed. At least 1 representative from each Area with inquests on the agenda must be present for the meeting to proceed together with a representative from the Communications Team, an Executive Director or the Head of Legal & Insurance Services. 4. CHAIR The Chair shall be the Head of Legal & Insurance Services and the Executive Director in attendance will chair when the Head of Legal & Insurance Services is not able to attend. The Chair s responsibilities include: Scheduling meetings and notifying members Inviting specialists to attend meetings when required Guiding the meeting according to the agenda and time available and Ensuring all discussion items end with a decision, action or definite outcome 5. MINUTE TAKER The role of the minute taker is to: Prepare agendas and issue invites for meetings and ensure all necessary documents requiring discussion or comment are attached to the agenda. 11
Distribute the agenda one week prior to the meeting Take notes of proceedings and preparing minutes of meeting Distribute the minutes to all members one week after the meeting The minutes shall be accepted by meeting members as a true and accurate record at the commencement of the next meeting. 6. DURATION OF MEETINGS Meetings shall be held every two months for a period of 1.5 hours. A special or extraordinary meeting may be called by the Chair to discuss and plan for a single inquest or trial in the immediate run-up to the event. 7. FUNCTIONS Functions of the Inquest Planning Meeting are: i. To facilitate sharing of information about all pending inquests, trials and serious case/domestic homicide reviews between representatives from clinical Divisions and those from Corporate Services such as the Governance and Communications teams ii. To single out those cases which by their nature are of a higher profile and require detailed planning iii. To determine which cases require the Trust to have legal representation and to plan for this iv. To determine the level of communication plan that needs to be developed in each case v. To gain assurance that the responsible managers have carried out their role in terms of quality assurance of reports and statements, preparation of witnesses and adherence to Being Open principles with the families vi. To keep under review outcomes from previous cases which highlighted failings that had not previously been investigated as part of the original root cause analysis (RCA). vii. To provide opportunities for sharing of wider organisational learning that emerges from the inquest process. 8. REPORTING Key lessons learnt and shared via these meetings will be reported to the Quality, Improvement and Development Forum as part of the Head of Legal & Insurance Services biannual report. 9. AMENDMENTS The terms of reference shall be reviewed annually from the date of approval. They may be altered to meet the current needs of all group members. The above Terms of Reference for the regular Inquest Planning Meeting for Southern Health NHS Foundation Trust have been agreed to by the Chair and attending members at the meeting held on 1 November 2013, and was reviewed again in August 2016. 12