TRAINING - Clinical negligence and the Emergency Department
Jan 25 2022
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Coroners have played a vital role in society since 1194 and have been subject to very little reform since 1887. In 2003, publication of the Shipman Inquiry and a Fundamental Review of Death Certification and Investigation identified serious weaknesses in the coronial system. There was very little consistency in the way that Coroners, their Deputies and Assistants acted. In some cases Coroners were efficient and Inquests were held fairly quickly, whilst in other cases, bereaved families were expected to wait for well over a year or more. There was a distinct lack of national supervision, leadership and an absence of rights entitling bereaved families to participate in the process.
A number of reviews formed the building blocks of what was to become the Coroners and Justice Act 2009 ("the Act"). It cherry picked the best of what used to work at that time and introduced a number of structural changes to the coronial system. The new Act was designed to offer a user focused, transparent, effective and responsive coronial system for victims, bereaved families and the general public.
The balance lay in improving the services Coroners offer, but also ultimately allowing families more opportunities to participate.
In brief, the Act provides the following structural changes which take effect from June 2013:
It has been suggested that there may be specialist groups / specialist Coroners who deal with certain types of death, such as deaths in custody, service deaths or deaths in a healthcare setting. Further consultation on this proposal is expected to follow in due course.
The power for a Coroner to make a Rule 43 recommendation is already well established, allowing Coroners to make a report to a person or organisation where he or she believes that action should be taken to prevent future deaths, requiring a response within 56 Days.
Going forward, Rule 43 recommendations and their responses (which will be required within one month) will not only be shared between the Interested Persons, but also copied to the Chief Coroner, and summarised in the Chief Coroner's annual report to the Lord Chancellor. A copy will be laid before the Houses of Parliament. Therefore, what used to be a rather private “telling off” will now become a public naming and shaming exercise and Rule 43 Recommendations should not be ignored.
Therefore, going forward, more emphasis needs to be paid at the Inquest preparation stage to ensure that organisations can demonstrate what actions they have taken to prevent future deaths from occurring. Only in cases where the Coroner is fully satisfied that the organisation has taken reasonable steps to prevent future deaths from occurring will the Coroner refrain from making such a public recommendation.
These changes are due to take effect at some stage this month.
It is likely that organisations will need to review their internal investigation procedures to ensure that investigations are completed promptly without compromising on the detail required.
It is hoped that the changes will result in a more consistent approach which in turn should enable healthcare professionals and organisations to gain a better understanding of what will be expected of them, and what challenges they may encounter.
The recent years have seen an increase in the number of inquests, including increased analysis of deaths in healthcare settings. It is anticipated that this growth will continue. It is hoped that the 2013 changes will go some way to ensuring that our Coronial service is better equipped to handle such an influx in a user friendly manner.
Undoubtedly, the enhanced importance of Rule 43 Recommendations will be a focus for all organisations, and ensuring responsibility internally for the implementation of recommendations will be of key importance. Thorough preparation before the inquest will continue to play a vital role.