Care home providers may well become involved in the inquest process, which can be a daunting experience for staff called to give evidence at a hearing. Whilst the purpose of the inquest is a fact finding investigation to establish the following:

  • who the deceased was;
  • when they died;
  • where they died; and
  • how they died,

It can also touch on wider issues of practices and procedures which sometimes often piques the interest of the CQC, and can lead to an inspection.

The Coroner also has a duty to make a report where they consider that action should be taken to prevent future deaths.

Here, we consider some common issues explored at inquests relevant to care home providers, and which are important for care home providers to be aware of:

1. Delays in ambulance attendances

We are all aware of the considerable strain on ambulance services currently, which is leading to longer wait times for ambulances to arrive. Care home providers should ensure they have processes in place to look after residents whilst ambulances are awaited, particularly if a patient has sustained a fall and cannot be safely moved. Consideration should be given to regularly updating staff training to ensure that staff are confident and qualified to give appropriate first aid. This should include basic life support training to minimise the risk of panic and distress taking over in an emergency situation.

2. Record keeping

During the inquest process, a provider’s care records are likely to be scrutinised. It is important to ensure that care plans, daily care notes and risk assessments are thorough and audited regularly. These documents will assist staff to explain the care provided to a particular service user at an inquest which may take place some time after the death.

Care providers have been criticised at inquest for failing to retain staffing rotas, training documents and incident reports and for failing to keep accurate and up to date records for service users. It is imperative that providers have good audit systems in place to ensure that documentation accurately reflects the care provided to service users. This is of course a CQC regulatory requirement in any event.

3. Implementation of care plans

Care home providers face significant challenges to ensure all staff are aware of all elements of a service user’s care plan. A common theme at inquests involving care homes are incidents where a service user has choked at meal times. There is a real challenge in ensuring an appropriate care plan is in place, that the service user is supported at meal times, that the catering staff are aware of individual service users’ particular needs and that there is appropriate supervision of service users whilst in the dining room.

Providers should use nutrition communication cards to ensure all staff, including catering staff, are aware of any dietary requirements. There should also be dining room supervision and 1:1 assistance provided where appropriate.


This is intended to be a snapshot of recent issues identified at inquests involving care home providers. Involvement in inquests can be difficult and distressing for care homes, and particularly staff members. Our inquest team can provide support from the outset to ensure that your staff are fully supported and that your organisation is represented fairly at any hearing. Should you require any support or assistance in relation to the inquest process, CQC inspections or serious incident investigations please do not hesitate to get in touch.

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