Inquests are something which affect a vast range of NHS and private organisations, as well as individual clinicians, and so we provide a brief overview of recent developments as well as a couple of key potential changes to come.

What should an Inquest cover – case law update

The scope of an Inquest has expanded significantly, and the ambit of a Coroner's investigative powers and duties is often a key area of dispute between representatives for the family and other Interested Persons. In R (on the application of Maureen Speck) v HM Coroner for District of York, we have had a useful restatement of the position from the High Court. The Inquest concerned a death of Ms Speck while detained under section 136 of the Mental Health Act at a police station. The family judicially reviewed the Coroner's decision to not leave the jury to consider the fact that the local hospital did not have a specialist medical facility for the detention of people under the Mental Health Act. The High Court agreed that the Coroner's approach was correct, and reiterated that although the Coroner has a discretion to leave non-causative matters to the jury there is no obligation to do so.

This was further emphasised in R (on the application of Teresa Tainton) v HM Coroner for Preston and West Lancashire, but with an important additional clarification. The Inquest concerned a delayed diagnosis of cancer contributed to by prison medical staff. These failings were in fact admitted by witnesses during the Inquest. However, the Coroner did not leave the jury to consider whether the admitted failings significantly hastened the Deceased's death. This was on the basis that the evidence heard during the Inquest as to the causative impact of the delay was based on a number of suppositions, and so a conclusion as to the effect of the delay would be unduly speculative and therefore unsafe. The High Court rejected the family's judicial review of the Coroner's decision, confirming that, in light of the causation evidence, it would have been unsafe to ask the jury to consider that particular issue.

However, it should be noted the High Court added that admissions of failures made during the course of an Inquest should form part of the record of Inquest, even if they cannot be said to have been causative of the death. There should be an additional sentence or paragraph to make clear that although there were admitted failings, there is no evidence of their causative impact.

These cases provide helpful guidance to healthcare organisations and individuals as to the limits on issues which properly form part of an Inquest and its conclusion. However, they do also emphasise the need for care though when admitting any failures.

The Chief Coroner's view – what should be changed?

The Chief Coroner has recently published his annual report, and this contains some useful observations. He has noted the fact that there is currently no legal duty upon doctors to report deaths to the Coroner, and nor are they assisted by any statutory guidance in this regard. We are aware of this having been a difficulty for doctors in the past, and has often led to doctors simply referring deaths as an abundance of caution. It is hoped that Parliament will take note of this issue, and provide greater clarity for doctors in due course.

The Chief Coroner also considers one of the unfortunate, and perhaps unintended, developments of the case law dealing with Deprivation of Liberty Safeguards ("DoLS"). As the test to determine those to whom DoLS applies has been significantly widened by the Cheshire West judgment, Coroners have become inundated with swathes of additional deaths which require investigation by way of Inquest. The Chief Coroner has therefore recommended amendment to the legislation so that the death of an individual subject to DoLS is removed from the definition of 'state detention' so that an Inquest would not automatically be needed. This would be a welcome development, particularly to those in the care sector as it should mean a reduction in the number of deaths requiring coronial investigation.

Please see below for links to the cases mentioned in this update (where available), as well as to the Chief Coroner's update:

Tainton v HM Coroner for Preston and West Lancashire

Hamilton-Jackson v Coroner for Mid Kent and Medway

Cheshire West

Chief Coroner's Annual Report