Our final healthcare seminar of 2015 welcomed Ms Nadia Persaud, Senior Coroner for the Eastern Area of Greater London, who gave her perspective on the coronial process and recent developments.

Recent changes

The Coroners (Investigations) Regulations 2013 and Coroners (Inquests) Rules 2013 came into force in July 2013, governing the practice and procedure of coroner investigation of deaths under the Coroners and Justice Act 2009. Key points noted by Senior Coroner Persaud included the following:

  • Deprivation of Liberty (DOL) inquests: the 2009 Act states that a coroner must commence an investigation into a death which occurred whilst the deceased was in state detention. The Chief Coroner’s guidance is the death of a person subject to a DOL order should be the subject of a coroner investigation and inquest. The Law Commission is presently reviewing DOL inquests, with the proposal for coroners to be informed of a death, but that inquests are only required for a DOL patient if the coroner considers that there is a duty under Article 2 of the European Convention on Human Rights to investigate the circumstances of the individual’s death.
  • Investigations: initially the number of inquests declined, as a result of the new Rules and Regulations. This was due to the introduction of the concept of investigations. Previously, where toxicology or histology was requested, an inquest had to be opened. The new legislation however allows investigations to be opened. If the further testing reveals a natural cause of death, the investigation can be discontinued. The impact of DOL inquests has however increased again the number of inquests.
  • Minimally invasive post-mortems: the 2013 Regulations allow practitioners other than pathologists to conduct post-mortems, such as radiologists. This has been welcomed, particularly by certain faith groups, as it allows for non-invasive or minimally invasive post-mortem examinations, in appropriate cases. Unfortunately, at present, the cost of scans has to be borne by the family.
  • Preventing future deaths reports: the relevant wording has been changed from “power” to “duty”, meaning more reports are being produced.

Case law

Senior Coroner Persaud highlighted the decision in Bloom v Senior Coroner West London [2014], which related to the death of a 51-year-old woman.

The Claimant asked the Court to quash the Coroner’s findings, and order a further inquest. At the first inquest, the Coroner had accepted a pathologist’s finding that the deceased died from septicaemia and had been properly treated. Following the inquest, the deceased’s family obtained evidence questioning this finding. On the basis of the new expert evidence, the first inquest was quashed.

The second inquest resulted in a narrative verdict, but the jury had not heard evidence from the anaesthetist instructed by the family, raising questions of neglect. The Coroner in the case had instructed her own expert and had refused to call the family’s expert, as this might have given an appearance of bias. If she allowed all interested parties to call their own expert, then it would result in a trial by experts. The Court found that this was within the range of decisions reasonably open to her. The inquest had not however considered all of the relevant issues and the second inquest was also quashed.

The Court also considered whether a jury was needed for the re-hearing of the inquest. The Court considered that the inquest involved complex medical issues and would be best heard by a coroner experienced in medical law issues and not a lay jury. The Court did not make a formal direction in this regard.

Healthcare providers

Senior Coroner Persaud commented on ways in which healthcare providers can assist the smooth running of the coronial process.

Observations on how witnesses can make a good impression included the following:

  • A good impression begins before the witness attends court. If notes are full and legible, they give the impression of someone who is competent.
  • Accuracy in reports is important. Small errors can be upsetting to the families, and give the impression of not caring.
  • In the witness box, witnesses should dress appropriately (dress as if for an interview) and stand unless told to sit.
  • Re-read reports and the relevant medical records before the inquest.
  • Use layman’s language and remain calm. Use Post-it notes to tab the important pages of the medical records.
  • Photographs, props and diagrams can assist the coroner, jury and family with complex medical points.
  • Witnesses should know the relevant local policies and ensure they are up to date with changes in practice and procedure, including those involving the investigation of a serious untoward incident (SI).

Senior Coroner Persaud also suggested ways in which healthcare providers can assist, for example:

  • Timely communication: provide documents when requested and explain delays. Provide revised dates by which you can comply.
  • Communication with the family should be ongoing. Explanations should be provided and the healthcare provider should be open and honest. The process is inquisitorial, not adversarial.
  • Detailed and robust SI investigations, proactive disclosure of SI reports, ideally not anonymised, and all relevant evidence (including CCTV) will assist the coroner.
  • SI reports should have clear, focussed and complete action plans.
  • Ensure the correct records are available at the inquest hearing. Original records must be available.


It appears the increase in DOL inquests, together with the duty to write reports to prevent future deaths, will increase the pressure on the coronial system. However, this will be offset to some extent by the introduction of investigations.

Healthcare providers can help the coronial process run smoothly by adopting the practices suggested by Senior Coroner Persaud, which will increase the speed and efficiency of inquests. The risk of receiving a prevention of future deaths report also ensures healthcare providers focus on learning and improving patient safety.