How preparing for an Inquest may actually prevent a ‘Prevention of Future Deaths’ Report

Topics covered: coroner, COVID-19, inquests

Given the nature of their work, a large number of health and social care providers will at some point become involved in an inquest.

The Coroners’ Courts have adjourned a lot of inquests because of COVID-19 restrictions but we expect them to start getting pretty busy over the coming months, trying to deal with the backlog and increasing numbers of deaths during the period of the pandemic.

We have written previously on the importance of providers engaging in the inquest process. The purpose of that engagement is, at least in part, to try and take the sting out of negative evidence presented at an inquest, and to avoid being the addressee of a prevention of future deaths report (a “Regulation 28 Report”).

Regulation 28 Reports are sent by a Coroner to parties where the Coroner has “concerns” and believes that future deaths can be prevented by that party (alone or with others) taking appropriate action in response to the concerns.  These reports are usually published on the Chief Coroner’s website and are sent to all Interested Parties, so may provide a basis for persons, such as families, to launch a civil claim if concerns about care have been highlighted.

It is worth noting that some relatively low-level issues can attract significant criticism and can form the basis of concerns raised in a Regulation 28 Report. We have looked at a number of Regulation 28 Reports published on Judiciary UK recently which have been addressed to care home providers.  Concerns raised include record keeping errors, gaps in training, using forms which don’t record enough detail, failing to seek follow up treatment quickly and inadequate communication or engagement with multidisciplinary teams and other third parties.

What may seem like a relatively simple oversight or isolated shortfall could, in a scenario where that has caused or contributed to death, form the basis of significant public criticism of a provider and/or their staff. If nothing else, this should serve as a reminder to providers that what may, in isolation, seem a relatively low level issue, can attract significant criticism and/or a Regulation 28 Report, both of which can cause economic and reputational damage.

As things slowly ease out of lockdown for the rest of us, providers will still have significant work to do not only in dealing with ongoing infection control requirements but also in trying to adjust ways of working to get back to a “new normal”. This is likely to require attention to various policies, practices, procedures and risk assessments. This would therefore be a good time to take a step back and review systems processes and policies within the organisation, and ensure audits and quality checks are being carried out and that there is good and accurate record keeping. If providers identify any shortfalls in compliance, however minor they may seem in isolation, they should be addressed.

If there have been any unexpected deaths in a service, or any deaths might have been, or might be, referred to a coroner providers should ensure that there is a good document trail of any internal investigations which have taken place (subject to any external investigation which would take precedence, such as a police investigation), to include outcomes and actions taken and evidence that any lessons learned have been put into practice.  This may provide assurance to the Coroner that sufficient action has been taken to avoid a Regulation 28 Report.

Providers are already battling on multiple fronts at the moment, they do not want, or need, to attract criticism from a coroner to add to the mix. Financial viability and bed vacancies are a real concern for many providers at present and a Regulation 28 Report is only likely to make a provider’s position more precarious. Taking steps now to identify and deal with any shortfalls will put providers in a better position at any future inquests.

If you require assistance with the preparation for an inquest, including understanding where criticisms may arise and how best to deal with those, please contact us on 0207 317 0340.

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