News & Events
Radical reform of the system of coroner's inquests is well overdue
Updated 1st May 2009
By Ken Thomas, Partner and Medical Negligence lawyer at Harding Evans Solicitors.
There are proposals in the pipeline to reform radically the system of coroner's inquests in Wales and England.
These changes are relevant in the context of healthcare because, for some years new, coroner's inquests have become increasingly important in the investigation and resolution of clinical governance issues.
The reforms are, in the eyes of many commentators, well overdue. Many certainly feel the current system is rather idiosyncratic and in some ways archaic.
Where a family decides to peruse a medico-legal investigation into the death of a loved one, they sometimes seek legal advice at the point the case goes to inquest.
This is sensible on the basic that evidence heard at an inquest can often highlight issues about the deceased person's care that can underpin any subsequent claim for damages.
On the other hand, some families only decide to launched a medico-legal investigation after the inquest has been held, which can be unfortunate as an opportunity to do some initial groundwork on the case has therefore been missed.
In Wales, inquests examining the circumstances leading to a hospital death are regularly reported in the press.
Late last year the Cardiff inquest into the tragic death of baby girl hours after being discharged from her local accident and emergency unit made headlines nationwide.
"The planned reforms to the coroner system will hopefully allow the medical profession to learn further lessons from tragic failings in the past"
» Ken Thomas, Partner and Medical Negligence lawyer
The inquest decided that a doctor who had made a fundamental error in that case had been found wanting by an earlier inquest into a previous death, but that information had not been shared between neighbouring NHS trusts when that practitioner moved hospitals.
Meanwhile, an inquest in Gwent highlighted significant failings in the care of a mother who died after an emergency Caesarean section.
Where a healthcare provider, such as an NHS Trust, believes that a claim might ensure, quite often it will send legal representatives along to the inquest.
Having said that, it should be noted that a coroner's inquest is not intended to determine a civil liability.
A coroner may be scathing in his criticism of the medical care the deceased person received prior to his or her death, but that does not necessarily mean that a civil court would find that the person died as a result of medical negligence.
By the same token, just because coroner does not offer extensive criticism of an individual's care, it does not mean a subsequent clinical negligence claim would fail.
The Coroners and Justice Bill, which would enable the reforms, is currently working its way through Parliament and it includes plains to create a national coroner service, lead by a chief coroner.
The charity Inquest, which campaigns on behalf of families, feels the Bill could be strengthened in order to prevent the current delays, the inconsistency of approach between coroners and glaring lack of resources in some places.
Time will tell whether their concerns are well founded.
Coroners do have some powers to write to relevant authorities and bodies and this function does have a role in 21st -century clinical governance.
The planned reforms to the coroner system will hopefully allow the medical profession to learn further lessons from tragic failings in the past - whether due to a system failure or shortcomings on the part of the individual.
Ultimately we must hope that, where such tragedies occur, the subsequent inquest will help, as far as possible to avoid a repitition.