We recently represented the bereaved family at an inquest into the death of Eva Eileen Wheeler who passed away at Ysbyty Cwm Cynon in February 2020. Mrs Wheeler developed a sigmoid volvulus which led to bowel obstruction and perforation. Due to a communication error at the hospital, an emergency ambulance was not called and Mrs Wheeler sadly died that day of abdominal perforation.
An inquest was heard and the Assistant Coroner issued a Regulation 28, Prevention of Future Deaths (PFD) report.
During the inquest, there was little evidence from the Health Board as to how the proposed changes and learning had been implemented since Mrs Wheeler’s death, so we are pleased that the Assistant Coroner has engaged her powers to issue a PFD report. While the family still feels that there were failures which extended beyond communication issues, it is reassuring to know that proactive steps will now be taken to improve patient care.
This tragic case is a very useful example of what happens during an inquest and how the powers of the Coroner can be used to put right previous mistakes to help protect future patients. We have developed the following guide so that families in this unenviable position know what to expect from the inquest process.
When does a Coroner become involved?
A Coroner is notified if:
- The cause of death is unknown
- A post-mortem is needed to find out how the person died.
- An inquest needs to be held when: a. the cause of death is still unknown after a post mortem; b. the deceased died a violent or unnatural death; c. the deceased may have died in police custody or prison.
The purpose of an inquest
The inquest process is not adversarial and there to find or place blame or negligence. The coroner’s role is simply to find out who died and how, when, and where they died.
The process
The next of kin will be notified by the Coroner’s Office of the date of any pre-inquest hearings and the inquest itself. As the family of the deceased, you can instruct a Solicitor or Barrister to act on your behalf and make submissions to the Coroner during the inquest process.
The Coroner may decide to call a pre-inquest review (PIR) hearing. These hearings are held to help the Coroner identify what documents/medical records will be disclosed at the inquest and who will need to be called to give written or oral evidence.
The Coroner will declare a list of “interested persons”, anyone who the Coroner recognises as having interest in the investigation. This will include: spouses, civil partners, partners, child, siblings, grandparent, grandchildren, step-parents, half-siblings, and can also include doctors and nurses who had care of the deceased prior to death.
The length of an inquest will depend on the complexity of the individual case and most will be heard within a day. Most inquests are held without a jury, however there are circumstances where one would be called, including:
- if the death happened in prison, in police custody or another type of state detention (except if the death was from natural causes); or
- if the death resulted from an accident at work;
- if the senior coroner thinks that there is sufficient reason for doing so.
Conclusion of an inquest
Section 10 of the Coroners and Justice Act 2009 (the 2009 Act) requires the coroner to make a ‘determination’ of the matters to be ascertained by the investigation – i.e. who the deceased was; and how, when and where he or she came by his or her death – and make ‘findings’ for registration purposes, i.e. the particulars required by the Births and Deaths Registration Act 1953.
The Coroner has two alternatives for conclusions, either a short-form conclusion or a narrative conclusion which is free form factual statement.
What Powers does the Coroner have?
Where an investigation gives rise to concern that future deaths will occur, and the investigating coroner is of the opinion that action should be taken to reduce the risk of death, the coroner must make a report to the person the s/he believes may have the power to take such action.
These prevention of future deaths reports are known as PFDs. At their core, PFDs are about learning and patient safety to minimise the risk of other deaths occurring in similar circumstances. A response from the named responsible body must detail the action taken or to be taken and the timetable for it.
Funding
A “No Win No Fee Agreement”, also known as a Conditional Fee Agreement (CFA) is essentially a contract which a client and solicitor enter into to cover the costs of any civil proceedings. In this context, a CFA will usually be for work carried out to prove a clinical negligence claim.
A CFA can cover advocacy and investigations into the inquest. However, CFAs will only help you if you intend to bring civil proceedings in clinical negligence against the healthcare provider.
If you are successful in proving your civil claim in clinical negligence, then all or part of the costs of the inquest may be recoverable from the other party. For your inquest costs to be recoverable, your solicitor must show that the costs incurred at the inquest are costs of or incidental to the civil claim.
At present, families can apply for Exceptional Case Funding in order to secure legal representation at inquests. As of 12 January 2022, there are changes to the way bereaved families can apply for legal aid funding for inquests. You can read more here.
Further investigation beyond an inquest
Although the inquest process is essentially a fact-finding exercise to find out who died and how, when, and where they died, information can sometimes reveal that the standard of care provided to the deceased was of an unacceptable standard and this will often lead to a civil Clinical Negligence action.
At Harding Evans, we can help you through this difficult time
Experiencing the loss of a loved one is always distressing, not least if the death is reported to the Coroner and an inquest needs to be held. Where there has been a suspicion of sub-standard medical care, our team of experienced and sympathetic clinical negligence solicitors can help support and guide you and your family through the entire inquest process. Call us on 01633 244233 or email us at hello@hevans.com.
