Deaths in Hospital – When is a Coroner’s Inquest Ordered?

The role of the coroner is to investigate deaths and to establish who the deceased was, where they died, when they died and how they died. In general terms a Coroner has the power to inquire into deaths which occur in the following circumstances:

• Death was unexpected or unexplained;

• Death was the result of violence;

• Death was the result of an accident;

• Death was the result of negligence;

• Death from any cause other than natural illness or disease;

• Death in circumstances which require investigation.

Reporting a Death in Hospital to the Coroner

In relation to deaths in hospital the key issue for the Coroner will invariably be identifying the cause of death and whether a death could have been avoided. Deaths in hospital should be reported to the coroner if:

1. There is a question of negligence or misadventure about the treatment of the person who died.

2. A person died before a provisional diagnosis was made and the GP is not willing to certify the cause of death.

3. The patient died as the result of the administration of an anaesthetic.

Once a death is reported the Coroner will make inquiries which will generally involve ordering a post-mortem examination to be carried out on the deceased. Once the Coroner has received the post mortem report and made all necessary inquiries, they will make the decision on whether or not to order an inquest.

In 2013 a landmark Court of Appeal Judgment in the case of baby Axel Desmond expanded the jurisdiction of the coroner to order an inquest in to stillbirths in hospital. Prior to this coroner’s were unable to investigate stillbirths.

The Coroner’s Inquest

After conducting their preliminary inquiries the Coroner has a discretionary power to order an inquest. The inquest is non adversarial in nature. The purpose of the inquest is to investigate the circumstances and establish the facts surrounding the death. An inquest is entirely different from civil or criminal proceedings where the purpose is to establish fault or secure compensation.

In cases which involve a death in hospital an inquest can be ordered where the death is the result of a doctor or other healthcare professional’s negligence. The Coroner will not order an inquest in to every death in hospital where negligence is alleged. They will consider a range of factors and will often obtain independent medical evidence to inform their decision.

At the end of an Inquest the Coroner will report their findings on the circumstances which caused the death and whether or not this could have been avoided.

The Importance of Legal Representation at an Inquest

The role of solicitors in an Inquest is to represent the next of kin or any other ‘properly interested person’ and to ensure their interests are protected during an inquest. Those who can apply to have ‘properly interested person’ status at an inquest include:

• The next of kin;

• Other relatives of the deceased;

• An executor of the deceased’s will or appointed personal representatives;

• Anyone who may be responsible for the death in some way;

• Others appearing to the coroner to have a proper interest.

The coroner can direct written submissions from legal representatives which provides an opportunity to address any issues on behalf of a properly interested person or to request that medical evidence be obtained for example.

A solicitor can also request that an Article 2 Inquest be conducted which essentially provides the Coroner with greater scope to investigate a death than they would have in normal circumstances. An Article 2 inquest relates to Article 2 of the European Convention of Human Rights which places a positive obligation on the state to:

• Refrain from unlawful deprivation of life;

• Investigate deaths in suspicious circumstances;

• Take steps to prevent avoidable losses of life.

An Article 2 investigation may be ordered for example in the case of a death in hospital if the Coroner finds that there was a failure to adequately protect against the risk of death where it was known or ought to have been known that there was a real and immediate risk to life.

Our human rights solicitors are highly experienced in representing clients at inquests and have particular expertise in deaths which occur in hospitals. In the aftermath of an inquest we can advise the family of the deceased on further legal remedies including claims against the relevant healthcare Trust or hospital.