The coroner role & preparing for a coroner's inquest

This virtual conference focuses on the role of the Coroner, the coronial investigation and inquest process, and preparing effectively for a Coroner’s Inquest. The conference will provide an important update on current developments in the coroner system, including the impact of the statutory Medical Examiner system and Death Certification Reforms on referrals, investigations and learning from deaths.

The conference will explore the Coroner’s investigation from notification and referral through to the inquest, preparing witness statements and giving evidence, supporting staff involved in proceedings, and understanding what families want and need from the process. Practical sessions will provide an opportunity to understand how an inquest works in practice and develop confidence in preparing for and attending Coroner’s Court.

Following the introduction of statutory Medical Examiner scrutiny, all deaths in England and Wales now undergo independent review either by a Medical Examiner or through investigation by a Coroner. Emerging national evidence suggests that the reforms are leading to fewer unnecessary referrals to coroners and more appropriate use of the coronial process. The conference will examine how Medical Examiners, Coroners, patient safety teams and clinical governance functions can work effectively together to identify concerns and ensure learning leads to improvement. The conference will also consider how organisations manage PSIRF learning responses, complaints, claims and coronial investigations in parallel. HSSIB has highlighted that coroners’ expectations can influence organisations’ choice of learning response under PSIRF, demonstrating the importance of clarity around the different purposes and requirements of patient safety learning and the coronial process. There will be a strong focus on learning from deaths and Prevention of Future Deaths reports, including identifying themes, responding effectively within the required 56-day timeframe and ensuring recommendations and concerns result in demonstrable and sustained improvement.

Delegates will also be updated on the developing Public Office (Accountability) Bill, widely known as the Hillsborough Law. The Bill proposes a statutory duty of candour and assistance for public authorities and public officials engaging with inquests, inquiries and investigations, alongside provisions designed to improve the participation and representation of bereaved families.

This conference will enable you to:

• Understand the role of the Coroner and current developments in the coroner system

• Understand notification and referral of deaths and when a Coroner has a duty to investigate

• Examine the impact of the Death Certification Reforms and statutory Medical Examiner system

• Understand the relationship between Medical Examiners, Coroners and organisational learning from deaths

• Reflect on a family’s experience and understand what bereaved families want from a Coroner’s investigation and inquest

• Understand the Coroner’s investigation, the scope of an inquest and the role of Interested Persons

• Develop your skills in preparing for an inquest, including writing witness statements and giving evidence effectively

• Learn from the experience of Coroners and healthcare professionals who have attended Coroner’s Court

• Improve support for staff before, during and following an inquest

• Understand how PSIRF learning responses, complaints, claims and coronial investigations can be managed effectively in parallel

• Explore openness, candour, disclosure and the implications of the developing Public Office (Accountability) Bill/Hillsborough Law

• Understand Prevention of Future Deaths reports, the 56-day response requirement and current Chief Coroner arrangements

• Identify key strategies for learning from deaths and ensuring findings lead to sustained improvement

• Understand how learning from mortality reviews, Medical Examiner scrutiny, patient safety responses and bereaved-family concerns can be brought together

• Reflect on your own practice and identify areas for improvement

• Support CPD professional development and provide evidence for revalidation. This conference provides 5 hours’ training for CPD, subject to peer group approval for revalidation purposes.

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