Guidance for when a social care provider is called to an inquest

As we are all aware, deaths do unfortunately occur in social care settings and instances arise when social care providers are required to participate in the Coronial process and attend an inquest – the inquisitorial investigation into the circumstances of a death. Social care providers may be requested to assist HM Coroner with an inquest investigation by providing statements or oral evidence at a hearing. A Coroner has powers to compel the disclosure of any documentation, (including statements, investigation, care records, CCTV, training records) where information may assist the investigation.

Evidence may be required to provide chronological details of the care of an individual, details of a specific incident or event or a response to concerns raised in respect of care provided in the period prior to death.

Similarly, a Coroner will summons a witness to attend an inquest to provide oral evidence, where it is their view that they can assist with addressing the key questions of who, when, where and how an individual came by their death. Witnesses may include senior managers and care workers.

What are the common issues for social care providers at inquests?

The scope of any inquest investigation may vary and will be dependent on the particular circumstances. A social care provider may be required to provide evidence for an inquest as part of a wider inquiry which may include acute hospital trusts, community and secondary care or external organisations and agencies. A social care provider may then be required to play a small part in the inquest process, the evidence provided is however no less important.

Alternatively, the care provided to an individual in a social care setting may be crucial to establishing the cause of death and providing context for a death. In these instances, the evidence provided by a social care provider will be central to establishing the circumstances by which an individual died.

A Coroner’s investigation is concerned with the circumstances of death and this can include a particular incident, the presentation and care management of an individual prior to death or an investigation of particular concerns. Issues considered during the course of an inquest, particularly relevant to social care providers, can (and often have) included a consideration of the overall quality of care prior to death, staffing levels, training and supervision, communication and care planning, assessment and management of risks including in particular the management of falls risk, nutrition pressure sores, medication errors or incidents of abuse or neglect. Often central to an examination of these issues is the importance of clear and accurate record keeping, robust policies and procedures and appropriate training.

A Coroner has a duty to issue a Prevention of Future Death Report /Regulation 28 Report in circumstances where there is a concern that a risk of a future death may arise. This may relate to any issue that is evident during the investigation, causative or not. This duty emphasises the need to investigate and implement any learning following a death. An inquest will often consider the findings of any internal investigation. Providers should be clear that actions that have been undertaken to address any issues identified in an internal investigation to ensure that the risk of a Regulation 28 report is mitigated.

Social care providers should be aware that these reports are published and shared with CQC. CQC may, of course, also attend an inquest and any concerns may then prompt further CQC inspections or enforcement action.

What do you need to consider?

Care providers should consider what support is required for staff (whether management or care staff) in preparing witnesses statements and to provide oral evidence at inquest hearings. If your organisation is requested to provide evidence and/or attend an inquest, consider seeking legal advice at an early stage, this will enable identification of potential risks and criticisms, management of disclosure and any associated regulatory or criminal proceedings, to ensure that appropriate representation is provided through the legal process.

Five top tips for social care providers

  • seek advice and support at an early stage
  • consider whether insurance provision for legal support for inquest is available
  • ensure staff provide contemporaneous accounts of incident/death and continue to ensure disclosure of any documentation is appropriately managed
  • do not underestimate the impact that participation in an inquest may have on staff, ensure staff are appropriately supported throughout the process -from collating written statements and evidence to attendance at an inquest to provide oral evidence
  • ensure that any learning from an incident is fully investigated and addressed

Our dedicated inquests team is here to advise and support you at every stage of the inquest process. Contact the team to discuss how we can help.