Coroner’s Court – trends from the Annual Chief Coroner and Statistics Reports

• A drop in inquest numbers, 5% fewer deaths being reported to Coroners (11,465) and 18% fewer inquests being opened (7,107, in 2017 compared with the previous year).  It is difficult to say if this is the start of a pattern in decreasing numbers of inquests because of the effect of no longer automatically having to hold an inquest for DoLS (Deprivation of Liberty cases) after 03.04.17 but locally there seems to be no actual reduction in the number of hospital inquests but many more hearings where hospital staff statements are read out under Rule 23 rather than requiring attendance and more complex matters called for a pre inquest review to flush out the crucial issues at earlier stage.
• In April 2019 the proposed Medical Examiner system will be introduced; the pilot schemes showed a significant increase in cases being reported and so we may see a trend in that direction .It now seems likely the ME system will be  focussing on acute secondary Trust deaths than those in primary care or the community
• A decrease of 8% of deaths in state detention including prison, police custody and MHA patients.  A 22% drop in deaths of patients detained under MHA 196 in 2017 compared with 252 in 2016.These are encouraging statistics if the organisational risk management measures and preventative policies are now being more effectively implemented.
• The average time from death to inquest was 18 weeks. It does seem that more straightforward cases are being heard sooner but more complex hospital cases are still being heard 12 months or more after the events.
• There were 375 PFDs (Preventing Future Death Reports) issued .This is an important development. Trusts need to ensure their SI action points are well advanced prior to the inquest hearing if Regulation 28 reports are to be avoided. It does take some time for SI Reports to be finalised if CCGs are involved and wish to impose additional comments and action points.

Some of the statistics are confusing even excluding DoLS deaths there has been about a 50% reduction in Natural Causes conclusions since 2014; is this because of a trend towards more narrative conclusions (unclassified) which Coroners often consider more accurately reflect the more complex multi–factorial medical situations and families feel disappointed at shorter form conclusions.

One steady statistic is the proportion inquests held with juries which remains at between 1% and 2% for the past decade.

Looking to the future, there will be more mergers of small coronial areas into larger areas; discontinuance of investigations where the cause of death is identified through another source other than a post mortem; more Inquests without a hearing where the facts are not contentious and there is no need for oral evidence, with amendment to the guidance for legal aid at inquests, there is likely to be an increase in legal representation at more complex healthcare inquests.

Finally, a 120% increase in non-invasive post-mortem examinations by techniques such as CT scanning has more than doubled in year 2016 to 2017. This is a positive step and gives a more informed pathology conclusion and is certainly less traumatic for grieving families and a safer and more reliable substitute than the traditional invasive autopsy. Why not combine technology with pathology expertise in getting to the underlying medical causes of death.