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Inquests Be Prepared!

The number and range of Inquests seem to have increased dramatically in the last decade. One of the influential factors in this growth has been the need for Courts to comply with the European Convention on Human Rights, since the introduction of the Human Rights Act 1998. Article 2 of the Act, that provides that “everyone’s right to life shall be protected by law”, has imposed greater obligations on Coroners, in their capacity as representatives of the State, to ensure that the Inquest provides for a full and thorough investigation of the deceased’s death.

Many of the recent cases that have come before the High Court, where challenges have been made to the decisions of Coroners, concern mental health patients. This is particularly so where death has occurred in prison. Increasingly, the Coroner is called upon to consider systemic issues in the context of investigating such deaths.

The consequence of such developments is that Inquests are now frequently much more detailed and last longer than they did prior to the introduction of the Human Rights legislation. This situation means that, even more than previously, the need for good record keeping is essential. If a healthcare professional fails to maintain good records and/or makes a very inadequate entry in the records at a relevant time then this can have a seriously detrimental effect on the outcome of the Inquest. Many Coroners take the view that “if it isn’t written down it didn’t happen”.

Most Coroners will seek disclosure of relevant documentation prior to the Inquest, including for example any correspondence that took place prior to the Inquest between a Commissioner and provider of care about perceived failures in services, or correspondence with the regulator, the Care Quality Commission. It is therefore important to consider that this correspondence may become public when drafting it.

RadcliffesLeBrasseur provides an experienced team who specialise in healthcare to assist in the preparation for and representation at Inquests. In addition, members of the team regularly provide training on notetaking; this training has been recognised by many healthcare staff as being extremely useful in alerting them to the pitfalls of poor record keeping. For the reasons explained above, proper record keeping is a matter of good practice. However, where circumstances arise that cause a Coroner to investigate the death of a patient, inadequate records can lead either to public criticism or an adverse verdict on the Inquest.

Alexandra Johnstone
© RadcliffesLeBrasseur
January 2011


This briefing is for guidance purposes only. RadcliffesLeBrasseur LLP accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.