Written evidence from Ms Eva Pendreich, Head of Legal Services, South East Coast Ambulance Service NHS Foundation Trust

As Head of Legal Services for an ambulance Trust covering four counties and a unitary authority, I regularly attend inquests over these five different Coroners’ areas and appear before around 20 different Coroners on a regular basis.

The lack of consistency between the areas is stark, in the following realms:

The lack of consistency does undoubtedly result in a different outcome being achieved depending on location. In two of my coroner areas a PFD will be issued where the same case in the other three would not attract one. This cannot be right.

To focus on conduct of the inquest, issues include:

Looking at positives:

Particular issues for an ambulance service in relation to inquests are:

With regard to Coroner support/administration, four of our five principal coroners’ areas operate the traditional model of allocating one Coroner’s Officer to a case; that person will prepare the case with the Coroner and attend the inquest. This provides a good knowledge of the case, helpful continuity and aids good preparation as the Officer understands the case and can relieve the burden on the Coroner.  Many Coroner’s Officers are very experienced and knowledgeable.  In one area, Kent, the traditional model has been replaced by a different approach, whereby preparation and queries are dealt with by a team of less experienced admin people who are not allocated to a particular case.  Emails go to a group and can be picked up by any member of the team.  This model appears less satisfactory for the “user” and the Coroner, who ends up doing more of the case management and preparation themselves. No-one other than the Coroner has responsibility for the case until quite close to the inquest.  This system has resulted in:

In another of our Coroners’ areas, the Coroner has very little admin support indeed and this is the area where we see the longest delays in bringing cases to final hearing. One inquest, in respect of which the death occurred in July 2016, still remains far from listing and could well go on for another one to two years.

Prevention of Future Deaths reports

As stated above, the issuing or PFD reports is also inconsistent. Each area seems to have a (possibly unwritten) policy on whether they regularly issue PFD reports or not. My suggestions for the strengthening of the PFD regime are as follows:

August 2020