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:
- Delay to commencement of full inquest
- Circumstances in which the Trust is made an IP
- Quality of administrative support
- Whether an attendance inquest will take place (cf documentary only)
- When and to what extent advance disclosure is provided
- Duration of inquest
- Quality of courtroom facilities, particularly access to wifi and power, access to refreshments, the courtroom being big enough to accommodate the attendees reasonably comfortably
- Conduct of the inquest, particularly treatment of witnesses, adherence to the four questions to be answered, tolerance of aggressive questioning and general tone of the inquest
- Whether a rider of neglect is likely to be added or even considered
- Whether a PFD report will be issued.
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:
- Coroners clearly having made their minds up about conclusions and PFD before hearing the evidence
- Being so persistent with a witness that they eventually agree with the Coroner as they feel they have no alternative
- Allowing advocates to “brow-beat” witnesses
- Giving an introduction that is so long and wide ranging that it pre-judges the evidence and sets a tone that is difficult to deviate from, whatever the evidence
- Deviating substantially from the four questions to be answered
- Not giving advocates the opportunity to make submissions
- Practical issues such as regularly sitting well into the evening (when good planning and efficiency could avoid this).
Looking at positives:
- All Coroners take time to explain things to unrepresented families to ensure that they understand what is happening and have an opportunity to have their say
- One of our Coroner’s areas, Surrey, is a model of an efficient service with good admin support and coroners who are at the same time efficient, incisive, fair and empathetic.
Particular issues for an ambulance service in relation to inquests are:
- Late notice for inquest attendance; a lack of appreciation of the effect of late abstractions on our ability to deliver a safe service.
- Low grade employees (such as 999 call takers) being called to give evidence when the experience for them may be extremely upsetting. We have had more than one example of staff leaving after and as a direct result of giving evidence at inquest.
- A generalised high level of fear amongst ambulance crew of giving evidence. This is partly to be managed in house but is exacerbated by stories of a poor experience proliferating. It must not be underestimated; we have recently experienced a suicide attempt by a staff member, the “tipping point” for which was being called to give evidence at inquest.
- Lack of appreciation of what is and is not within the trust’s power. Where the issue at an inquest lies with a national system such as the national triage tool, the right body is often not involved.
- Such delay in cases coming to inquest that staff no longer have any recollection of the incident; despite informing the court that they will be able to add nothing to their written notes, still being called to give evidence in person.
- We have limited resources – being made an IP in an inquest where we have played a very small part places a huge burden on the service.
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:
- A much higher number of requests for evidence and calls coming from this Coroner’s area than any other
- Receipt of a large number of requests for evidence for incidents that SECAmb have not attended or been involved with in any way
- Being given on occasions directly conflicting information by more than one member of the admin team
- At inquest or PIR, the attending admin person not knowing what documents have been received from whom and generally not knowing the case well.
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:
- Only issue them when they are going to achieve something. If the Coroner has heard in evidence that appropriate changes to practice, policy or procedures have already been made or are actively in the process of being made, a report is ineffective. At times, responses to PFD reports just reiterate what was said in evidence as changes have already been made. This is not effective.
- Issue the PFD against the right body. There is little point in issuing a PFD against an individual trust when they were following national guidance or systems, or where their failings resulted from a simple lack of funding. To be effective, the PFD needs to be issued against the body that can actually make a difference.
- By aiming at national bodies rather than individual trusts, more deaths will be prevented. I would suggest the use of PFDs more for larger scale issues and less for local issues. Alternatively, there could be two levels of PFD report – local issue and national issue.
- Improve the method of dissemination of PFD reports – perhaps a periodic (monthly) round up of keys issues addressed distributed to all trusts’ Heads of Legal and Heads of Patient Safety? I appreciate that all PFDs are available on the Chief Coroner’s website but this requires individuals going to the site and searching rather than the data being sent to them. The website is not easily searchable under practice area or issue.