Written evidence from East Suffolk and North Essex NHS Foundation Trust



Identified potential remedial action point(where applicable) or further detail


A lack of consistency in approach both between different Coronial jurisdictions and between Coroners within a district.


There is variation between Coronial districts and this would benefit from improved standardisation by a more supervisory Chief Coroner role

A set of directives from the Chief Coroner for all Coroners to work to setting out what deaths are required to be reported. Rather than having a list of different causes of death It would be easier to stipulate parameters for issuing a certificate: In order to complete a medical Certificate of Cause of Death a clinician must have attended the deceased during their last illness, attended the patient in the 14 days prior to death or examine the patient after death and must be able to state a natural cause of death as the cause.


The Coroners service should be responsive to legislative changes and work with the secondary care service in a cooperative and helpful manner whereby we understand mutual needs and work towards benefitting the bereaved



Where a cause of death is not obvious there should be no pressure applied on the junior medical doctors to come up with a cause of death that is inaccurate*

Anecdotally there have been a number of occasions where a cause of death has been offered and the attending clinician has completed the certificate but the stated case would not be accepted at the Registrars without a Form A100 from a Coroner. The common example is 1a Pulmonary Embolism 1b Deep Vein Thrombosis 1c Fractured Neck of femur. On several occasions the certifying clinician has been asked by HMCO to move the 1c onto section 2 of the certificate as a contributing factor to “avoid the need for a post mortem”. However, though the clinician has often felt this is incorrect they have frequently felt pressurised by HMCO to amend this even though they do not feel this is accurate.


Enable access to Coroners PM reports – in cases where it enables improvement in patient safety and learning


There is growing concern where Coroners withhold post-mortem findings until Inquest statements are submitted that the inherent delay in this process is greatly detrimental to clinical governance within hospitals. What is reasonably considered by Coroners as ensuring unbiased information for inquests is, paradoxically, likely to be detrimental overall for patient safety

This can be particularly helpful where there is an on-going internal investigation or a complaint has been lodged against the hospital by the family. Often information from post mortem findings can help understanding of what went wrong. It can also be reassuring for clinicians (particularly for post-operative deaths) where the post mortem findings establish that nothing untoward occurred with the actual procedure/surgery


Improved dialogue with the ME service is necessary.

There is an unnecessary separation between Coroners and Medical Examiners. Closer working relationships would benefit both groups and allow cross-pollination of ideas and improved efficiency

Quarterly meetings between Lead MEs and HMCO to discuss service improvements, service issues, complaints, recurring themes, patient safety issues and learning points


Not being able to ring and speak to a coroner's officer to discuss cases as before is a real issue - online referral does not allow the 'nuance' of the situation to come across (more relevant to hospice/community deaths)

I think this is a national problem, but we do get a lot of people call the mortuary because they cannot get through to the coroner’s office. We now have very limited information on circumstances of death, since the police report no longer goes to the mortuary. It is frustrating for both us and the families to tell them, sorry we don’t know, keep trying the coroner’s office. We have on occasion been told, ‘Sorry this is not my case and that coroner’s officer has now gone home’ This is frustrating for both us and families.

Dedicated “hotline” for doctors to dial in on. *It is also difficult for Coroner’s Officers to contact doctors. Therefore dedicated lines at GP surgeries/hospital sites would also be helpful


Patients with COVID denied access to post mortem where something else has caused the death eg during surgery, following a fall

*Suspect this was more down to government issued guidance and guidance from RCPath than dictated by HM Coroner.


No flexibility around certain causes of death, eg pt who became lithium toxic due to dehydration and died of renal failure - options are PM/inquest or not to put the drug on certificate. Neither option feels right.

Form A issued and Inquest


After referral, delay in making decisions on whether the case will be taken by coroner or not. Made worse with COVID, currently 1-2 weeks in community.  Impact on the bereaved, as they have no idea when they will hear and if further action is needed

Ensuring sufficient staffing resource is available to conduct enquiries. Improving efficiency through use of MEs to more effectively “filter” unnecessary referrals, dedicated telephone lines to contact clinicians/HMCO


Coroner’s Officers being based remotely makes communication and information sharing problematic in many cases

Historically there were Coroner’s Officers based within Mortuaries/Bereavement Services at acute hospital sites. This enables first hand access to Coroner’s Officers of all available Health Records, face to face discussion with clinicians and families and identification statements to be taken efficiently and by someone trained specifically in this task. Identification statements are often delayed through waiting for police to attend and relaying these to HMCO from the police does not always occur in a timely manner; thereby creating further delays with investigations.


Lack of oversight or sharing with regard to performance data

If all Coroners had to report their activity and performance data on a monthly basis to the Chief Coroner and this was also shared with stakeholders this would give greater visibility and accountability. A “league table” made available to the general public would also be useful


Data sharing difficulties and delays often occur and cause additional distress and delays for bereaved people.

Making better use of IT solutions such as Sharepoint for information sharing rather than using email to exchange information.


Having a Coroners web based database for all Coronial activity with restricted access for stakeholders to upload information and refer deaths. Having everything on one platform nationwide would also provide a means for national performance and activity reporting, trends and themes being better detected and understood. The system in Australia operates one Coroner’s database covering the whole country.


If the role of the Coroner is to help prevent unnecessary deaths, the criteria for and scope of inquests would need to be much greater.

For example there are a number of ‘violent’ deaths (e.g. hip fracture) which must be referred but cause no concerns, whereas many deaths which do not mandate referral  (e.g. neonatal) would probably benefit more from routine Coronial scrutiny



Coroner’s knowledge of medical terminology, medical treatment and procedures is variable.

Coroners having access to Consultant Histopathologists and Medical Examiners for advice on medical matters would be helpful


Declining number of Consultant Histopathologists undertaking post mortem work. Increased pressure from cancer reporting activity on these individuals also impacts on ability to support Coronial activity.

It would be beneficial if Coroners had a pool of pathologists who undertake Coroner’s Post mortem work and who cover the Coroner’s whole jurisdiction. This removes a dependence on hospital based/employed consultants and supports independence and transparency.


September 2020