Acting to stop harm: the FCA and Appointed Representatives
Today, the Health Secretary announced “a new maternity strategy to reduce the number of stillbirths”. This strategy centres on the investigation of still birth deaths by the new Healthcare Safety Investigations Branch but it also included a planned change in the law to allow coroners to investigate full term still birth deaths. Currently there is no requirement for a doctor to refer a still birth death to the local coroner.
Today’s announcements come amid on-going concerns about the numbers of babies who have died in the UK due to problems in labour and birth. Although the rates have decreased over the last 25 years due to improvements in care, there are still concerns about the number of these deaths that are preventable and that reflect mistakes made by staff. A recent report by MBRACE-UK included the finding that in 8 out of 10 deaths different care might have saved the baby’s life.
Recently the Chief Coroner voiced concerns about the inadequacy of the law in England and Wales on referrals of still born deaths to coroners. There is no legal requirement for doctors to refer the death of a still born baby to the local coroner which is a lost opportunity to improve the safety of maternity care. In his last Annual Report he highlighted the lack of statutory or other clear criteria for medical practitioners reporting deaths to coroners. This ‘lacuna in the law’, as he described it, is an obvious cause of the inconsistent policies developed by senior coroners for reporting deaths locally. Some local coroners request doctors to report all still births and all child deaths but there is no legal basis for this approach and it is not uniformly adopted. This means that coroners are not routinely investigating still birth deaths and so the reasons why babies die in unexplained circumstances are not being discovered and lessons are not being learnt. Not only does an inquest bring to light the causes of deaths but it also requires coroners to make a formal Report to Prevent Future Deaths where concerns are identified. Such a report is public and sent to those with the power to make changes highlighting the practical steps that need to be taken with the intention of improving public health, welfare and safety.
Section 18 of the Coroners and Justice Act 2009 enabled the Lord Chancellor to make regulations requiring medical practitioners to refer deaths to senior coroners. However, before doing so, the Lord Chancellor was required to consult the Secretary of State for Health and the Chief CoronerAnchor. The Chief Coroner reported that discussion had commenced on considering whether stillbirths/near term deaths should be reportable cases but that any changes would be likely to require primary legislation. Today’s announcement in the House of Commons promises that these changes will be made after further consultation with the Ministry of Justice. The Health Secretary suggested in his response to questions from the House that this consultation might include considering whether or not “specialist” coroners will be needed in order to properly investigate these types of death.
 Para. 120 ibid.
 Paragraph 7, Schedule 5 Coroners and Justice Act 2009
Inquest proceedings, like other legal proceedings in the UK, have been significantly affected by social distancing restrictions and advice arising from the COVID-19 crisis. This blog looks briefly at the impact of the Coronavirus Act 2020 on proceedings, and examines the Chief Coroner’s guidance notes to coroners working during the crisis.
Inquests are always very sad affairs, and when the court is considering a suicide, it is particularly difficult for the loved ones of the person who has died.
At the end of the inquest in 2014 into the death of Ella Kissi-Debrah, the coroner concluded that this nine year old girl suffered an asthma attack, followed by a seizure, and died after unsuccessful resuscitation. This is one possible answer to the question of how Ella died. However, there is clearly a bigger question which needs to be answered.
As we discussed in our recent blog, some inquests will automatically be designated ‘Article 2 inquests’ if the deceased died whilst under the control of the state. Other inquests will only become Article 2 inquests if there is evidence of systemic failures of processes and systems to protect life. Therefore a case of ordinary medical negligence would not trigger Article 2, as confirmed in Parkinson  4 W.L.R 106.
In June 2018 the government announced that some bereaved families should find it easier to access legal aid funding for representation at inquests. The updated guidance issued by the Lord Chancellor allows caseworkers to waive the financial means test “for cases where the state has a procedural obligation to hold an inquest under Article 2”.
In February 2019 in its Final Report on the Review of Legal Aid for Inquests, the Ministry of Justice confirmed that it would not be introducing automatic public funding for families at inquests where the state is legally represented. This is hugely disappointing news for families, such as the family of PC Palmer, who have experienced the reality of an inquest where the state has the benefit of a highly experienced and well-resourced legal team while they are left to try and find lawyers prepared to represent them for free.
The husband and children of the school teacher, Ann Maguire, who was murdered by a pupil, William Cornick, in her classroom in April 2014 have been unsuccessful in their attempt to appeal against the decision of the High Court to dismiss their claim for judicial review of a decision of the Assistant District Coroner for West Yorkshire.
Today, the Health Secretary announced “a new maternity strategy to reduce the number of stillbirths. This strategy centres on the investigation of still birth deaths by the new Healthcare Safety Investigations Branch but it also included a planned change in the law to allow coroners to investigate full term still birth deaths. Currently there is no requirement for a doctor to refer a still birth death to the local coroner.
In the recently reported case of R (Silvera) v HM Senior Coroner for Oxfordshire  EWHC 2499 (Admin), the Divisional Court looked at the investigative duties placed on the state by Article 2 of the European Convention on Human Rights and the importance of the coronial process in ensuring that those duties have been met.
The recent decision of Mr Justice Holroyde in R oao Donald Maguire and ors v The Assistant Coroner for West Yorkshire (Eastern Area)  EWHC 2039 provides a salutary reminder of just how difficult it is successfully to judicially review the ‘case management’ decisions of a coroner – in this case a decision as to which witnesses to call at an inquest – and of the costs risks of bringing such a challenge.
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