Earlier this week, Mills & Reeve held two day-long events on Coroners' Inquests. Over one-hundred and twenty clients and contacts attended sessions in either Birmingham or London, for discussions on topics including disclosure of evidence to Coroners, preparing for hearings and proposals for change to the system.
It was interesting to note that a number of commissioners attended the event despite inquests typically being of greater concern to healthcare providers. In part this was no doubt because of the recent publication of the Francis Report. There is going to be increased focus on the role of commissioners in driving and maintaining quality in patient care.
In discussions with a Coroner who attended one of the events he agreed that where there appears to be a pattern of similar deaths or a death in circumstances where doubt had already been raised about a provider's ability to provide safe care there is an increasing likelihood of commissioners being required to attend an inquest. They would be asked explain what they had done to resolve concerns or satisfy themselves that the care they were commissioning was safe.
Commissioners have already been called to inquests to justify their decisions - Mills & Reeve acted in the inquest into the death of David Gray a patient killed by a huge overdose administered by a foreign out-of-hours GP - but such cases have been rare. Following Francis we expect these cases to become more frequent. Inquests are public hearings with the press usually in attendance. CCGs will need to ensure that where they know of concerns about safety and quality they take sufficient and appropriate action and that they record what they have done.