Other Inquiries into a Death

The Coroner’s inquest is not the only type of inquiry examining the circumstances in which a death occurred. There may be an internal investigation by the relevant authority or other statutory agencies may enquire into the death. In some circumstances a complaint may also trigger an investigation.

Deaths of a patient under care of healthcare providers

If the care of the deceased had been provided under the auspices of the National Health Service the NHS Complaints procedure may be invoked for the purpose of making a complaint about the provision of care.

The first stage of the complaints procedure (‘local resolution’) requires a complainant to make a complaint to the local healthcare provided (i.e. the hospital or General Practitioner who is the subject of the complaint) within six months of the event or within six months of knowing that there is something to complain about. The time limits may be waived if there is a good reason why the complainant was not able to complain sooner. A Patient Advice and Liaison Service (PALS) has been established in every NHS Trust and Primary Care Trust and information and advice may be sought from the PALS with this stage of the procedure. If an NHS Foundation Trust provided the care, this first stage may differ and advice should be sought from the Trust about how to complain. If the complaint is about social care, the complaint should be sent to the relevant social care organisation.

If a complainant is dissatisfied with the outcome of the complaint at local resolution, the complainant has the right to request an ‘Independent review’ from the Healthcare Commission (this is an independent watchdog for healthcare in England). The Healthcare Commission will only look at complaints arising from the local resolution stage if the request for a review is made within six months of the decision at local resolution. Complaints must be made in writing and if relating to the care of a dead person, the Health Commission will need to obtain the permission of the personal representative to obtain documents about the complaint.

If the complainant is still dissatisfied after local resolution and independent review there is a further right of complaint to the Parliamentary and Health Service Ombudsman.

Help with complaints relating to NHS healthcare can also be obtained from the Independent complaints advocacy service (ICAS) or from NHS Direct on 0845 4647.

There are no corresponding provisions for complaints about the care of a patient who died whilst under the care of private healthcare providers. However, independent clinics and hospitals registered with the Healthcare Commission are required to have a policy to deal with complaints. A complaint should in any event be made at local level to provide an opportunity for the healthcare provider to deal with it. A complainant who remains dissatisfied may complain to the Healthcare Commission, the Independent Healthcare Forum or Trading Standards.

Deaths in police custody

After a person has died in police custody, the Association of Chief Police Officer’s guidelines recommends that a Senior Police Officer should secure the scene, contact the Scenes of Crime Officers and contact the Coroner. A Senior Investigating Officer should be appointed to initiate an investigation.

A death in police custody should be reported to the Independent Police Complaints Commission (IPCC). The local police force may decide to investigate the death or the IPP may decide to supervise or manage the investigation, or in the most serious cases, may investigate the death itself. A complainant has the right to be told about how the complaint will be dealt with, what action may be taken and what the outcome is.

See also HOW TO ENFORCE YOUR RIGHTS

Deaths in prison

The Prisons and Probation Ombudsman will investigate deaths of residents of prisons, probation hostels and immigration detention centres. The Ombudsman is independent of the prison and probation service and will make recommendations if failings are found. A family liaison officer will be appointed and will keep the family in touch with what is happening in the investigations. At the conclusion of the investigation a draft report outlining the findings of the investigation will be produced and sent to the family as well as the relevant body. There is then an opportunity to comment on the draft before the final report is published. A copy of the final report is also sent to the family.

The police service may also conduct their own investigation into a death in custody in appropriate circumstances.

Deaths in custody are reported to the Coroner, who will sit with a jury at any resulting inquest.


Deaths of patients detained under the Mental Health Act 1983

If a patient is compulsorily detained under the Mental Health Act there will be an internal investigation into the death and if there is evidence to suggest that the patient was the victim of a homicide the police must be informed.

It is not mandatory for the death of a patient detained under the Mental Health Act to be reported to the Coroner, but such deaths must be reported to the Mental Health Act Commission within three working days of the death. The Mental Health Act Commission reviews deaths of detained patients to establish whether good practice was followed and whether lessons need to be learned.

Other inquiries

The Home Secretary has power to set up a public inquiry, usually if the circumstances surrounding the death/s are of significant public importance. There is statutory provision for discretionary inquiries, including into railway accidents, road traffic accidents, accidents in railway construction, and deaths on ships registered in the United Kingdom.