DAUK writes to Chief Coroner with concerns over guidance on healthcare worker inquests

The Doctors’ Association are the first to write to the Chief Coroner today about the guidance he published on 28th April 2020 into the investigation of healthcare worker COVID-19 deaths. We felt that the guidance sought to limit the opening of inquests into deaths caused by coronavirus and also the scope of those inquests that are opened. It is alarming that the guidance suggests that most deaths of healthcare workers caused by COVID-19 should not receive any investigation at all.

The letter is published in full here:

Dear Chief Coroner,

We note with great concern your guidance to coroners issued on 28 April, which we read as seeking to limit the opening of inquests into deaths caused by coronavirus and also the scope of those inquests that are opened. The guidance suggests that most deaths of healthcare workers caused by COVID-19 should not receive any investigation at all. It is wholly unacceptable that the families of those who have laid down their lives for the good of our country should be left with no formal investigation into their deaths and the failings which may have led to those deaths. What is more, the guidance you have issued appears to be contrary to the legal requirements imposed on coroners by statute.

Any death of a healthcare worker due to coronavirus raises questions which need to be answered. These include whether the virus was contracted in the workplace and, if so, whether poor operational decisions by hospitals/trusts or inadequacies in the provision of personal protective equipment were contributing factors. In cases that engage the Article 2 investigative duty, which the deaths of healthcare workers may well do, any coroner will need to have regard to his or her obligations under Article 2, including their duty to consider arguable systemic failures.  These questions may, in some cases, raise wider issues of policy which coroners conducting individual investigations are not equipped to answer in the context of a single inquest. To that extent we welcome your suggestion that coroners could, in appropriate cases, pause their individual investigations to allow the rights and wrongs of wide-ranging policy decisions to be examined in a more appropriate forum. We have already led the call for a full public inquiry into PPE provision and healthcare worker deaths to be held in the aftermath of the crisis.

We believe, however, that every death of a healthcare worker caused by the coronavirus requires the opening of an inquest. Your guidance refers to the statutory requirement that an inquest be opened where a coroner has reason to suspect that a person died an unnatural death, which includes a death from a natural disease where human error has contributed to the death. As you rightly point out, the threshold for assessing whether a death was unnatural is a low one. Unless and until there has been an appropriate investigation into operational procedures at hospitals and PPE provision, it remains an open question in respect of every death of a healthcare professional due to COVID-19 whether human failures were a contributing factor.

We are extremely concerned by your suggestion that coronavirus deaths of healthcare workers will not usually require investigation. We believe that it may deny grieving families the answers to which they are entitled. Unless inquests are opened in each case, vital evidence in relation to that individual case will not be preserved and the opportunity to find out what went wrong will be lost irretrievably.

We invite you to review your guidance and to amend it to ensure that it properly reflects the legal position and that these bereaved families receive access to the investigative procedures to which they are entitled.