Harmonising investigations: The importance of a collaborative relationship with the coroner's officer

I have been fortunate in being able to work on secondment at an NHS client trust for the past 19 months. This experience has allowed me to see the pressures clients feel from the moment that they are first notified of an inquest. 

A large part of any Trust secondment role includes liaising with Coroner’s Officers to action the directions of the Coroner during the preliminary investigation stage and up to the actual hearing. It is important that a relationship is built with the Coroner’s Officers to foster effective triangulation between an organisation, Coroner and the deceased’s family. 

The role of the Coroner’s officer 

The role of a coroner’s officer is a crucial part of the coronial system. Coroners are officials responsible for investigating and determining the cause of sudden, unexpected, or unexplained deaths. Coroners’ officers work closely with coroners to facilitate the investigation process.

Key aspects of the role of a coroner’s officer:

Initial Response: Coroners’ officers often play a role in the initial response to a death. They may be called to the scene of a death to gather preliminary information and coordinate with other relevant agencies.

Communication: Coroners’ officers act as a liaison between the coroner’s office, the police, medical professionals, and other agencies involved in the investigation. They ensure that all necessary information is gathered and shared appropriately.

Witness Interviews: Coroners’ officers may interview witnesses to the events leading up to the death, gathering statements and information that can assist the coroner in making a determination.

Documentation: They are responsible for maintaining accurate and detailed records of the investigation, including statements, reports, and any relevant documents. This documentation is crucial for the coroner’s findings and any potential legal proceedings.

Post-Mortem Arrangements: Coroners’ officers may assist in coordinating post-mortem examinations, working with pathologists to ensure that necessary tests and examinations are carried out to establish the cause of death.

Support for Families: Coroners’ officers often provide support and information to the families of the deceased. This may include explaining the coronial process, providing updates on the investigation, and answering any questions the family may have.

Court Preparation: In cases where an inquest is required, coroners’ officers assist in preparing the necessary documentation and evidence for the coroner’s court. They may also act as witnesses during the proceedings.

It’s important to note that the role of a coroner’s officer may vary depending on the specific coroner’s office and the nature of the death being investigated.

The importance of the liaison between organisation and Coroner’s office 

The way in which you prepare for inquests offers the Coroner and their officers a reflection of the organisation as a whole. Therefore, the quality and timeliness of the production of evidence is essential. 

Top tips

Here are my top tips in strengthening your organisation’s relationship with the Coroner’s Office:

1. Timely responses
    
   1. Respond to the initial directions within 48 hours of receipt. 
       
   2. Disclose statements (where possible) within 21 days of the directions order (or sooner if directed).
       
2. Communication
    
   1. Delays are sometimes unavoidable, but let the Coroner’s officer know at the earliest opportunity. 
       
   2. If you need a quick response, give them a call. 
       
   3. Provide updates along the way, especially for cases that are particularly complex and have many witnesses. 
       
   4. Understand how much communication they need and would like 
       
3. Quality of Disclosure
    
   1. Ensure there is a thorough review of all evidence prior to disclosure. 
       
   2. Do not send documents in a piecemeal manner, ensure full disclosure is effected, wherever possible, in one email. 
       
   3. Use the same format and template for all statements. 
       
   4. Do not disclose statements in which the author is unavailable for inquest, unless this cannot be helped. 
       
   5. If the disclosure is lengthy, paginate the bundle prior to sending to the Coroner’s office
       
4. Do not be the reason for adjournment
    
   1. Set internal deadlines so disclosure can be fulfilled ahead of the due date. 
       
   2. If there are any issues, give the Coroner’s office a call, followed up by an email.
       
   3. If you foresee an issue, escalate within the organisation to come up with an appropriate resolution, eg Investigation Lead unavailable for inquest. 

Conclusion

Fostering a strong and collaborative working relationship with the coroner’s officer is paramount for ensuring the efficient and effective conduct of an inquest. The benefits derived from this partnership extend beyond mere procedural facilitation, contributing significantly to the overall integrity of the investigative process. Through open communication, timely information exchange, and mutual respect, organisations, legal professionals and the coroner’s office can create an environment conducive to thorough and impartial investigations.