On 15 April 2024 the Department of Health and Social Care (DHSC) confirmed that new regulations governing medical examiners have been laid before parliament and a timeframe mapped out for the...

The deadline for all NHS Trusts in England to transition to the Patient Safety Incident Response Framework (PSIRF) - Autumn 2023 - has now passed. The transition to PSIRF, replacing the previous...

The case of Parkin v HM Assistant Coroner for Inner London (East) was published last week. The family has lost their judicial review of the decision of a coroner that Article 2 did not apply to...

*Trigger warning - Suicide* Most claims against mental health providers involving suicide fall into the following categories: Failure to assess...

We set out below themes arising from recent Prevention of Future Deaths reports relating to deaths in prison custody. These trends highlight issues that we see regularly in inquests where we...

The process of regulatory inspection often features strict confidentiality and lengthy paperwork, whilst lacking sensitivity and support. The significant, and often public, consequences of a...

Facing an inquest can be a naturally anxiety-provoking experience. The prospect of providing testimony and navigating the intricate legal process often gives rise to heightened stress and emotional...

On 12 December 2023, the Senior Coroner for Berkshire issued a Report to Prevent Future Deaths (PFD) to Ofsted, Reading Borough Council and the Department for Education (DfE) following the...

The sudden and unexplained deaths of children (SUDC) represent an incomprehensible tragedy, leaving families devastated and grappling with profound grief. Inquests into such cases are inherently...

The Chief Coroner’s Extraordinary Report on the impact of the reforms of the coroner service, 10 years post-reform, was published on 11 January 2024...

Two recent reviews highlight the need for essential changes to be made within the prison services healthcare sector.
These reviews highlight issues that we see regularly in inquests where...

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...