Coroners Court

1. Coroners Court Our experience of coroners court Laura Akehurst and Kat Foster

2. Objectives of the session • Brief explanation for attending coroners court • and the inquest process • Case Study- Mrs M • Discussion of our experience at Coroners Court • Reflection and lessons learnt

3. What is a coroner? • A specially trained doctor or lawyer who can investigate the • cause of someone's death. • A doctor may report the death to a Coroner if the cause of • death is unknown, the death was violent, unnatural, sudden • or un-explained. • The coroner may conduct or order and inquest into the manner • or cause of death. • A coroner must hold an inquest if the cause of death is still • unknown or if the person dies a violent or unnatural death or dies in • Police custody or prison.

4. What is an Inquest? An inquest is a public court hearing, held by the coroner in order to establish who died, how they died, when they died and where they died. The coroner contacts all relevant people prior to the inquest and asks them to provide a written report of their involvement with timescales. The legal team within CCC facilitate and support with this. This is what happened with our case study Mrs M.

5. Case Study Mrs M was a 92 year old lady who lived alone with local family support, she had a mattress variator via Adult Social Care, no long term care or other support. She lived in a house with bathroom and bedroom upstairs. She was recently in hospital with a chest infection and had a reablement package from discharge. She had heart problems Osteoporosis and irregular heart rate which could cause drop in blood pressure. No cognitive impairments. She was independently mobile however, it was noted her mobility had deteriorated since an admission to hospital. .

6. Case Study Her family reported that she wanted to remain as independent as possible and wished to continue to sleep upstairs. Adult social care sent out a self assessment form for the maintained equipment. When this was returned it highlighted that she was struggling on the stairs and requested an OT assessment. A new contact was logged and allocated to an OT. Before the initial visit was carried out Mrs M was found deceased at the bottom of the stairs by a re-ablement worker in June 2018. Due to our recent involvement OT Staff were contacted by the Legal team at CCC and asked to prepare a written statement for the coroner.

7. Statement

8. What happened next? • Coroner received all written statements and can call on practitioners to read their statement and answer any questions. • As the inquest is public we thought it would be beneficial to attend. • The inquest was held at the coroners court in Cockermouth, family members and representatives of other agencies were present. The inquest was held in December 2018 ( 6 months after the customers death).

9. Our experience • Evidence has to be sworn in and witnesses have to swear on the bible that this information they are providing is true. All the written reports were sworn in as evidence and all proceedings were tape recorded. • This included family members. • Firstly, the coroner requested the family gave background information regarding Mrs M and confirmed her identity, they also gave a description of her life and the type of person she was. • Other statements from police , doctors, hospital staff and reablement workers were read out and sworn in as evidence. • It was determined that the police investigated the death and determined there were no suspicious circumstances.

10. Our experience • From the statements a timeline of events was established. • The self assessment document was added into evidence of the case as well as the written statement from Laura. • Once all the reports had been verbally admitted as evidence the coroner then retired to review the evidence and determine the cause of death. In this case this took about 15 minutes although this could take longer. • Cause of death was accidental death from head injury. Cases at coroners court are not criminal, this is solely to determine the cause rather than blame. • This inquest lasted about 2 hours.

11. Refection using Gibbs Reflective Cycle and Emoji’s 

12. Feelings Before Worried Why Me? Have I done Everything I Should have Anxious about criticism

13. Feelings During Feelings After Emotional Relief More prepared if happened again Interested in The process

14. Evaluation and Analysis Interesting experience however not one we wish to have again soon More confident with the process Highlighted that all cases can potentially go to Coroners court not just complex cases so your input could be requested at anytime Consideration as to how we can prepare ourselves for future inquests on an organisational team and Individual level

15. Conclusion & Action Plan Organisational Level At an organisational level we wanted to spread awareness of the process. Team Level We checked that all self assessments are up to date, they are completed by the OT Team, we have a spreadsheet which accurately records these to ensure they are completed in a timely manor and that time is set aside to do this. Individual Level We have discussed in team meetings the importance of accurate, timely and up to date case notes.

16. Thank you Any questions?