FATAL Campaign

Families Advocating Transparency in Autopsies of Loved Ones

Concerns over inquest ‘failures’ after hospital deaths

15th November 2011

Some coroners in England and Wales are failing to fully investigate hospital deaths, the BBC has been told. Coroners have absolute discretion over how to conduct inquests, including which evidence to consider and which witnesses to call.

It has emerged that many do not routinely examine medical records. The government admits there are inconsistencies in the system, but says new legislation will tackle the problem.

Stanley Mack, 77, from Birmingham died in hospital after contracting clostridium difficile in 2008. His family wanted his death investigated after discovering vital drugs had not been given and routine observations missed.

They hoped an inquest would answer some of their concerns and asked for a number of medical staff on the ward to be called as witnesses. But the coroner refused and the only doctor called to give evidence was a consultant who had not seen Mr Mack in the 12 days before he died.

The coroner recorded a narrative verdict saying while there were shortcomings in Mr Mack’s care, it did not amount to neglect. The family were so concerned at the coroner’s conduct of the inquest that they challenged his decision in the High Court to try to get a new inquest, but lost.

However, earlier this year the court of appeal found in their favour. A new inquest will be held next year.

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