Coroners In England Issue Rare Warnings Over Avoidable Deaths During The Pandemic

Over-stretched services struggling to adapt to Covid-19

It is no surprise that during the pandemic that services, ranging from mental health and coastguard services to care homes, were over-stretched and struggled to adapt to the fast-changing conditions brought about by Covid-19. However, coroners in England have now said that lessons need to be learned from the failings made from these services, as details of inquests into deaths have recently come to light.

The Government previously said they were not ‘fully prepared’ for the wide-ranging impacts the pandemic had on society and services, which had to swiftly change the way in which they were operating.

The Guardian has reported that coroners are now highlighting failures made during the pandemic through reports that identify avoidable deaths.

These types of incidents, known as reports to prevent future deaths, are issued as rare cases and state if changes are not made then another person could die. The reports referenced by coroners include:

• A 41-year-old woman died in secure accommodation in Birmingham. Two months prior to her death, she was due to commence with electroconvulsive therapy, but due to an administrative error, the treatment was cancelled and thereafter could not take place as a result of coronavirus restrictions. An inquest jury found that had the woman received the treatment, then she would most likely have lived.
• A frail elderly woman thought to have contracted Covid-19, who fell and died in a care home after she was put into self-isolation. A coroner said the care home wasn’t suitable to care for the woman during her period of isolation as it wasn’t equipped to monitor her, which she required due to her risk of injury if she was left alone.
• A 54-year-old man died whilst sea kayaking after getting into difficulty. A coroner said that his death was partly due to the fact that there was a reduced level of coastguards on the Cornish coastline which was a result of the pandemic. The senior coroner for Cornwall and Isles of Scilly wrote in his report:
  
  “If the pandemic has caused a reduction in the level of coastguard protection in comparison to 2019, how has this been mitigated? Is the amount of cover now at an acceptable level?”

Coroners and Justice Act 2009

Under the Coroners and Justice Act 2009, coroners are obliged to issue a notice if they believe shortcomings by a person, organisation, or public body – such as a hospital trust, council, or Government department – could result in other people dying unless urgent action is taken.

At least 16 deaths have alarmed coroners to the point of issuing warnings. These reports highlight the hidden impact the pandemic has on vulnerable people and how measures need to be implemented to ensure people don’t keep dying when it could have just been avoided, if systematic failings are identified these need to be acted upon by relevant public authorities.

Preventing further death reports

Following an inquest, a coroner can make recommendations to prevent future deaths from occurring, known as ‘Preventing Future Deaths Report’ (set out in paragraphs 28 and 29) of the Coroners (Investigations) Regulations 2013.

The respondent is given 56 days to reply in writing, giving details of all actions that have been proposed to be taken, or an explanation as to why no action will be taken to prevent future similar deaths.