Powers of a Coroner

The Coroner of an Inquest has a number of options open to them, one of the options is to issue a Prevention of Future Deaths Report.

As occurred recently following the tragic death of a four‑year‑old which has prompted renewed calls for improved digital integration between hospitals and primary care. The inquest concluded that the little boy, from Northampton, “probably would have survived” if doctors had been able to intervene earlier—an outcome the coroner believes was hindered by limited access to vital GP records.

The Coroner has a legal power and duty to write a report following an Inquest if it appears there is a risk of other deaths occurring in similar circumstances.

One of the most concerning issues raised in the coroner’s Prevention of Future Deaths report was the limited access hospital clinicians had to the child’s medical background. Hospital systems could only view very basic summaries of GP interactions—such as simple lists of appointments and prescribed medicines—but lacked access to detailed clinical notes from primary care and community services.

Every doctor who gave evidence during that inquest agreed that greater access to primary care records would have significantly supported their decision‑making, giving a more complete picture of the young boy’s health.

The coroner warned that without seamless information‑sharing, the NHS risks forcing staff to “work in silos,” increasing the likelihood of crucial details being missed—especially when a patient or their family may struggle to provide a full medical history in an emergency.

Comment

This case demonstrates the real‑world consequences of that gap. When clinicians cannot see a patient’s complete medical background, diagnosis and treatment may be delayed—sometimes with devastating results.