Care Home Management

The Care Home Decision Makers’ Magazine

Insight & Analysis

In the event of a death

In the event of a death in care homes, social care providers may be requested to assist HM Coroner with an inquest investigation by providing statements or oral evidence at a hearing.

According to advice from Hempsons, a coroner has powers to compel the disclosure of any documentation, (including statements, investigation, care records, CCTV, training records) where information may assist the investigation.

Evidence may be required to provide chronological details of the care of an individual, details of a specific incident or event or a response to concerns raised in respect of care provided in the period prior to death.

Similarly, witnesses can be called to give answers the key questions of who, when, where and how an individual came by their death. Witnesses may include senior managers and care workers.

Issues considered during an inquest, and of relevance to social care providers, can (and often have) included a consideration of the overall quality of care prior to death, staffing levels, training and supervision, communication and care planning, assessment and management of risks including in particular the management of falls risk, nutrition pressure sores, medication errors or incidents of abuse or neglect. Often central to an examination of these issues is the importance of clear and accurate record keeping, robust policies and procedures and appropriate training.

A coroner has a duty to issue a Prevention of Future Death Report /Regulation 28 Report in circumstances where there is a concern that a risk of a future death may arise. This may relate to any issue that is evident during the investigation, causative or not.

Regulation 28 reports are published and shared with CQC, which may prompt a further CQC inspections or enforcement action.

This scenario emphasises the need to investigate and implement any learning following a death. Care home managers should ensure that there is a clear internal investigation following a death to mitigate the the risk of a Regulation 28 report.

What do you need to consider?

Care providers should consider what support is required for staff (whether management or care staff) in preparing witnesses statements and to provide oral evidence at inquest hearings.

If your organisation is requested to provide evidence and/or attend an inquest, consider seeking legal advice at an early stage. The care home needs to be aware of the potential risks and criticisms, management of disclosure and any associated regulatory or criminal proceedings

Five top tips for social care providers

  • seek advice and support at an early stage
  • consider whether insurance provision for legal support for inquest is available
  • ensure staff provide contemporaneous accounts of incident/death and continue to ensure disclosure of any documentation is appropriately managed
  • do not underestimate the impact that participation in an inquest may have on staff, ensure staff are appropriately supported throughout the process – from collating written statements and evidence to attending an inquest to provide oral evidence
  • ensure that any learning from an incident is fully investigated and addressed.


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