Covid-19 related inquests are rare because of guidance issued by the Chief Coroner, that where the deceased dies from Covid-19 an inquest is unlikely to be required. While there have been relatively few Covid-19 related inquests, two recent inquests into deaths in health and social care highlight why such cases will require careful preparation by care providers. 

The primary trigger for an inquest to be held is whether the deceased died an unnatural or unexplained death. Where there is clear evidence that the deceased died from Covid-19, that test is unlikely to be met. However, there may be exceptions where the cause is not clear or there are significant contributory factors arising from the way care was provided. Two such cases from Manchester have been reported in the news this week.

In the first, the inquest examined concerns about a resident who contracted Covid-19 in a care home. The coroner concluded that failings, in that case, gave rise to a risk of future deaths and issued a formal report requiring action to be taken by the care home, Public Health England (PHE), NHS England, the Care Quality Commission and the local Health and Social Care Partnership. The issues raised included;

• Concerns about infection control within the care home and measures to prevent Covid-19 being brought in by staff;
• Poor record keeping in the care home;
• Lack of clarity about PPE requirements because of the changing guidance; and
• Delays in attendance of an ambulance as a result of Covid-19 related pressures.

The second case related to the death of a hospital patient who contracted Covid-19 having been placed on a ward with another patient who had already tested positive. In that case, the coroner raised concerns that failings in relation to patient management by the hospital and guidance issued by PHE created a risk of future deaths.

The comments about PHE are perhaps more surprising as the Chief Coroner’s guidance suggests that inquests are not the forum to examine the national response to Covid-19 (hinting that this should be considered as part of any public inquiry). However, that does emphasise the key lesson for care providers. 

Covid-19 related inquests may be rare, but when they do arise they need to be taken even more seriously. The fact that an inquest is being held is almost certainly an indication that the coroner has real concerns that actions by those providing care and support have contributed to the death, and (assuming the Chief Coroner’s guidance is followed) the focus is more likely to be on the care or health provider than any wider systemic issues.