The inquest into the death of Awaab Ishak demonstrated the power of coroners to provoke and support change, not just for those parties directly involved, but across whole sectors and society.

Over the last three years, inquests involving housing providers have received increased focus and attention. Inquests have covered issues such as window restrictors, cuckooing, hoarding, the escalation of welfare concerns, lack of engagement and even the impact of the shortage of social housing. 

In this blog, we provide an overview of what an inquest is and what housing providers should do if they receive contact or a request from the coroner. 

What is an inquest? And how might a housing provider be involved?

Inquests are a fact-finding investigation where the coroner seeks to determine the identity of the deceased as well as when, where and how they died. The coroner may request that a housing provider and/or its staff provide a witness statement and documentary evidence to assist them with their investigation. 

In addition to this, the coroner may designate the housing provider as an ‘interested person’. Interested persons have the right to see all the evidence the coroner considers relevant for the inquest, to be legally represented at the inquest hearing and to ask witnesses at the hearing questions. 

What are the risks for housing providers? 

If the coroner has concerns regarding the acts or omissions of the housing provider or its staff, they can express this in the following ways:

• The coroner could be critical of the housing provider in their conclusion. Whilst the coroner can’t use words to attribute liability, they can say something should or shouldn’t have been done.
• The coroner could add a rider of neglect to their conclusion. This means that the death was contributed to by a ‘gross failure’ to provide basic care or medical attention to a dependent individual.
• The coroner could issue a Prevention of Future Deaths (PFD) Report. The coroner will issue such a report where they consider there is a significant risk that has been identified through the inquest evidence, which, if not addressed, may cause further deaths. The coroner will detail in a report the risks that they think need to be addressed and give the recipient of the report 56 days within which they must take action and report back to the coroner. PFD Reports, and the responses to them are publicly available and published online. 

Inquests can receive a significant amount of press attention, particularly where a PFD Report is issued. The outcome of an inquest can also influence any potential or ongoing civil claims and any regulatory investigations. Regulators such as the HSE and CQC will often wait for the inquest to conclude before deciding what action to take. Registered providers of social housing (RPs) will need to consider communication with the Regulator of Social Housing (RSH) at all stages through the inquest process. 

What should you do if you receive contact or a request for information from the coroner? 

Seeking legal advice from the outset of the inquest process and making early preparations is essential (including the collation of all relevant records and documentation). Providing a clear witness statement, supported by comprehensive evidence, may cause the coroner to determine that the witness is not required to attend the hearing to provide evidence. 

Where witnesses are called to provide evidence, providers must ensure all staff and leaders are informed of what to expect at the hearing. Being briefed on the possible outcomes can help them to stay focused on providing clear, factual information in a stressful and emotional situation. 

We regularly work with providers to prepare evidence that can be presented to the coroner to provide reassurance that a PFD Report is not necessary. This evidence typically sets out the changes in policies, procedures and processes that have taken place since the deceased’s death, and explains how any risks relating to the circumstances surrounding the deceased’s death have been addressed. This evidence can then also be useful when corresponding with the RSH.

We can advise you through the inquest process. Most insurers recognise our expertise and will work with us, at your request, ahead of their usual panel firm. We also offer bespoke training that can be tailored to any level of your organisation, from operational staff to boards.

If you receive contact from the coroner or would like advice following the death of a tenant, resident or service user, please contact us.