Joanna Lloyd and Debbie Rookes of Bevan Brittan’s clinical risk department examine the coroner’s role in patient safety with a particular focus on hospital related inquests.
This article considers the lessons being learnt as a result of inquests, whether these are being disseminated widely –and what more could and should be done
In the wake of the Francis Inquiry – and the numerous other inquiries which followed it, including the Berwick Review into patient safety – there has been a clear shift in the NHS towards a greater emphasis on patient safety, and quality of care.1
At the institutional level, there have been several notable changes: NHS Improvement (incorporating NHS Patient Safety), through the National Patient Safety Alerting System (‘NPSAS’) and the Central Alerting System (‘CAS’) provides guidance to healthcare providers aimed at preventing incidents which may lead to patient harm or death; the introduction of a statutory ‘duty of candour’ in November 2014, aimed at transparency and overall improvement in care; the publication of data and other relevant information about ‘never events’ by NHS Improvement; and the launch of the Healthcare Safety Investigation Branch, to “act as a catalyst to promote a just and open culture across the whole health system”.2
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