Page 123 - When Things Go Wrong

ANNEXE: STRUCTURE FOR SPECIAL PROCEDURE
INQUESTS

EVENT/ACTION PROCESS
STANDARD PROCEDURE
1A Fatal event Multiple fatalities i.e. 2 or more deaths
occurring in circumstances giving rise to
serious public concern or for other good
reason

1B Fatal event Any death which a coroner has reason to
suspect requires investigation and which, by
reference to another death or deaths, may
give rise to issues of systemic failure
The issues may arise either (i) from an
inquest or inquests already held or (ii) from
a death or deaths (including deaths in other
coroner jurisdictions) in which no inquest
has yet been held
In the latter case one or more transfers may
take place under existing provisions in ss.2,
3 Coroners Act 2009 and inquests held
together

2 Report of death or deaths to By doctor, police, prison, Local Authority
local Senior Coroner (SC) (LA), news media, other
See the Notification of Deaths Regulations
2019
Report of death in SC’s area is a pre-
condition to the duty to investigate: s.1
Coroners and Justice Act 2009 (CJA 2009)

3A SC commences investigation s.1, CJA 2009
immediately
SC orders post-mortem where s.14, CJA 2009
necessary
See Chief Coroner’s Mass Fatality Checklist
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