Page 38 - When Things Go Wrong

Procedure

2.55 Our recommended procedure for the SPI is set out in the Annexe. There should
be a special and recognised focus on the needs of families throughout the
process, and from a very early stage. Bereaved people and survivors with
interested person status should be entitled to full disclosure of relevant (but not
closed) material.

Immediate action

2.56 The SPI should follow a report of the death(s) to the local Senior Coroner. The
Senior Coroner would commence their investigation immediately in the usual
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way, ordering a post-mortem where necessary. The Senior Coroner should
immediately inform the Chief Coroner of any “specified deaths”.

2.57 The family or families of the deceased (where identity known) should be
contacted immediately following the report to the Chief Coroner and they
should be provided with information on the actions already taken, in addition
to the provision of information as outlined at paras 3.33-3.37, below.

2.58 The Senior Coroner should consider the release of the body for burial or
cremation. They should then open inquests to receive evidence on identity (if
possible) and to explain the future procedural steps. The inquests should then
be adjourned.

Special procedure

2.59 The Chief Coroner would decide on the available information whether the SPI
is required, making further inquiries as necessary to inform the decision. The
Chief Coroner should inform Government that a decision has been made or is
pending.

2.60 Alternatively, Government may recommend that the Chief Coroner establishes
an SPI. This should not prejudice Government’s ability to establish a
public inquiry under Section 1 of Inquiries Act 2005. Some matters, such

99 Coroners and Justice Act, ss. 1, 14.
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