Page 39 - When Things Go Wrong

as infected blood, involving over a thousand deaths and wide-ranging socio-
economic and cultural issues may remain better suited to a public inquiry. 100

2.61 The establishment and conduct of the SPI should be guided by a clear and
publicly accessible Protocol. The Protocol would include standard terms
of reference, to be adapted according to the circumstances of the case.

2.62 If the SPI is not invoked, the local Senior Coroner will continue the
investigation and inquest as standard. The local Senior Coroner and family
should be notified and reasons given within seven days (to enable any judicial
review to be considered).

2.63 If the SPI is invoked, the Chief Coroner should within seven days of the fatal
event appoint a judge or Senior Coroner (local or other) to conduct the new
procedure. Appointments should be taken from a pool of judges and Senior
Coroners trained in advance and ticketed to conduct SPI hearings.

2.64 The SPI would permit judges and Senior Coroners to hear and, if appropriate,
rely upon “closed” evidence, i.e. evidence heard in the absence of the public.
101
Where a decision is made that evidence must be heard in closed proceedings,
this must be explained clearly to interested parties. 102

Hearings

2.65 The appointed judge or Senior Coroner should announce the date and venue of
the first preliminary hearing, to be held within 14 days of the event and at a
local venue. The date and venue of the hearing should be published on the
coroner’s page of the Local Authority website and on the Office of the Chief

100 See ‘Contaminated Blood Scandal Statistics’, Factor 8.
101 See Coroners (Inquests) Rules 2013, r. 11.
102 See Sheldon QC, supra note 88: “…it is important to remember, particularly for those representing
families of the deceased, that the replacement of an Inquest by a Public Inquiry can be something of a
double-edged sword. On the one hand it will be a relief that a ‘full and fearless’ investigation can be
conducted, with consideration of all the relevant evidence, including that which would otherwise have
been excluded by PII. On the other, that consideration will take place, to a significant extent, in the
absence of the families or their representatives”.
32