Page 61 - When Things Go Wrong

invokes the SPI, bereaved people should be directed to an engaging, clear
and professional quality video on what to expect at an inquest. It could
feature bereaved family members who have experienced the process as well as
court professionals explaining their roles and should lead viewers through
actual inquest locations to give a realistic impression of the process. The
production should be made with the collaboration of bereaved people.

The post-mortem

3.43 Where a coroner has ordered that a post-mortem examination take place,
Regulation 13(3)(a) of the Coroners (Investigations) Regulations 2013 requires
that particular people be notified. 163 However, the experience of our members
is that notification often comes too late for family members to make informed
decisions about the possibility of non-invasive post-mortems or objecting to
the post-mortem altogether. Article 8 ECHR may oblige a coroner to take
reasonable steps to identify relatives in advance of the post-mortem,
“reasonable steps” being dependent on the circumstances of death and the
urgency of the post-mortem. 164 We recommend that where a post-mortem is
to take place, the coroner should notify all family members whose details
are known to the coroner’s office.

3.44 Under Rule 13 of the Coroners (Inquests) Rules 2013, interested persons have
a right to receive, on request, a copy of the post-mortem report and any other
report or relevant document, subject to the qualifications set out in Rule 15.
From our experience, some coroners adopt a paternalistic approach to post-
mortem results, in extreme cases preventing bereaved people from reading the
results when they consider that these might be distressing. This approach is
unlawful and denies bereaved people autonomy. We recommend that in order
to give fair notice of potentially distressing content, post-mortem reports
disclosed to family members should be concealed within two envelopes,
with a warning inside the outer envelope that the report may contain
distressing information.

163 The next of kin or the personal representative of the deceased or any other interested person who has
notified the coroner in advance of his or her desire to be represented at the post-mortem examination.
164 Thomas QC, Straw, Machover and Friedman QC, supra note 148, paras 19.14-15.
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