Parents assert inquests lack power to prevent future deaths

Bereaved parents have stated that families who anticipate inquests will avert future fatalities are relying on reforms that will not materialize. Christian and Julia Rogers expressed this view following an inquest into their child’s death, which issued several recommendations that remain unimplemented and are beyond the coroner’s enforcement capabilities. A separate report, commissioned by the Department of Health and Social Care (DoHSC), identified that the extensive quantity of recommendations issued by coroners constituted a burden on an “already pressurised healthcare system” due to their sheer volume. This report proposed the establishment of a central monitoring system. Louis was a healthy, energetic young boy with good development. However, at 13 months old, he experienced his initial febrile seizure. His parents were informed at that time that such seizures were quite common and not a cause for concern. He subsequently experienced additional seizures, with Mr and Mrs Rogers receiving the same reassurance each time. Then, in 2021, his mother placed him in bed at their residence in south-west London. Upon checking on him an hour later, she discovered he had passed away, six weeks before his second birthday, without any cry for assistance or sound. Initially, his death was classified as Sudden Unexplained Death in Childhood (SUDC), a designation for deaths where the precise cause remains undetermined. Since then, his parents have had to strive to ascertain the circumstances of his passing. “A lot of people can put their grief and bereavement towards something. If it’s a criminal offence, you can put the blame somewhere.” “Some families have a diagnosis – so they can almost pre-grieve before their loved one dies.” “But in this case, it was so sudden. The inquest almost became our raison d’etre, to tell Louis’ story and seeing if we can help other people.” To secure an inquest, Mr Rogers contacted the local coroner, detailing his belief that Louis’ death required additional clarification and to determine if any mistakes were made by the health organizations responsible for his care. An inquest was ultimately conducted last year at Surrey Coroners’ Court, where Dr Karen Henderson, the coroner, concluded that febrile seizures had played a role in his death. She also issued a Prevention of Future Deaths (PFD) report containing six recommendations directed at several health bodies. “We left thinking ‘this is fantastic’,” Mr Rogers stated. “The report was really wide-reaching so we were really pleased with the outcome because we thought it would lead to change, and that it was going to help other families.” Their hopeful outlook was short-lived. The health bodies were given 56 days to reply to the coroner. After these responses are received, the coroner’s function is considered complete; no system exists to guarantee the implementation of recommendations. “The responses back – they’ve committed to nothing. They’ve committed to no change, they didn’t give us a timeline or expectation,” Mr Rogers commented. He noted that one responding entity, the Royal College of General Practitioners (RCGP), incorrectly used the deceased’s name, leading the family to perceive the response as a “copy and paste administrative job” that had not been thoroughly reviewed. “It’s just so insensitive.” “It felt like it was an annoyance to them”. The RCGP issued an apology, acknowledging that its procedure for addressing PFD reports “fell short in this instance.” It further explained that its honorary secretary, a qualified and experienced GP, reviews all reports, often in conjunction with another suitable clinician, typically its medical director for clinical policy. The couple expressed their belief that the respondents replied out of obligation, but that the recommendations were not mandatory for implementation. “We actually went back and asked the coroner if she was going to compel them to do so, and she admitted she’s toothless to do anything.” “Why make the recommendations when you know full well that you can’t make those bodies do anything about it?” “If the NHS or these bodies aren’t willing to make changes, at what point does non-action become a contributory factor to other children’s deaths?” Mrs Rogers additionally stated: “It’s really disappointing.” “I actually feel it’s quite dangerous that they’re making recommendations that can help to prevent future deaths and there’s no sense of urgency or they don’t see it as an opportunity to help prevent further deaths.” “Coroners should have the power to go back to authorities and say it’s not good enough.” Their experience aligns with the conclusions of a report from the Health Services Safety Investigations Body (HSSIB). Last year, coroners issued 569 PFD reports, marking a 41% increase compared to the previous year. The HSSIB indicated that the “significant volume of recommendations” directed at the healthcare system resulted in providers struggling “to prioritise and implement recommendations, concentrating on those which are addressed directly to the provider, or where there are immediate patient safety risks.” Some recommendations were redundant or conflicting, and the failure to implement actions “compounds harm to patients.” The body proposed establishing a monitoring system, such as a searchable database, to track recommendations issued and subsequent actions. In reply, the DoHSC commented: “This report is a step in the right direction for improving patient safety and patient outcomes, a priority area for this government.“We will never turn a blind eye to failure and will work to root out poor performance and improve patient safety.” Regarding the recommendations in Louis’s case, the NHS stated it had modified its website to incorporate epilepsy on its febrile seizures webpage and had provided a link to the SUDC charity on its Sudden Infant Death Syndrome webpage. The RCGP affirmed that it views the guidance it provides to GPs on febrile seizures as “appropriate and comprehensive” and that this topic is included in its curriculum for all GP trainees. For the best of BBC Radio London, tune into Sounds and follow BBC London on Facebook, X, and Instagram. Story ideas can be sent to hello.bbclondon@bbc.co.uk. Copyright 2024 BBC. All rights reserved. The BBC bears no responsibility for the content of external websites. 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