• Whilst evidence gathering for a PSIRF learning response and for an inquest must remain distinct so that each achieves its intended aim, it will be helpful for in-house legal and patient safety teams to work together to facilitate a shared understanding of both processes and what additional evidence may be needed for the inquest. At the outset, legal teams should notify the patient safety team of a death that is being investigated by a coroner.
• Legal and patient safety teams should also have ongoing communication about the status of the different investigations and reviews. 
• Consider whether patient safety teams can support legal teams to obtain additional evidence needed for the inquest and prevent duplication. Documents and communication generated by patient safety teams will likely be disclosable and not protected by legal privilege and any legal advice should be clearly marked as such to ensure that privilege is not waived inadvertently

Legal teams should collaborate with patient safety teams to review all deaths that are proceeding to a Coroner’s inquest to ensure that:

• The incident is recorded on Datix;
•  A proportionate learning response has been agreed in accordance with your organisation’s Patient Safety Incident Response Plan (PSIRP) and information from all relevant sources, including outputs from M&M reviews and any concerns or opportunities raised by families/carers and the Coroner about the need to understand and address system issues. 
• Careful consideration should be given to ensure that there are equal opportunities for those affected to raise questions and/or concerns when someone has died.  A Health Equity Impact Assessment (HEIA) can be used to ensure that patient safety investigations and improvement actions consider health inequalities and do not unintentionally disadvantage certain groups.
• M&M meetings are held in a timely way and, where possible, include the outcomes of any relevant SJRs and/or PSIRF learning outputs. To this end, organisations may wish to re-structure processes to ensure that learning from each different process feeds into the other, irrespective of the order in which they take place. 
• The decision-making process for the agreed PSIRF learning response is clearly and contemporaneously documented so that evidence can be presented to the Coroner to explain the approach taken, including the rationale and scope of the PSIRF learning response/investigation undertaken. To assist with this, it may be beneficial for minutes of meetings to be recorded. It may also assist to provide guidance or a template for staff tasked with taking the minutes about what information to record. 
• There is a process which enables a review of the decision about which learning response under PSIRF will be used, if required – for example, in the event of new information or concerns, including concerns raised by family members. 

• Ensure compliance with the NHS England patient safety response resource standards. This includes ensuring PSIIs and other learning responses are undertaken by those with required, training, skills, experience and time to support the activity.
• Ensure a system based method is used as part of any learning response – national tools, templates and guidance are available. 
• Ensure there is a process for checking the quality of learning response outputs (for example, using the learning response review and improvement tool). 
• Ensure there is a governance process for reviewing any recommendations from learning responses to align with existing improvement work and where relevant to develop and monitor safety actions.  
• Once the report is completed, ensure it is shared appropriately, including with all staff involved, especially those who may be giving evidence at an inquest (whether a factual or organisational learning witness).

• If possible, allocate a single point of contact for families, such as a Family Liaison Officer, who can explain the interconnections between the inquest and any internal processes such as the role of the Medical Examiner, the PSIRF learning response and formal complaint. The individual should be able to explain the distinctions between the PSIRF response and an inquest or know where to obtain this information. This 'Factsheet for Families' on inquests from the Coroners’ Courts Support Service is a good resource to share with bereaved families. Patient Safety Learning has also published A Simple Guide to PSIRF which outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident.
• Explain how family members can ask questions about the death of their loved one and raise any concerns about the care or treatment provided.
• Keep family members updated on the actions being taken to investigate the incident under PSIRF, including the rationale for decisions made about the choice of learning response and likely timelines.
• Invite families to be involved in devising Terms of Reference where appropriate e.g. for a PSII.
• The fact that an inquest will be taking place should not preclude or delay the investigation of any complaint through the organisation’s standard complaints process. Respond to any concerns or complaints raised by family members in a timely manner and, where possible, in advance of the inquest hearing. This includes family concerns relating to matters falling within and outside the scope of the Coroner’s investigation. The Coroner’s investigation is focused on determining how the deceased came by their death. Accordingly, concerns that do not relate to how the person died, or that post-date the death (e.g. complaints regarding the manner in which the family was notified of the death) will not be examined by the Coroner and must be addressed by the responsible organisation directly.  
• Keep a detailed log and evidence of all communications with the family, including copies of all written correspondence. This documentation is likely to be relevant disclosure for the Coroner.

• Liaise with your local Coroner to ascertain what documents need to be disclosed for the inquest, together with the deadline for disclosure. Where medical records are to be disclosed, confirm the specific time-period to which those records should relate. 
• Notes of governance discussions should be stored or shared centrally, for example on the clinical governance drive with access provided to the Legal Services Team to facilitate timely disclosure of relevant information to the Coroner. 
• Consider developing an internal checklist of items which are routinely required to be disclosed for inquests along with details of where to locate them on your organisation's systems. This disclosure checklist could include details of what has been specifically requested by the Coroner, deadlines for disclosure and dates documents have been provided. 
• It may also be helpful for legal teams to have regular file reviews and as part of this, to check the progress of any parallel processes e.g. PSIRF investigation or complaint. These reviews should take place at appropriate points before (but well in advance of) an inquest. This will ensure that the file is reviewed prior to the inquest, and any outstanding items identified and disclosed. 

• Witness statements for coroners are not gathered as part of a patient safety learning response.   The legal team will need to identify (in liaison with the coroner) which staff will need to provide a witness statement for the purposes of the inquest. 
• Legal teams should consider how best to support staff to write witness statements. Having a witness statement template is advisable. Our witness statement guide provides guidance and a template.

• Learning responses under PSIRF, even PSII reports, will not cover cause of death or causation. The learning response outputs will not therefore be sufficient for an inquest where questions about causation are anticipated. In these cases, you will need to give careful thought to your evidence on causation – you may need to obtain a clinical opinion on causation from a clinician in the relevant specialism or prepare a separate Position Statement on behalf of your organisation. In exceptional cases you might consider obtaining independent expert evidence on causation: The causation evidence required in each case will be fact specific and often informed by specialist legal advice. 
• In complex inquests, the Coroner may instruct their own expert to comment on causation. The Coroner should seek input from the Interested Persons on what specialism is required and what questions to put to the expert. If the Coroner obtains an expert report, the Legal Services team should ensure they share the report with the witnesses in good time prior to the inquest and understand any differences of opinion that may exist.

• In certain cases, the healthcare provider may wish to provide the Coroner with evidence to explain the outcome of the internal investigation and provide assurance that organisational learning has been, or is being, implemented. PFD reports are not intended as a punishment; they are made for the benefit of the public. However, if an organisation has already made or is committed to making changes then it is obviously preferable to provide the Coroner with evidence to demonstrate this and avoid a PFD report if possible. 
• The Chief Coroner’s Guidance states that in considering whether they are under a duty to make a PFD report, Coroners should focus on the current position i.e. at the date of inquest and not at the date of death. The Chief Coroner’s Guidance states that the Coroner should consider evidence and information about relevant changes made since the death or plans to implement such changes. 
• PSIRF outputs, including any improvement actions, can provide valuable evidence of organisation learning. However, organisations will need to consider whether it is necessary to prepare an additional, detailed organisational learning statement, to provide the Coroner with assurance that lessons have been learned and changes adopted to prevent the risk of future deaths occurring. Browne Jacobson’s guide to preparing and delivering a Prevention of Future Deaths Report provides useful guidance.
• Be clear whether all organisational learning reviews are complete or whether any processes are still ongoing. Additional reviews are sometimes required if new information or concerns arise.
• Be clear on what improvement work has been completed and what, if any, is still ongoing. If remedial action is outstanding, provide the Coroner with estimated timelines for completion. 
• Provide evidence to demonstrate that the learning has been communicated effectively and that changes have been embedded e.g. through audits, training, broader system changes.
• Authors of PSII reports or other learning response outputs may be called to give evidence at the inquest about organisational learning where they have been involved substantively in the learning response output and/or development of actions. If a member of staff has been involved in a learning response output as a meeting facilitator or note-taker only, it will be necessary to explain that to the Coroner and identify a more appropriate witness to provide the organisational learning evidence for the inquest. Good channels of communication with the local Coroner will assist with these conversations and consensus about the most appropriate person to provide the organisational learning evidence. 
• The organisational learning witness will need to explain the findings of any investigation, the actions taken and planned to address organisational learning. The witness may be asked: are you able to provide an assurance that all reasonable steps have been taken to address the learning from this case and reduce the risk of recurrence? However, the Coroner will not limit these questions to the organisational learning witness. It is important that all witnesses are prepared to answer questions about lessons learned from a death and the steps that have been taken to address these.