The first case to look at follows the death of a 19 year old woman while in the care of Richmond Psychosocial International Foundation. While this case was being investigated by the CQC, the coroner, HM Assistant Coroner John Taylor, has also taken separate action against a witness, Dr Duncan Lawrence, for his non-compliance with a Schedule 5 notice which required Dr Lawrence to give evidence at the inquest into the patient's death. Mr Taylor has ruled that a fine should be imposed on Dr Lawrence personally as he was heavily involved in the deceased patient's care yet failed to attend the inquest into her death in February 2019. Dr Lawrence could have provided crucial evidence into the patient's death, yet chose not to turn up at the inquest to assist the coroner as had been requested of him. Mr Taylor's imposed fine shows that individuals cannot simply choose not to turn up and give evidence in connection to a serious incident, especially when they have previously been so involved with the deceased. In addition to the fine, Mr Taylor will also refer Dr Lawrence to the Director of Public Prosecutions, Crown Prosecution Service and the police who will consider whether any further legal action should be taken in addition to the fine imposed.
Within a few weeks of the fine being handed down by Mr Taylor, Isle of Wight Coroner Caroline Sumeray also gave a £500 fine to the Isle of Wight NHS Trust's chief executive for a series of disclosure issues spanning over numerous serious incidents. The Trust had delayed in beginning their investigations into a series of deaths and other serious incidents due to a "number of historical cases" which had caused a backlog of incidents being investigated. Once an incident was eventually investigated the report provided was far too late to address the issues relevant to the incident and also contained incorrect and inadequate information, likely due to the passage of time. These reports were also often drafted by very junior people with little investigative or medical experience in order to keep the backlog moving. One such investigation into the death of a patient wasn't started until 13 months after the incident, and was referred to by the Ms Sumeray as a 'dog's dinner'. The Trust's chief executive was fined £500 by the coroner due to their failing to promptly inform the coroner of serious incident investigations, although not disclosing reports on incidents promptly to families of the deceased means that the NHS Trust also breached its duty of candour.
These 2 recent cases set a crucial precedent within the health care sector, and show that Coroners are not afraid to use their powers and impose fines on those that choose to withhold their assistance and/or relevant documentation following serious incidents.
