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Inquests into patients who die while under a deprivation of liberty order

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h501 (Published 09 February 2015) Cite this as: BMJ 2015;350:h501
  1. Sarah Ormond-Walshe, HM assistant coroner Inner South London, West London, and South Staffordshire; barrister (non-practising),
  2. Richard Furniss, barrister, 42 Bedford Row Chambers, London, UK,
  3. Andrew Harris, HM senior coroner Inner South London,
  4. Katie Winfield, Third year medical student, Keele University Medical School, Staffordshire,
  5. Dominic A Haigh, Intern, University of Oradea, Campus Universitar, Oradea, Romania

Coroners have received guidance from the chief coroner that an inquest should be held after the death of a patient who is under a deprivation of liberty order. Sarah Ormond-Walshe and colleagues consider the legal situation and its implications for doctors

Coroners’ inquests usually deal with unnatural deaths, but they are also necessary when someone dies in custody or other state detention, even if the death is from natural causes. Guidance from the chief coroner advises coroners to hold an inquest for patients who are under a deprivation of liberty (DoL) order. The guidance is not a judgment or ruling and is subject to rulings in the High Court on future cases, but it is likely to be taken into account by coroners.

Many people in England and Wales are now subject to DoL orders (a safeguarding order in accordance with schedule A1 of the Mental Capacity Act 2005 or a DoL order made through the Court of Protection). This new situation has consequences for doctors, families of the deceased person, and, of course, coroners themselves.

In July 2014 the chief coroner for England and Wales, Judge Peter Thornton QC, spoke of “the likely requirement to hold an inquest with a jury in cases where a person dies in local authority accommodation under deprivation of liberty safeguarding orders.”1 New guidance from the chief coroner, published on 5 December 2014, guides coroners definitively to hold an inquest when such a person dies.2

We now face a potentially huge logistical challenge if every death of a DoL patient results in an inquest and the floodgates open. The coronial service is already stretched. Many coroners are under considerable strain in complying with the chief coroner’s direction that inquests should be heard within one year of referral (specifically, that they report to …

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