Coroners Investigation (It’s not Silent Witness) © Eastbourne Coroner's Office © Mrs A Warner Coroner's Officer 2009

© Eastbourne Coroner's Office History Medieval tax gatherer ‘The Crowner’ Over 800 years old Stamp out the clandestine murder of Normans © Eastbourne Coroner's Office

© Eastbourne Coroner's Office The Coroner Independent judicial office holder Investigate deaths that are violent, unnatural, unknown or in police custody/state detention Coroners and Justice Act 2009 and The Coroners Rules 2013 The Chief Coroner © Eastbourne Coroner's Office

© Eastbourne Coroner's Office The Chief Coroner Collate, monitor and publish coroners’ reports to authorities to prevent other deaths (PFD) Allows delegation of administrative functions to Coroner’s Officers (investigation) © Eastbourne Coroner's Office

SOME ROLES OF CORONER’S OFFICERS Coroner’s “right-hand person” Medical investigator Forensic investigator Coroner’s Officer Administrator Jury arranger Family liaison Media relations Counsellor and advisor Statement taker Court clerk Police liaison © Eastbourne Coroner's Office © Mrs A Warner Coroner's Officer 2009

Deaths Coroners Officers Attend © Eastbourne Coroner's Office

Investigation at scene Gather relevant history/information for Coroner & Pathologist Hands on! Take photos Statements Seize exhibits Give advice and support to Police officers Immediate family contact Continuity to mortuary Pass information to other agencies, e.g., H&S Ex, Fire…. © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Type of Post Mortem Coroner’s PM (to establish cause of death) Can be invasive or non invasive Special PM (extended skills) Forensic PM & 2nd PM’s © Eastbourne Coroner's Office © Mrs A Warner Coroner's Officer 2009

© Eastbourne Coroner's Office Type of Inquest Two types of Inquest:- Jamieson (who, how, when & where) Middleton (Article 2 of HRA includes ‘in what circumstances’) © Eastbourne Coroner's Office

Suspension of Inquests Homicide offence or equivalent Prosecuting authority informs Coroner IPCC HSE Accident Investigation Branch © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Case Study 1 © Eastbourne Coroner's Office

Man dies in Hailsham tyre company incident A man has died at a Sussex tyre supplies company in an "industrial incident", police have said. The 54-year-old was killed on Monday at about 1400 GMT while transporting heavy equipment. The man was pronounced dead at the scene. A post-mortem examination is due to take place on Wednesday. Sussex Police said it was working with the Health and Safety Executive to establish what happened. © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Case Study 2 © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Case study 2/b © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Case Study 2c © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Case Study 2d © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Outcome of the Inquest Upon his death in 2010 an investigation was held by Sussex Police and the Health and Safety Executive. Apaseal as a company was fined for breaches of health and safety. That investigation came to a close in April 2014, allowing the inquest hearing to proceed in order to determine how Mr Parsons came by his death The inquest heard how the skates had been a suitable choice of equipment to handle the weight of the machine in question but that after the worker’s death, one of the skates was found with its disc unattached next to the scene. A jury of eight returned a unanimous verdict of misadventure. © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Manslaughter? A roofing firm boss has been jailed for 12 months for manslaughter due to gross negligence after a 20-year-old employee fell 20ft (6m) through a skylight. During the 13-day hearing, the court heard Mr Hoofe did not have a harness and there was no safety net. "wholly untrained to work at height," not supervised at the "critical time", and "provided with inadequate and insufficient materials to do the work safely". © Eastbourne Coroner's Office

© Eastbourne Coroner's Office Conclusions Accident or misadventure Alcohol/Drug related Industrial disease Lawful/unlawful killing Natural causes Open Road traffic collision Suicide Narrative © Eastbourne Coroner's Office

England and Wales (Total) Statistics   England and Wales (Total) Total conclusions recorded Accident and misadventure Natural causes Suicide Drugs/Alcohol Related Road Traffic Collision Industrial diseases Unclassified conclusions Open All other conclusions* 2005 26,814 9,498 6,175 3,235 . 2,567 1,952 2,531 856 2006 27,547 9,353 6,828 3,220 2,496 2,406 2,378 866 2007 27,360 8,930 7,011 3,007 2,332 2,923 2,242 915 2008 28,996 9,230 7,556 3,305 2,474 3,333 2,167 931 2009 29,781 8,673 8,281 3,330 2,623 3,797 2,240 837 2010 29,385 8,113 8,382 3,252 2,560 4,180 2,115 783 2011 29,858 7,775 8,818 3,471 2,569 4,400 2,117 708 2012 30,123 7,705 8,849 3,515 2,756 4,634 2,059 605 2013 31,579 8,166 8,881 3,754 2,766 5,343 1,920 749 2014 29,153 7,941 4,873 3,851 1,645 602 2,874 5,261 1,882 211 2015 35,473 7,977 11,043 3,899 2,267 779 2,733 4,870 1,736 169 © Eastbourne Coroner's Office

Reports to Prevent Future Deaths Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. All reports and responses must be sent to the Chief Coroner. In most cases the Chief Coroner will publish the reports and responses on this website. Details of the procedures are set out in Regulations 28 and 29, Coroners (Investigations) Regulations 2013. © Eastbourne Coroner's Office

Reports to Prevent Future Deaths Clear, brief, focused, meaningful and wherever possible, designed to have practical effect Can be made before or after Inquest hearing (urgent action required) ‘A PFD report is a recommendation that action should be taken, but not what that action should be’ © Eastbourne Coroner's Office

© Eastbourne Coroner's Office PFD’s Should be sent out within 10 working days of Inquest Sent to the Person the Coroner believes may have the power to take such action 56 days to respond Detail action to be taken or explain why no action proposed © Eastbourne Coroner's Office

© Eastbourne Coroner's Office If only? © Eastbourne Coroner's Office