NHS staff coronavirus inquests told not to look at PPE shortages

Inquests into coronavirus deaths among NHS workers should avoid examining systemic failures in provision of personal protective equipment (PPE), coroners have been told, in a move described by Labour as “very worrying”.

Robert Booth www.theguardian.com 

The chief coroner for England and Wales, Mark Lucraft QC, has issued guidance that “an inquest would not be a satisfactory means of deciding whether adequate general policies and arrangements were in place for provision of PPE to healthcare workers”.

Lucraft said that “if there were reason to suspect that some human failure contributed to the person being infected with the virus”, an inquest may be required. The coroner “may need to consider whether any failures of precautions in a particular workplace caused the deceased to contract the virus and so contributed to death”.

But he added: “An inquest is not the right forum for addressing concerns about high-level government or public policy.”

Labour warned the advice could limit the scope of investigations into the impact of PPE shortages on frontline staff who have died from Covid-19, including 82 NHS workers and 16 social care staff, according to government figures, though these are believed to be an underestimate.

“I am very worried that an impression is being given that coroners will never investigate whether a failure to provide PPE led to the death of a key worker,” said Lord Falconer, the shadow attorney general. “This guidance may have an unduly restricting effect on the width of inquests arising out of Covid-19-related deaths.”

Doctors and nurses’ unions have repeatedly warned that their members do not feel safe at work because of a lack of PPE. Three weeks before he died, a Reading doctor, Peter Tun, warned Royal Berkshire hospital that unless it supplied vital protective kit “it will be too little and too late”.

A coroner has been in touch with his family but it remains unclear whether there will be an inquest. The hospital has begun a serious incident investigation into the death, the Guardian has learned.

Rinesh Parmar, the chair of the Doctors Association UK, said: “The provision of PPE is so vital to the safety of health workers that to suggest coroners do not consider its supply in detail misses a big part of the picture. Only comprehensive inquests into the deaths of every NHS and care worker will give the bereaved the ability to ask questions and have the circumstances of their loved ones’ deaths fully explained.”

Explaining his newly issued advice, Lucraft cited a court ruling that found it was right for an inquest to consider whether a soldier had died because a flak jacket had been pierced by a sniper’s bullet, but not to consider whether more effective flak jackets could and should have been supplied by the Ministry of Defence.

However, coroners have in the past ruled on the provision of protective equipment. When the Oxfordshire assistant deputy coroner Andrew Walker investigated the death of Steve Roberts, a tank commander who died in Iraq when he was not supplied with enhanced body armour, he concluded that the lack of appropriate basic equipment was “unforgivable and inexcusable and represents a breach of trust that those soldiers have in the government”.

A spokesman for the chief coroner at the Judicial Office said the guidance was “an expression of the law as it currently stands” and “to provide consistency for coroners”.

About half of doctors working in high-risk areas told a British Medical Association survey this month there were shortages or no supply at all of long-sleeved disposable gowns and disposable goggles, while 56% said the same for full-face visors. Supplies of PPE to care workers remain patchy and a promised government supply system, known as Clipper, is yet to get properly up and running.

With no public inquiry into the coronavirus crisis yet established, inquests remain the only official forum to investigate deaths. Daniel Machover, one of the UK’s leading inquest lawyers, said the guidance could be subject to judicial review by lawyers acting for bereaved families.

“This points to the need for a public inquiry,” he said. “As you widen out the issue from one death to several deaths you get into a situation where an inquest format is not suitable and you want to be dealing with systemic issues.”

Deborah Coles, the director of Inquest, a charity which advises on investigations into state-related deaths, said: “Bereaved families legitimately ask whether failures in the provision of safety equipment played a part in the deaths of their loved ones.

“It follows that coroners should, where appropriate, examine this question. In the absence of a public inquiry inquests will play a vital role in identifying systemic failings in the protection of frontline workers. This scrutiny is key to learning lessons and holding people to account in order to prevent future deaths.”