Lancashire Inquests, Extents, And Feudal Aids: 1310-1333...

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ONS data is available online at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsregisteredinenglandandwalesseriesdrreferencetables ↩ Pressure on NHS front line services has meant that clinicians have not always been available to attend inquests, causing delays, although many have attended remotely, a trend which is likely to continue after the pandemic. Marshall loved football and supported Burnley FC. He also enjoyed fishing and gaming. He was a fierce and loyal friend. The family are heartbroken that they will never see him grow up and fulfil his dreams. Since October 2017, Marshall had been under the care of Child and Adolescent Mental Health Services (CAHMS) run by Lancashire and South Cumbria NHS Foundation Trust. He had been diagnosed with schizophrenia and prescribed antipsychotic medication. The Care Quality Commission (CQC) annual report on Monitoring the Mental Health Act can be found here: http://www.cqc.org.uk/content/monitoring-mental-health-act-report. ↩

Once any post-mortem examination (including any histology or toxicology) has concluded, the coroner must decide how to proceed. There are three main options: Coroners operate within a legal framework and have a duty to investigate all deaths of unknown cause, violent or unnatural deaths and deaths that occur in custody.

Any object at least 200 years old which the Secretary of State considers to be of outstanding historical, archaeological or cultural importance.

The number of deaths reported to coroners in 2021 varied markedly by coroner area – from 247 in City of London to 5,984 in Hampshire, Portsmouth and Southampton. The number of deaths reported in each area will be affected by its size, resident population, demographic breakdown and profile, so comparisons of deaths reported to coroners across coroner areas should be treated with caution. Marshall had previously been admitted under section to the Cove Children and Adolescent inpatient facility on two occasions for 131 days and 315 days. The court heard that the average length of stay is far lower at four to six weeks. Marshall hated the Cove. He was discharged into Jane’s care in January 2020, despite not having improved significantly.

Reporting treasure finds to the coroner

Keep a register of coroner investigations lasting more than 12 months and take steps to reduce unnecessary delays; deaths were reported to coroners in 2021, the lowest level since 1995 [footnote 1] – down 5% (10,300) compared to 2020. INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians.

Once a death has been reported to the coroner an investigation will commence which usually starts with a post mortem. In Lancashire, post mortems are usually non-invasive and are carried out simply by undertaking a CT scan, but occasionally a full internal post mortem is required. In the majority (79%) of deaths referred to coroners, there is no inquest. In 2021, there were 60,084 reported deaths which did not lead to an inquest where a post-mortem was held. The percentage of non-inquest cases that required a post-mortem has seen an increase from 34% in 2020 to 39% in 2021. This figure had previously remained fairly stable since 2017. On 18 August 2016 the Lord Chief Justice, after consultation with the Lord Chancellor, appointed His Honour Judge Mark Lucraft QC as the second Chief Coroner of England and Wales. Judge Lucraft took up post on 1 October 2016, following the retirement of His Honour Judge Peter Thornton QC. An inquest into his death, which concluded on Friday, heard that a council inspection missed the “trench” in the middle of the road because inspectors were “primarily focused” on making the road safe for motorists. Inquest concludes into death of Jake Anderson at Peterlee Police Station who died 12 hours after being detained

The coroner found that there was no risk assessment in place at Marshall’s discharge and that the referral to Children’s Social Care did not happen for another three months. The coroner described evidence about the discharge from Marshall’s Care Coordinator as ‘unimpressive’ and found that the referral should have taken place much earlier. This is where the coroner makes a brief and factual statement at the conclusion of the inquest rather than returning a short-form conclusion. Non-inquest cases Inquest conclusions up 4%, the largest rise seen in accident/misadventure, suicide and unclassified conclusions Within the ‘Key Findings’ sections, figures greater than 1,000 are rounded to the nearest 100. The following symbols have been used throughout the tables in this bulletin:

Marshall’s mother Jane Ireland was a mum of three. Her family describe her as a fun and loving person who brightened every room she walked in to. She was a talented makeup artist and worked on theatre productions and photoshoots. She was also a qualified Reiki therapist and dreamed of opening a retreat. The family strongly feel that throughout his care insufficient efforts were made to get down to Marshall’s level and to engage him in a way that was meaningful to him. Once that MCCD reaches the registrar there are two possibilities depending on whether the deceased was seen before or after death. If a medical practitioner (who does not have to be the same medical practitioner who signed the MCCD) attended the deceased within 28 days before death (a new, longer timescale) or after death, then the registrar can register the death in the normal way. Second, if there was no attendance either within 28 days before death or after death, then the registrar would need to refer that to the coroner. Medical practitioners’ duty to notify coroners In 2021, 772 investigations were suspended (and not resumed) by the coroner under Schedule 1 [footnote 7] of the Coroners and Justice Act 2009 because criminal proceedings took place. Of these, 729 had an inquest open at the time of suspension, representing 2% of all inquests concluded, no change compared to 2020.

Colledge, a member of the Cleveleys Road Club, was described as fit and active at the time of his death, the inquest heard. Prior to July 2013 when the Coroners and Justice Act 2009 was implemented, deaths were either categorised as ‘inquest’ or ‘non-inquest’ cases. Changes in the way coroners investigate mean that there is now a third category of ‘potential inquest’ cases. This means that the coroner has opened an investigation into the death but has not yet decided whether it is necessary to hold an inquest. Depending on whether the coroner deems it necessary to hold an inquest, these cases will all eventually end up in either the ‘inquest’ or ‘non-inquest’ category. In 2021, there were 8,330 potential inquest cases being dealt with by coroners in England and Wales, with 79% requiring a post-mortem. The number of potential inquests in total has increased by 14% in the past year.