There have been numerous reports regarding the failure of Hampshire Mental Health Trust, Southern Health, to properly investigate the unexplained deaths of over 1000 people who were under their care following the negligence surrounding the death of Connor Sparrowhawk.
Typically, matters of this nature, would be made the subject of a formal investigation in the Coroner’s Court. This investigation is known as a Coroner’s Inquest and is employed when someone has died for some unknown reason, either in a violent or unnatural way, or someone has died whilst in custody or state detention. The Inquest will look to establish the following facts:
- Who has died;
- How, when and where they died;
- Any information required by the Births and Deaths Registration Act 1953;
- Whether there have been any breaches of the European Convention of Human Rights.
An Inquest is very limited in determining someone’s death. Whilst it can establish ‘why’ someone has died the Court does not have the power to attribute responsibility to an individual or body. The Senior Coroner and Jury are prohibited from given any opinion as to who should be blamed for what has happened and it is typically the case that if negligence is suspected – a solicitor is instructed to pursue a separate civil claim against that person or body.
As can be seen in the recent Inquest into the death of Mr Sparrowhawk; the Senior Coroner can make specific recommendations to institutions and organisations for changes to be made to avoid repeat scenarios if there are any criticisms to be made when investigating a death.