Are RPs geared up to deal with inquests?

Posted: 3rd July 2024 Fiona Underwood, Executive Chair, Altair and Samantha Grix, Partner, Devonshires,

Inquests often make headlines and when Registered Providers (RPs) are involved, the spotlight is on the condition of housing and service provision. This scrutiny brings significant legal, regulatory and reputational risk so effective management and mitigation is imperative.

The untimely death of a customer is always tragic and the distress this causes for staff and/or other customers should not be underestimated. While RPs are usually well set up to deal with the emotional impact of an untimely death, the practical side is all too often dealt with haphazardly and without policies and procedures to guide staff. This chaotic approach increases risks and should be a priority for governance and regulatory teams.

Common challenges we see arising out of inquests are as follows:

  1. Knowing who to escalate to when an untimely death occurs

In the event a customer passes away in what is perceived to be an untimely manner (this being not due to natural causes) and where their housing/support was central to the circumstances, this should be escalated to a senior member of staff. Failure to do so can result in the loss of key information and data, which creates risk.

  1. Correspondence from the Coroner

Failure by staff to pass enquiries from the Coroner to the correct person within the organisation is something we see a lot. It can frustrate the Coroner and compress timelines for complying with the request which puts pressure on the organisation.

  1. Reviewing the circumstances

An immediate investigation/review of the circumstances leading up to the death is crucial. It should include reviewing the RPs records and speaking to relevant people. This should be undertaken as soon as possible after notification.

Where serious failures are suspected, consideration should be given to outsourcing the review to an independent organisation so that an objective and skilled review can be undertaken. This approach has proven very effective in mitigating risk of negative findings for many of our RP clients.

  1. Communications and PR

When instances become public, it is essential to manage communications with the public, stakeholders, staff and residents. Consideration should be given to the capacity of in-house communications teams and whether to utilise specialist communications agencies to support the delivery of appropriate messaging to mitigate reputational damage.


The risks

The risks we refer to throughout this article are fourfold.

The first relates to a Prevention of Future Death report (PFD) being made by the Coroner where they think a similar death could occur again due to a failure by the RP. This is a published report and is something the Regulator will want to know about. As such, by determining the extent of the issues and implementing recommendations to resolve them before the inquest takes place, RPs can mitigate and often prevent the need for the Coroner to make a PFD.

Where the circumstances leading to the death present a breach of any of the Standards, consideration of a self-referral to the Regulator will need to given, and they will decide if action is necessary. Where there is concern of serious failures, it is far better to be transparent with the Regulator than wait for them to read about the issues in the news. The recently launched revised consumer standards set a robust expectation to self-refer to the Regulator on all material issues that relate to non-compliance or potential non-compliance with the standards.

Where there is evidence of neglect, for example, RPs risk being subject to civil proceedings. This is usually something that occurs after the inquest as next of kin will wait to see what evidence comes out of it before deciding if there is a claim.

Finally, RPs need to consider the reputation risk. This is something that needs to be handled carefully and with third party advice at times where there is a lot of media interest. Ensuring accurate and sensitive information is provided can help protect the organisation’s reputation.


I have been representing RPs in inquests for going on 15 years and the same challenges come up time and again. I think this is because they happen so infrequently (thankfully) so staff aren’t familiar with how to deal with them. However, the risks of not being prepared are high and my best advice for RPs is to ensure that they have a policy and procedure for dealing with untimely deaths and that matters are dealt with efficiently upon becoming aware of an untimely death. This will mitigate the risks and allow the appropriate people to coordinate the action plan.

Samantha Grix, Partner at Devonshires 

Having been involved in investigations that have been referred on to the Coroner’s office, it is crucial to have an independent view of the issues and to identify where opportunities may have been missed and lessons that can be learned. Investigations have to be undertaken with complete confidentiality and sensitivity while thoroughly addressing the core issues. Working closely with other professionals ensures all avenues are explored and risks mitigated.

Fiona Underwood, Executive Chair, Altair


Register your interest for our seminars: “Proactive Preparedness: Ensuring Compliance and Best Practise for Inquests”

We plan on running a series of three in-person regional seminars in the latter part of the year to discuss the challenges of inquests. These seminars will feature shared experiences from those who have dealt with inquests within their organisations and offer strategies to mitigate risk. We will also have guest speakers to provide diverse insights and perspectives.

If you are interested in attending, please register your interest using this link:

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