Coroners

During our maternity investigations we collect and create records, which coroners may ask us to disclose to assist with their investigations or inquest hearings.

At present, we recognise that we cannot legally protect information from disclosure where there is a legal compulsion or a court order to disclose information. However, it is Maternity and Newborn Safety Investigations (MNSI) programme policy not to voluntarily disclose information unless there is evidence of a serious and continuing risk to patient safety or an overriding public interest in disclosure.

Where a death has occurred and a coroner has commissioned a post-mortem examination, MNSI will request a copy of the post-mortem examination report from the coroner. This provides evidence that may assist our subject matter advisors in understanding the clinical factors involved.

MNSI does not attribute blame or liability and our staff do not act as expert witnesses or provide any opinions during any inquest.

Investigation records

During our investigations records are collected from third parties, for example medical notes from healthcare providers.

We also create records during our investigations, for example NHS staff interviews, subject matter advisor (SMA) reports and investigation reports.

As part of their investigations, coroners may ask us to disclose these records.

Interviews

We may interview the family members, people who have power of attorney, NHS staff engaged in the provision of care and/or any other person that we think is relevant for the purposes of carrying out the investigation.

Under General Data Protection Regulations (GDPR) such personal data must be processed on a valid lawful basis. The family members and/or powers of attorney are asked if they consent to be interviewed and whether they allow us to process their personal and confidential data.

NHS staff engaged in the provision of care are interviewed on the basis that we process their information in the performance of a task carried out in the public interest or in the exercise of official authority vested in MNSI.

NHS staff are encouraged to speak in confidence with us to allow for a more candid view of events to be shared. On this basis it is far more likely the interview will reveal underlying systemic reasons that lead to patient harm occurring.

Recorded interviews are considered personal and include confidential medical and organisational/corporate information.

Interviews often describe the provision of care and the relationships between the family and healthcare professional during a given period.

Some interviews may contain the opinions of staff and on occasion these opinions may be critical of the employer or colleagues.

At present, we recognise that we cannot legally protect information from disclosure where there is a legal compulsion or a court order to disclose information. However, it is MNSI policy not to voluntarily disclose information unless there is evidence of a serious and continuing risk to patient safety or an overriding public interest in disclosure.

Disclosure of information to coroners

After receiving a request to disclose information we consider the type of disclosure request made - informal request to disclose or formal Schedule 5 request to disclose - and what records we could disclose.

Informal request to disclose

These are the records we disclose under an informal request:

MNSI final report.
MNSI draft report (only after factual accuracy completed by the NHS trust and approved by the family).

This is deliberately limited as wider information disclosure would be highly damaging to achieving candid discussion between MNSI and individuals interviewed in future investigations. This would likely have a serious and direct knock-on effect with NHS trusts and other health organisations and their willingness to cooperate with us.

Formal request to disclose

These are the records disclosable under a formal Schedule 5 request under the Coroners and Justice Act 2009:

NHS staff interviews (redacted)
family interviews
subject matter advisor (SMA) reports
meeting notes
terms of reference
pulse report (this is an internal MNSI document detailing what is to be discussed with subject matter advisors at review panels)
any other record listed in the appendix of a final report.

Before any disclosure we seek to ask the coroner to consider the public interest in such disclosure, the purpose of the inquest and the serious and direct knock-on effect this may have on how we work with NHS trusts and other health organisations and their willingness to cooperate with us.

If the coroner, having had due regard to MNSI representations, still requires disclosure, we will comply with the legal requirement.

The coroner may approach the MNSI information governance team to request a copy of any interviews.

Attendance at an inquest

Any MNSI employee called to give evidence at a coroner’s inquest will assist the court by substantiating the factual findings of our safety investigation.

They may assist the court to provide an explanation of the material included in the MNSI report and a personal statement of the role they played. We ask that the coroner specify in advance the date and allocation of the inquest and any specific areas in the report they intend to explore, to ensure the correct individual attends.