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News and updates from today's conference focusing on the role of the Coroner and preparing and attending Coroner’s Inquests.
EXTENDED SESSION: Learning from Deaths: The Coroner’s Investigation and the Inquest
Speaker: Ms Nadia Persaud
Area Coroner for East London
Nadia talked about the role of the coroner, she said "The role of the coroner is to determine the cause of death, who, when, where and how the individual died".
Nadia also said "Our focus is on the systems and the trusts, we are not there to place blame on individuals"
A Clinician’s Perspective of Investigations and Inquests
Speaker: Dr Martin Farrier
Associate Medical Director Chief Clinical Information Officer and Consultant Paediatrician, Wrightington, Wigan and Leigh NHS Foundation Trust
Martin discussed how they collect and use data at his trust. He said "Was the death preventable? This is the question we ask ourselves" " Every week we review notes, write a report and then send this out, it summarises, includes data and tells stories of patients, which enables conversations", "This then leads to making change happen".
Martin also said "Data doesnt tell stories, If you want people to engage, you have to tell stories". "In the future I believe we will be building systems to monitor our data".
Learning from Deaths and Implementing Coroner Recommendations at a Local Level
Speaker: Dr Dee Traue 
Medical Examiner, Royal Free London NHS Foundation Trust
Dee spoke about what medical examiners do, she said "We have to find out what caused the death? was the coroner notified? and we also need to look at if the care before the death was appropriate?"
Dee also said " We are independent, looking at deaths all over our geographic area", "We review in three parts, firstly looking at the medical records, then we speak to the doctor who cared for the patient to get their views, and then the really central part of our role is to speak to whoever is going to register the death".
Dee concluded by saying "With 90% of deaths there are no concerns about the care provided".
