Coroner enquiry form

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A Coroner’s inquest is a legal inquiry into the cause and circumstances of a death. In Scotland this is known as a Fatal Accident Inquiry, which is called by the Procurator Fiscal.

You may be asked by the Coroner’s Court/Procurator Fiscal to explain what care was given to a patient who died in circumstances where the reason for the death is unclear or unexpected.

Your employer鈥檚 legal team should support you with statements for coroners and prepare you for inquests, and we would advise speaking to them in the first instance. If you are being supported by your employer, you do not need to inform us.

If you are a witness or an interested person and you are not being supported by your employer, please read our advice guide and complete the form below in full. If you are not sure which of these you are, please clarify this with your employer before completing the form. This will enable us to assess your situation and arrange appropriate advice and support for you without delay. Note that you must have been in the correct category of membership at the time of the incident for RCN to check your statement or provide legal support.

Please confirm that you have read our advice

Contact details

Full name: RCN membership number: Address: Best contact number: Please note that RCN Direct will not usually call you. Where an onward referral is required, provided you were in the correct category of membership on the date that you had contact with the deceased we will provide your contact details to the RCN's Legal Department.Do you give us your consent to pass on this information? Yes No Can we leave you a voicemail? Yes No Can we contact you on this matter by email? Yes No If we need to pass your enquiry to a specialist RCN department, would you like any emails from them to be password protected? Yes No Email address you would like us to reply to Please confirm the email address you would like us to reply to Please list any times that you are unavailable for calls during the next week (9am-5pm):

Employment details

Place of work Employer When did you start working with your current employer? Ward or department Job category Job title Weekly contracted hours Do you have any meetings scheduled? Yes No If yes, please give date, time and location: Are you already being supported by a rep? Yes No If yes, please include details below: Are you in the UK on a visa? Yes No If yes, please include details below (including how long you have been in the UK):

Coroner inquest or fatal accident inquiry

THIS SECTION IS VERY IMPORTANT.

Whilst we do not require in-depth detail at this stage, you must give us enough information so that we do not need to contact you for further information, as this may cause unnecessary delay in arranging support.

Please note, we do not need to see the correspondence between yourself and anyone else involved at this stage; however, you should retain all documentation as our legal team may require this.
Date of patient death: Are you a person of interest or witness? Person of interest Witness Not sure If you are not sure, ask your employer to clarify this for you. Is your employer supporting you? (If you are being supported by your employer, you do not need to inform us) Yes No IMPORTANT: If your employer isn't supporting you, what reason have they given you for not supporting? Have you received correspondence for the inquest or inquiry? Yes No If yes, please provide the sender鈥檚 details: Is there an inquest or court date? Yes No If yes, please include details: Were you responsible for the patient immediately prior to the death? Yes No How long before the death were you responsible for this patient? Has your employer carried out an internal investigation as a result of this patient鈥檚 death? Yes No If yes, what was the outcome of the investigation? Please provide any other relevant details surrounding the inquest or inquiry: Have you been asked to write a statement? Yes No

Statement

If the incident was at a different workplace than the workplace noted above, please explain this below: Who has requested this statement? Employer Coroner Have you been asked for this statement in writing? (If not, please ask for a written statement request) Yes No Have you been given a deadline for the statement to be submitted? Yes No If yes, what is the date? Please give details of your statement request (tell us briefly why you have been asked to write a statement):

Can we update your personal details if any of the above does not match the data we currently hold on your record? Yes No

By submitting this form, you are giving the RCN permission to contact you about your submission.

You can control the information you receive from the RCN by updating your preferences at MyRCN.

We don’t update your contact details unless you ask us to. The best way to check and update the details we hold for you is by visiting MyRCN.

The information you provide in this form will be stored by the RCN.

Protecting your privacy is very important to us. Please view our privacy policy to find out more about the information we collect and how it is used.

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