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COASA Training Day
11th April 2019

The coroners investigation following a death where there are mental health issues

s37 of The Coroners and Justice Act 2009 creates a statutory requirement for all coroners' officers and other coroners' staff to be trained
The study day will enable the delegate to develop knowledge and understanding of how the considerations for a coorners investigation of a death where there are issues concerning the mental health of the deceased 
It will place the knowledge within the context of the legal framework and procedural requirements of the coroners' investigation following such a death
The day will be suitable for any person working within or in association with the coroner service
Come along and find out about national guidance, share good practice and develop your professional network

Flyer and booking form will be available in due course

Past Training Events

Maternal, Perinatal & Neonatal Deaths - the coroners investigation 25th July 2018
Learning outcomes
• legal framework, range of enquiries, relevant information and  documentation to conduct an investigation into maternal, perinatal and neonatal deaths
• antenatal & perinatal care from a midwifery perspective
• causes of perinatal death
• information required by the pathologist in a maternal death
We had very interesting and informative input from:
Lynzie Cotton, midwife & delivery suite co-ordinator - Antenatal and Perinatal care
Professor Nicola Robertson, perinatal neuroscientist - Perinatal Hypoxia-Ischaemia: risk factors, prevention, treatment & outcomes
Professor Sebastian Lucas, pathologist - Maternal Death and Post-Mortems
Tom Osborne, senior coroner Milton Keynes - The Coroners Investigation

The Coroners' Investigation following the Death of an Infant or Child 8 October 2015
Learning Outcomes
- perspective & different needs of bereaved families following the death of a child
- ​roles & responsibilities of the professionals involved in a multi-agency response
- legal framework and national guidance to inform best practice for coroner’s officers & other staff
We were very pleased to welcome the Chief Coroner as our keynote speaker 
We are had interesting and informative input from:
- Ann Rowland, Director of Bereavement Services, Child Bereavement UK - The Family Perspective - what families need from you 
- DI Phil Hayes, Child Abuse Investigation Unit, Thames Valley Police - The Police Response to the Death of an Infant or Child 
- Dr Joanna Garstang, Honorary Clinical Associate Professor & Consultant Community Paediatrician - The Role of the Paediatrician in Unexpected Infant or Child Death
- Lydia Judge-Kronis, Senior Mortuary Manager, Great Ormond Street Hospital - Paediatric Post-Mortem,how the APT can assist the coroners' officer
- David Jones, Chair, Association of Independent LSCB Chairs - Local Safeguarding Childrens Board (LSCB)
- Christopher Dorries, Senior Coroner, Yorkshire South West - The Coroners Investigation and the Legal Framework

The Coroners' Investigation following the Death of an Adult at Risk 9 October 2014
The introduction of the Coroners and Justice Act 2009 placing a statutory duty to hold an inquest following the death of a person in any state detention and therefore the requirement to hold an inquest following the death of a person while under a DoLS authorisation has recently taken prominence
We were very pleased to welcome the Chief Coroner as our keynote speaker 
We are had interesting and informative input from:
- The Coroner’s Gatekeeper: Christine Hurst, Senior Coroner’s Officer, Cheshire Constabulary
- The Local Authority Role in Adult Safeguarding: Rachael Elliott, Adult Safeguarding Unit MCA/ DOLS lead, Cheshire East
- The Police Investigation: Jeff Riley, Detective Chief Inspector, Surrey and Sussex Major Crime
- The Legal Framework and The Inquest: Penny Schofield, Senior Coroner, West Sussex
- Speaking up for Adults at Risk: Lynne Phair, Independent Consultant Nurse & Expert Witness, Lynne Phair Consulting Ltd
Lynne was the lead health investigator in the multiagency safeguarding team that investigated the neglect and abuse that occurred at Orchid View in West Sussex. 

Summary of training sessions facilitated by COASA:

in partnership with Teesside University (please note: these courses are now closed):

in partnership with:

COASA study days:



Further Information

2018 July
Investigating Maternal, Neonatal and Pernatal Deaths

2015 October

Investigating the Death of an Infant or Child


2014 October

Investigating the Death of an Adult at Risk


2014 July

Understanding Grief and Bereavement


2013 December

Investigations: putting the new law into practice

click here

2013 July

Organ & Tissue Retention Following a Coroner's PM

click here


Medicine for the Coroner Service

click here

2012 September

Deaths Abroad: The Coroner's Investigation

click here

2012 June

Medical Terminology: An Introduction

click here

2012 May

Diagnostic Testing

click here

2011 September

Introduction of the Medical Examiner


2010 July

SUDIC: A Coroner's Investigation


2009 July

Working Together for the Future to Deliver Reform


2008 July

An Unexpected Outcome of Hospital Treatment


2007 February

Deaths in Care Homes


2006 October

Fire Related Deaths


2006 February

Multiple Fatalities


2005 October

Mental Health Deaths


2005 June

Deaths Overseas


2005 February

Effective Communication with Bereaved People


2004 October

Deaths in Prison


2004 February

Child Deaths



Witness Evidence in Coroner's Court



Medical Deaths



But Is It Evidence?



Road Death



Asbestos Related Deaths



Whose Body Is It Anyway?



Psychological Factors Associated With Sudden Death



Death Investigations Involving the Health and Safety Executive



The Coroners Officers Role in Multiple Fatalities



The Coroner and the Pathologist



Registration and Liaison with the Coroner



Body Recovery at Major Incidents



Options for Donation After Death


Coroners' Officers and Staff Association