Recurring concern

Failure to ensure coronial authority governs donation decisions

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First reported 11 Nov 2013•Latest report 3 Jan 2024

Definition

What this concern includes

Includes failures in arrangements governing organ or whole-body donation when a death is subject to, or may require, coronial investigation, including unauthorised interference with the coroner's decision, unclear or incorrect interpretation of the coroner's authority, and resulting prevention or delay of donation where the coroner has no objection.

Not included

  • Excludes ordinary organ- or tissue-donation consent failures where no coronial authority or death-under-investigation issue is identified.
  • Excludes general police, family-communication or bereavement deficiencies that do not affect a coronial donation decision.
  • Excludes routine coronial investigation, autopsy or body-release failures where donation is not the material safety condition.
  • Excludes substantive disagreement with a coroner's properly made donation decision where the decision is not improperly interfered with or obstructed.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
5

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
Kent Police1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. East Riding and Hull

    AI-generated summary

    James Arthur HOLGATE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Arthur HOLGATE, aged 89, was admitted after recurrent falls and progressive decline, sustained a traumatic head injury after a fall in the Emergency Department, deteriorated, and died on 1 November 2023. The report raises concern that medical research and training establishments may be unable to accept body donations where an inquest is pending, potentially because of an anomaly or uncertainty in the interpretation of the Human Tissue Act 2004.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unclear or incorrect legal interpretation preventing medical research/training establishments from accepting bodies subject to inquest

    Wider context from the report

    “Nottingham politely declined, they indicated that they were prevented from accepting due to what appears to be an anomaly in the law. As the matter was subject of a coronial inquest they could not accept the donation. In non-inquest matters reported to the coroner, where post mortem examination is not required and the coroner is content there is no requirement to investigate further, a form A is signed to indicate this and the coroner is then able to return the deceased back in to the care of their family/personal representative/funeral director to allow funeral arrangements or body donation to proceed. In these instances medical research/training establishments are able to accept donation. Where a coroner is likely to hold an inquest in a situation where a post mortem is not necessary as a cause of death statement can be obtained and the coroner is content that there is no further need to retain the deceased for any further examination, the coroner must also ensure that the deceased is returned back to the care of the family/personal representative/funeral director as soon as practicable. This normally allows for funeral arrangements to proceed. In both instances the coroner authorises release of the deceased, in majority of cases the person is cremated ie they will not be available nor required for the coroner, even when the matter is proceeding to inquest. All relevant enquiries have to be made and sufficient evidence obtained before the release is authorised. It is surprising therefore that the medical research/training establishments are stating that they are prevented from accepting people that are to be the subject of an inquest due to the Human Tissue Act. I fully accept there may be some circumstances where it would be inappropriate however if the coroner has no reason to object then the fact that the death is the subject of an inquest should not prevent the donation. On reading the legislation, the establishments are either indicating an anomaly in the law or interpreting it incorrectly and guidance may be required. Human Tissue Act 2004 covers donation. Section 11 covers permission required from a coroner, it reads: 11 Coroners (1)Nothing in this Part applies to anything done for purposes of functions of a coroner or under the authority of a coroner. (2)Where a person knows, or has reason to believe, that— (a)the body of a deceased person, or (b)relevant material which has come from the body of a deceased person, is, or may be, required for purposes of functions of a coroner, he shall not act on authority under section 1 in relation to the body, or material, except with the consent of the coroner. However the medical research/training establishments refer to section 1(3) of the act which explicitly states the body cannot be accepted unless the death has been registered. Section 1 Subsection (3) HTA states: 1 Authorisation of activities for scheduled purposes 1(3)The use of the body of a deceased person for the purpose of anatomical examination shall be lawful if done— (a)with appropriate consent, and (b)after the death of the person has been registered— (i)under section 15 of the Births and Deaths Registration Act 1953, or (ii)under Article 21 of the Births and Deaths Registration (Northern Ireland) Order 1976. Matters that proceed to inquest are not registered until the close of the inquest. Some inquests are dealt with in a very timely manner, however some may take some months to conclude. It appears that the consent in Section 11 may have the ability to override the consent required in Section 1(3), if it is then organisations are not interpreting it this way. ”

    Source location

    James Arthur HOLGATE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Discuss with the Human Tissue Authority how to clarify guidance and codes of practice on body storage and use criteria, including their interaction with section 11.

    Verbatim wording from the response

    “The Department appreciates that the need for coroners’ consent in section 11 of the Human Tissue Act could allow room for confusion with regards to the criteria for storage and use of a deceased body for anatomical purposes under Section 1, particularly where a coroner is holding an inquest but has released the body. We propose therefore to discuss with the Human Tissue Authority how they can ensure that their guidance and codes of practice provide”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 8 January 2024

    Open published response

  2. Inner North London

    AI-generated summary

    Timothy Patrick CLAYTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Timothy Patrick Clayton died after sustaining an unsurvivable traumatic head injury during a sustained attack in which he was kicked to the head and body. Although his family consented to organ donation and the coroner decided not to object, Kent Police contacted the family about the effect on the homicide prosecution, leading them to withdraw consent. The report’s principal concern was that this placed an improper burden on the grieving family and subverted the coroner’s decision, resulting in six organs not being donated.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to comply with the coroner’s judicial decision

    Wider context from the report

    “1. Kent Police approached Mr Clayton’s family to consider a decision that is, by law, conferred upon HM Coroner. This action placed Mr Clayton’s family in desperately difficult and desperately painful position. Having already given their consent to donation, they were asked to go back on this and to make a further decision based upon the likely success of prosecution of Mr Clayton’s killer, rather than this separate decision resting with a trained, experienced, dispassionate judge – the coroner. This must have added horribly to their distress, and it was a wholly improper burden to place upon them. 2. As the coroner with responsibility for this matter, I did not make the decision not to object to organ donation on a whim. I did so after a great deal of discussion and thought. Though I am a senior coroner with particular experience of organ donation, a subject on which I have lectured to doctors, nurses and police officers on several occasions, I nevertheless sought out a senior coroner colleague on a Sunday afternoon, to try to ensure that I had not missed anything. I was transparent in my thinking, I listened carefully to all advice, including that of the senior investigating officer, and I gave detailed reasons for my decision. Nevertheless, that police officer sought to subvert my judicial decision. He did not ask a more senior police officer to contact me to discuss the matter further. He did not seek to challenge in a higher court. Instead, he effectively reversed the decision made by a judge because he preferred his own view of the matter, and he did this by bringing pressure to bear on a grieving family. In short, a police officer has subverted the rule of law. You may be surprised that I write to you about this matter by way of a prevention of future death (PFD) report. I do so because in this instance, six organs were lost to their potential recipients - two lungs, two kidneys, a small bowel and a pancreas. Six organs represents six lives. ”

    Source location

    Timothy Patrick CLAYTON · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to leave organ-donation decisions conferred on the coroner with the coroner

    Wider context from the report

    “1. Kent Police approached Mr Clayton’s family to consider a decision that is, by law, conferred upon HM Coroner. This action placed Mr Clayton’s family in desperately difficult and desperately painful position. Having already given their consent to donation, they were asked to go back on this and to make a further decision based upon the likely success of prosecution of Mr Clayton’s killer, rather than this separate decision resting with a trained, experienced, dispassionate judge – the coroner. This must have added horribly to their distress, and it was a wholly improper burden to place upon them. 2. As the coroner with responsibility for this matter, I did not make the decision not to object to organ donation on a whim. I did so after a great deal of discussion and thought. Though I am a senior coroner with particular experience of organ donation, a subject on which I have lectured to doctors, nurses and police officers on several occasions, I nevertheless sought out a senior coroner colleague on a Sunday afternoon, to try to ensure that I had not missed anything. I was transparent in my thinking, I listened carefully to all advice, including that of the senior investigating officer, and I gave detailed reasons for my decision. Nevertheless, that police officer sought to subvert my judicial decision. He did not ask a more senior police officer to contact me to discuss the matter further. He did not seek to challenge in a higher court. Instead, he effectively reversed the decision made by a judge because he preferred his own view of the matter, and he did this by bringing pressure to bear on a grieving family. In short, a police officer has subverted the rule of law. You may be surprised that I write to you about this matter by way of a prevention of future death (PFD) report. I do so because in this instance, six organs were lost to their potential recipients - two lungs, two kidneys, a small bowel and a pancreas. Six organs represents six lives. ”

    Source location

    Timothy Patrick CLAYTON · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete a formal review of the circumstances underlying the Prevention of Future Deaths report and the coroner’s concerns.

    Verbatim wording from the response

    “The report from the Coroner states the concerns that there is a risk that future deaths will occur unless action is taken by Kent Police and that it is the Coroner's statutory duty to report to me. The reference to the use of a PFD report is due to the perceived belief that 6 transplant organs were lost to potential recipients and that 6 organs represents 6 lives. This PFD report concerns the issue therefore of organ donation from Timothy Clayton, a 45 year old homeless male who was a homicide victim. The circumstances concerning his death thereby being a live criminal investigation. Following receipt of the PFD report, however, a formal review has been commissioned and completed into the circumstances that led to the report being issued. The review has thoroughly considered the circumstances and the Coroner's concerns and is therefore appended hereto.”

    Source location

    2013-0558-Response
    Page 1 · response
    Published 11 November 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind Kent and Essex Police senior investigating officers of relevant homicide investigation guidance.

    Verbatim wording from the response

    “In accordance with the requirements of Regulation 29, I now write to confirm that all Senior Investigating Officers in Kent Police and Essex Police have been reminded of the guidance contained within the Journal of Homicide and Major Incident Investigation published by the National Policing Improvement Agency. All Senior Investigating Officers are to be advised that any challenge to a decision by HM Coroner is through the Courts processes.”

    Source location

    2013-0558-Response
    Page 2 · response
    Published 11 November 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Advise senior investigating officers that challenges to coroner decisions must proceed through the courts.

    Verbatim wording from the response

    “In accordance with the requirements of Regulation 29, I now write to confirm that all Senior Investigating Officers in Kent Police and Essex Police have been reminded of the guidance contained within the Journal of Homicide and Major Incident Investigation published by the National Policing Improvement Agency. All Senior Investigating Officers are to be advised that any challenge to a decision by HM Coroner is through the Courts processes.”

    Source location

    2013-0558-Response
    Page 2 · response
    Published 11 November 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include the case circumstances in future senior detective training.

    Verbatim wording from the response

    “The circumstances that arose in this particular case will also be included into future Senior Detective training and has been drawn to the attention of senior personnel in the Association of Chief Police Officers Homicide Working Group for national consideration. What is also of note, however, is that no one has been provided with either the original or a copy of Mr Clayton's organ donation card, despite this appearing to have been the catalyst for the consent being sought from the family. The family had not requested the consideration of organ donation.”

    Source location

    2013-0558-Response
    Page 2 · response
    Published 11 November 2013

    Open published response
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Data last updated 7 September 2026