29 May 2020

Instead of investigating these deaths fully, fearlessly and thoroughly, identifying the role of the State in failing frontline workers, the effect of your guidance is likely to stymie, limit and frustrate the investigations into the deaths of frontline workers from COVID-19.

Deborah Coles, Director of INQUEST

INQUEST has written to the Chief Coroner following his guidance on COVID-19 deaths and possible exposure in the workplace. INQUEST and members of our INQUEST Lawyers Group are concerned that the guidance advises that inquests are not the place to discuss, for example, the adequacy of policies and arrangements for the provision of PPE.

The letter raises the following points for further consideration:

  • Frontline workers are risking their own lives to a significant degree in order to care for vulnerable people, protect the lives of patients and keep all of us safe from this deadly disease.
  • There are well documented concerns that they are often doing so in agonising circumstances, without adequate access to Personal Protective Equipment (PPE), contrary to World Health Organisation (WHO) guidance, and at grave risk of infection and the fatal consequences that may bring.
  • This appears to be the result of inadequate provision of PPE caused by a range of failures by the State organisations and officials responsible for ensuring that frontline workers are able to perform their duties safely and without risking their lives.
  • Conducted properly, applying the law and respecting the requirements of the right to life, inquests are a powerful mechanism for ensuring justice, accountability and effective lesson learning.

Inquests that achieve those outcomes are the least that the bereaved families of deceased frontline workers deserve. They will also be what the public rightly expects.


Dr Peter Tun raised concerns about an apparent lack of PPE on his ward. In one email to management he said “it's only a matter of time before our ward patients and ourselves get infected."

His son spoke to Channel 4 News about the coroner's decision not to open an inquest into his death, and the unanswered questions he has been left with as a result.

Deborah Coles said that the guidance is likely to lead to inconsistency across the country meaning that many deaths of frontline workers, such as that of Peter Tun, may not be subject to the necessary proper scrutiny. 


For more information on INQUEST's response to COVID-19 and additional resources, visit this webpage.

See also: Deaths of frontline workers must receive proper scrutiny, 9 May 2020


INQUEST are concerned about the lack of information available to bereaved families following a COVID-19 related death, including of key workers. On this webpage, we lay out responses to the most common questions asked by bereaved families and includes essential information about how to protect your rights.