Criticism at a coroner’s inquest

The scene

A patient attended his GP, concerned about symptoms of chest pain and shortness of breath. He was known to have ischaemic heart disease, and had previously been under the care of a cardiologist at the local secondary care trust. He was on maximal medical therapy.

The GP was concerned that his presentation represented a progression of his disease and made an urgent referral to the same cardiologist. She included a brief history in the referral letter, and had intended to send copies of previous correspondence and a summary sheet including the patient’s past medical history as attachments. 

Unfortunately, she inadvertently omitted to do this, and the cardiologist only received the brief covering letter which did not contain all of the relevant clinical information. The cardiologist was on leave, and the referral was downgraded to ‘routine’ by a different cardiologist who did not review the previous medical records.

Several weeks later the patient had a myocardial infarction and died.


The GP was then asked to attend an inquest by the coroner. She was also an experienced forensic medical examiner and had often attended inquests in that capacity. Because of this, she felt comfortable doing so again and did not seek MDU advice before attending the inquest, although the context of her attendance in this case was different.

At the inquest, the patient’s family and the secondary care trust were both legally represented. The barristers for the family and the barrister for the trust both questioned the GP robustly about the content of her referral letter, suggesting that if it had been more complete or if the intended attachments had been sent, the referral would not have been downgraded and the patient would have been seen before his fatal heart attack.

The GP had not expected to be aggressively questioned, and felt unable to point out that while she had not attached all of the information that she had intended to, the patient’s history was well known to the trust and was extensively documented in the trust’s own records. The coroner echoed the barristers’ criticism in the final determination.

MDU advice

The GP contacted the MDU for help. The MDU's medico-legal adviser explained that the GMC must be notified if a doctor is criticised by an official inquiry. This includes criticism at a coroner’s inquest, if that criticism relates to serious matters that could call the doctor’s fitness to practise into question.

The MDU adviser suggested that the GP discuss the case with senior colleagues, including her responsible officer (RO). The MDU also instructed a solicitor to consider the implications of the coroner’s comments.

Having done so, and having reflected on the case and taken steps within the practice to minimise the chances of a similar oversight in future, the GP decided that the threshold for a referral was not met in this case. The GP’s RO discussed the case with a GMC employment liaison adviser, and agreed with the GP’s decision. 

Learning points

Attending an inquest can be a challenging experience, even for doctors who are familiar with acting as a witness. It is always worth contacting the MDU before you attend an inquest, or before you provide a statement for the coroner. We can discuss the case with you and determine if there are possible vulnerabilities you had not considered, and whether it is worth instructing a solicitor to represent your interests. 


This page was correct at publication on 02/07/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.