The coroner holds an inquest if a death has been sudden and unexplained, when the cause is unknown, or the death is unnatural.
A coroner's inquest is usually held in a court, but can also be held in other public places. The coroner is not concerned with why the patient died or with civil or criminal liability.
The coroner's remit is to ascertain the circumstances of the deceased's death and to determine who the deceased was, where and when the deceased died and how the deceased came about their death. The coroner does not determine why a person died.
Witnesses are called by the coroner as they feel is appropriate to answer the questions about the deceased. They can include expert witnesses, healthcare professionals and family members. All those who have been given interested person status will be provided with reports of the witnesses whose evidence is to be used in the inquest.
Witnesses can attend voluntarily or be served with a summons, in which case they must attend or be in contempt of court. We would advise doctors to cooperate fully with the coroner and attend an inquest if that is requested, since this is in accordance with doctors' ethical obligations as set out in the GMC's Good medical practice:
'You must cooperate with formal inquiries and complaints procedures and must offer all relevant information while following the guidance in Confidentiality.'
The coroner usually sits alone, but may also sit with a jury in exceptional cases. For example, this would usually occur if:
- the deceased died in custody or state detention, and the death was violent or unnatural, or the cause of death is unknown
- the death resulted from an act or omission by a police officer or a member of a service police force, in the execution of their duty
- the death was caused by a notifiable accident, poisoning or disease.
In most cases where doctors give evidence at an inquest, legal representation isn't necessary and the role of solicitors at inquests can be limited, as the coroner presides over the court.
However, if you think the medical care you provided might be criticised by the coroner, for example if the family or other witnesses have expressed concerns, we would encourage you to contact us for advice, since sometimes separate legal representation can be appropriate.
If the coroner names you as an interested person, please contact the MDU for advice. According to section 47(2) of the Coroners and Justice Act 2009, an interested person relates to 'a person who may by any act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so'.
Preparing for the inquest
The inquest might not take place for some time after you write your report, so read it again carefully beforehand and take a copy with you to the hearing.
It's also helpful to review the records, and if they've already been sent to the coroner you should check they're available at the inquest for review. If they have not been provided to the coroner, you should take a copy of the records to the inquest and be familiar with them, to assist you in giving evidence.
The media may attend and report on any newsworthy inquest. If someone from the media contacts you, remember that you have a duty of confidentiality to the deceased patient and do not make any comment without first taking legal advice, except to offer your condolences to the family.
Find out more about dealing with the media, or contact our press office if you need help with a press enquiry.
Evidence is given under oath or affirmation. Some coroners will ask you to read all or part of your report; others will ask questions based on it. After the coroner's questions, the deceased's family or legal representatives, members of the jury (if present), a solicitor or barrister representing you or another witness at the inquest, may also ask questions.
The coroner is obliged to exclude any inappropriate questions not relevant to the limited scope of the inquiry, and no witness is obliged to answer questions that could incriminate them.
If you think your professional conduct or competence is called into question while you are giving evidence, you can ask the coroner for an adjournment of the inquest and contact the MDU or your trust legal team for advice. This is unusual, and practitioners will normally have already sought advice if they think there may be criticism of the care and treatment given to the deceased.
Advice on answering questions
- Listen to the question carefully. It's easy to try to answer the question you want or expect to hear.
- Don't try and interpret the question by assuming that the words used are imprecise.
- Ask for clarification if the question is unclear.
- Keep your answers short. More questions can be asked if more detail is required.
- Answer as clearly, honestly and succintly as you can.
- Don't be afraid to say that you do not know the answer, or to ask to refer to the records if you need to.
- Avoid speaking too fast; the coroner and others in the court may be making a note of what you say.
- Avoid medical jargon where possible. The inquest is a chance for you to explain clearly what happened to the coroner and the family of the deceased, and it is unlikely that they will all be medically qualified.
- Keep a professional composure, even if the questions seem repetitive. If you do not understand a question, ask for it to be rephrased. If you do not know the answer to a question, or it is outside your expertise, you should make this clear and must not speculate.
We suggest that you clarify with the coroner's office which of your expenses can be reimbursed.
Fees and all reasonable expenses should be paid straight after the inquest. Contact the coroner's officer or the court after the hearing to arrange for reimbursement.
At the end of the inquest, the coroner will summarise and record their own findings and conclusion in a Record of Inquest.
When a jury is present, the coroner will sum up the evidence and direct the jury on any points of law. The question of how the person died should be answered by a brief summary of the circumstances leading to the death, as determined by the jury and in view of the evidence given.
The coroner will record:
- the deceased person's name
- the injury or disease causing death
- the time, place and circumstances in which the injury occurred
- the conclusion as to death
- the registration particulars.
The conclusion may consist of a short-form conclusion or narrative conclusion, or a combination of both.
Typical short-form conclusions include:
- natural causes
- industrial disease
- lawful killing
- unlawful killing
Coroners increasingly use narrative conclusions, which set out a factual summary of what happened. These may include references to failings or omissions on the part of medical staff and very occasionally may include a finding of neglect.
A finding of neglect may arise where the coroner considers there was a gross failure to provide medical care. It does not correspond to a finding of negligence at all.
Reports and recommendations
At the end of the inquest the coroner can report certain matters to relevant authorities, to prevent similar fatalities happening in future. These could include a trust or a GP practice. If your practice or care is implicated, seek advice from us as soon as possible, since the body must respond in writing to the report within 56 days.
If a doctor's care is criticised by a coroner, such that their fitness to practise is called into question, they must tell the GMC without delay. If you find yourself in this situation, please contact the MDU as soon as possible for advice.
I recently attended an inquest into the death of one of my patients. The coroner was very critical of my management and said so quite bluntly. To my mind, his comments were inappropriate. I feel that I have been defamed and I would like to take legal advice.
The coroner is entitled to judicial immunity regarding civil proceedings and in connection with words spoken while exercising his judicial duty, except where the words are in excess or outside his jurisdiction. In the circumstances that you describe, it would not be advisable to pursue an action for defamation.
I am due to go on holiday in three weeks, but have been asked to attend an inquest during the period that I will be abroad. Can the coroner compel my attendance?
Yes. The coroner has power to compel the attendance of witnesses under pain of fine or imprisonment for contempt. Depending on how crucial your evidence is, or how central to the case, the coroner may well look sympathetically at receiving your evidence simply in the form of a statement. Alternatively, he may consider postponing the inquest. He has the authority to compel you to attend, regardless of any inconvenience, but this is rarely exercised.
After the inquest on one of my patients who died tragically at the age of two, I spoke to the parents to express my condolences. It was rather awkward, as during the inquest they had criticised my management. Have I compromised myself by doing this, if they try to sue me? Have I in some way admitted liability?
Expressing sympathy to the family is not an admission of liability. It is a common courtesy that anyone would wish to extend to relatives who have been bereaved recently. The GMC advises doctors, 'If a patient under 16 has died you must explain, to the best of your knowledge, the reasons for, and the circumstances of the death to those with parental responsibility'.
This guidance was correct at publication 05/06/2019. It 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.