Attending a coroner's inquest in the Republic of Ireland

Understanding your role and responsibilities when attending a coroner's inquest.

  • Although being asked to attend an inquest may appear daunting, most are uncontentious.
  • You can expect to be asked factual questions about your involvement in the deceased's care.

If you have never given evidence at an inquest before, you may find it helpful to attend one as a member of the public - if you have not previously done so as part of your professional training. It is useful to see first-hand the layout of the court and how witnesses are questioned by the coroner and other representatives.

Legal representation

Although in many cases it won't be necessary to have legal representation at an inquest - and it can paradoxically send the wrong signal to the family of the deceased where a doctor attends with a solicitor when this was not expected - there are occasions when it is prudent.

Whether you need legal representation will depend on the circumstances of the individual case, but it can be helpful to have a discussion with the coroner if you are called to give evidence.

Two questions are helpful when assessing whether it is necessary to have legal representation:

  • whether the family of the deceased are legally represented
  • whether the coroner is aware of criticism of the care provided wholly or partly by you.

Finally, the question of legal representation is likely to arise in circumstances where there is a jury inquest1 (juries are not required for every case).

  • If you work in the hospital sector, you may find there is a legal services manager involved to liaise with the coroner and to arrange legal representation, if necessary - so it's helpful to find out if this is happening. Keep in mind that there might occasionally be a conflict of interest between you and the hospital. The hospital's legal advisers will normally let you know if such a conflict arises and you can contact the MDU for advice if it does.

At the inquest

When giving evidence in any forum, it is important to be honest and trustworthy and, as in the written report, not to deliberately leave out any relevant information. Your responses to questions should be factual and you should avoid giving an opinion, disparaging colleagues or trying to answer questions that are beyond your expertise or experience.

The purpose of an inquest is to determine who, when, where and how a person died - and, to the extent the coroner considers it necessary, to establish the circumstances in which the death occurred, to make findings about those matters and return a verdict.2 The 'who, when and where' are not usually an issue for inquests attended by doctors, and the focus is on the cause of death (the means).

The means of death will be returned in a verdict, the possibilities of which include accidental death, misadventure, medical misadventure, suicide, natural causes, open verdict or a narrative verdict. A verdict of unlawful killing can also be returned, but this would not be expected in an inquest relating to the medical care of a patient. Coroners or juries can also make recommendations of a general nature to help prevent further, future deaths or that "are considered necessary or desirable in the interests of public health or safety"3.

While the purpose of an inquest is not to apportion blame4 with regards to the circumstances of the deceased's death, or to consider questions of civil or criminal liability5, it is possible in some circumstances for a doctor to be criticised about their involvement in the patient's care. This might not only relate to the clinical care they provided and decisions they made, but also to their documentation or communication with the patient or their family. Again, this highlights the importance of making full documentation of any interactions with patients and their loved ones.

When the inquest is over, take the opportunity to reflect on the issues that arose and related to you, and apply what you have learned to your professional practice6.


1 Coroners Acts 1962 - 2019, section 40

2 Coroners Acts 1962 - 2019, section 18A

3 Coroners Acts 1962 - 2019, section 31(2)

4 Coroners Acts 1962 - 2019, section 31(1)

5 Coroners Acts 1962 - 2019, section 30

Medical Council (8th Edition 2019) Guide to professional conduct and ethics for registered medical practitioners, paragraph 66.3

This page was correct at publication on 08/03/2021. 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.