Being asked to attend a coroner's inquest may appear daunting, but most are uncontentious.
You can expect to be asked factual questions about your involvement in the deceased's care.

If you've never given evidence at a coroner's inquest before, you might find it helpful to attend one as a member of the public - if you haven't 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 - 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 us for advice if it does.

At the inquest

When giving evidence in any forum, it's 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 has died, and when, where and how they 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.²The '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
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 practice (Medical Council Guide, paragraph 61.3).

How we can help

Our medico-legal advisers can help answer any concerns or questions you may have before attending a coroner’s inquest. You can contact us here.

For more advice, read our guide to writing a report for the coroner.

¹ Coroners Acts 1962, part IV, as amended by Coroners (Amendment) Act 2019, sections 26 and 27

² Coroners Acts 1962, section 18, as amended by the Coroners (Amendment) Act 2019, section 12

³ Coroners Acts 1962, section 31(2), as amended by the Coroners (Amendment) Act 2019, section 19

⁴ Coroners Acts 1962, section 31(1), as amended by the Coroners (Amendment) Act 2019, section 19

⁵ Coroners Acts 1962, section 30, as amended by the Coroners (Amendment) Act 2019, section 18

Attending a coroner's inquest in the Republic of Ireland

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