An inquest is a fact-finding inquiry, not a trial.
It is held by a coroner when they decide a death may not be due to natural causes, or where the cause of death is not known.
You might be asked to give statements about the care and treatment you provided to patients who have died and, if required, attend inquests as a witness.
Want to know more? Watch our webinar on managing the risks of the coroners' courts.

Types of deaths to refer to the coroner

Regulations introduced in October 2019 in England and Wales require doctors to report specific types of deaths to the coroner.

The Notification of Deaths Regulations 2019 requires a medical practitioner registered with the GMC and with a licence to practise to notify the coroner in the area where the deceased's body lies, under certain circumstances.

Some of the relevant circumstances surrounding deaths that need to be reported to the coroner include where there is reasonable cause to suspect more than a minimal contribution to the death by:

poisoning, including by an otherwise benign substance (such as salt/sodium) and refers to either deliberate or accidental intake of poison
the use of a medical product, controlled drug or psychoactive substance
violence, trauma or injury (including those that are self-inflicted as well as assaults and accidents)
self-harm
neglect, including self-neglect
person undergoing a treatment or procedure of a medical or similar nature
an injury or disease attributable to a person's employment
where the practitioner suspects the person's death was unnatural
deaths in custody or state detention
cause of death or identity of the deceased is unknown.

Medical certificates of cause of death

You should be familiar with the requirements for completing medical certificates of the cause of death (MCCDs) and only sign statements you believe to be true. The MCCD must be completed by a medical practitioner who attended the deceased during their lifetime.

In England and Wales, once the cause of death has been decided, the death should be discussed with a medical examiner (ME), whose role is to scrutinise the death. The medical examiner will submit the MCCD to the registrar.

If you can't complete the MCCD, you should refer the matter to the coroner and tell the deceased's family.

Referring a death to the coroner

The coroner receives notifications from a number of sources, including doctors, the police, medical examiners, medical referees and the registrar of births, deaths and marriages.

Even if you're aware that a death has already been reported to the coroner - for example, by the deceased person's family or the police - the regulations make clear you must still report the death, to make sure all the relevant information is given to the coroner.

This is the case regardless of how much time has passed since the death.

Where the death is clearly unnatural, it is important to inform the coroner straight away. Otherwise, the registered medical practitioner should take reasonable steps to establish the cause of death (for example, by discussing with the ME) and report to the coroner as soon as reasonably practicable. There is no timescale in the regulations but this should be 'prioritised'.

Suspicious deaths should be reported to the police immediately.

The guidance also recommends that doctors making a notification to the coroner include their GMC number as part of the 'further information that they consider to be relevant to the coroner'.

The coroner's investigations

Once a death has been referred, the coroner will investigate the circumstances in which it occurred. This can involve ordering a post-mortem as part of the investigations.

Inquiries are usually conducted by the coroner's officer, who is often also a police officer. You should cooperate fully by providing medical records and information if you're asked to.

Coroners and confidentiality

Although the duty of confidentiality still applies after the death of a patient, there is an exception when giving information to the coroner (or procurator fiscal in Scotland).

The Coroners and Justice Act 2009 introduced the power to require the production of documents to the coroner. Not doing so could result in a fine and may also constitute a criminal offence.

If the coroner asks for information about living patients as part of the inquiry, you normally shouldn't hand this over before the inquest without the patient's consent. However, the coroner can order you to do so during the inquest.

In this situation, it could well be prudent to contact the MDU for advice and you may need to seek an adjournment in order to enable you to do so.

In the case of a suspected murder or manslaughter, the coroner will pass the investigation to the police, to whom you can then disclose the medical notes directly.

Fatal accident inquiries in Scotland

All sudden, suspicious, accidental, unexpected and unexplained deaths in Scotland are investigated by the procurator fiscal, rather than a coroner's office. Read more in our guide on fatal accident inquiries (FAIs).

There are some differences in the way the coronial system operates in Northern Ireland. If you need details, speak to the MDU's medico-legal advisers.

Q&A

I'm a practice manager. The coroner has asked for a report about a patient who was seen by several different GPs at the practice. It looks as if some blood results were not acted on, possibly because of a problem with our system that we're planning to investigate. Who should write the report?

It's generally preferable for the doctor who had the most recent contact with the patient to write the report on behalf of the practice. That doctor will be able to describe their own contact with the patient and might have important recollections as well as information from the notes.

Where there has been a potential problem with a practice system, it would be sensible for a GP partner to be involved.

I'm a salaried GP acting as a duty doctor. I've been asked to write a report for the coroner about a patient I only met once, months ago. They were seen by other doctors subsequently but none of them are currently available. Should I be the person writing that report?

Every doctor has a responsibility to assist the coroner. It's not always practical for the doctor who had the most contact, or the most recent contact, with the patient to write a report.

It's reasonable to write a report about care provided by other people as long as it's clear from the report what your personal involvement was. Whatever you say about the involvement of others must reflect exactly what is in their records. Writing reports takes time and care and is unlikely to fit into a duty session.

A patient, a woman in her 60s, died recently. She had only been on my list for six months and I saw her on one occasion three months before her death. I was aware from her notes of a problem with alcohol abuse and her relatives now tell me that she was neglecting herself. In short, I don't know whether I could sign a death certificate. Should I ask the coroner's permission?

A doctor who attended the deceased patient during their lifetime can complete a death certificate, giving the cause of death to the best of their knowledge and belief.

This generally means a medical practitioner who cared for the patient and who is familiar with the patient's medical history, investigations and treatment. They must have access to the relevant medical records and the outcome of any investigations.

Chronic consequences of smoking or alcohol do not need to be reported to the coroner. However, if there's reasonable cause to suspect that the death was due wholly or in part to self-neglect, then this should be reported. You can discuss with your local medical examiner first.

Coroners' inquiries

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