Coroners' inquiries

An introduction to coroners' inquiries in England and Wales and your duties as a doctor.

  • 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.

Types of cases to refer

Regulations introduced in October 2019 in England and Wales mean doctors must notify the coroner of certain categories of deaths.

The Notification of Deaths Regulations 2019 require a medical practitioner (who is registered with the GMC and has a licence to practise) to make a notification to the senior coroner in the area where the deceased's body lies, under certain circumstances. Some of the relevant circumstances surrounding death which need to be reported to the coroner include:

  • 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
  • death due to a 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.

You should be familiar with the requirements for completing medical certificates of the cause of death (MCCD) and only sign statements you believe to be true. The MCCD must be completed by an attending medical practitioner who has seen the deceased either in the 14 days before the date of death (28 days in Northern Ireland), or after death. 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 are 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 suspicious, it is important to inform the police straight away. For deaths that are not suspicious, but need to be reported to the coroner, the expectation is that this will be done as soon as reasonably practicable. 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.


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 attending the deceased patient in their last illness is required by statute to complete a death certificate, giving the cause of death to the best of their knowledge and belief.

If you feel you don't have the knowledge and belief to complete the certificate, then it can be completed to show that the death has been reported to the coroner. The registrar cannot register the death until the coroner has finished their inquiries.

If a medical examiner has been appointed in their locality, doctors may wish to discuss the cause of death with them in the first instance, which may resolve any uncertainty about the cause of death.

Where a medical examiner has not yet been appointed or where the uncertainty is unresolved, doctors may wish to avoid delay by reporting a death informally to the coroner and seeking advice on whether it's appropriate to issue a death certificate. While the coroner can't give you authority to sign a death certificate, they may be able to explain whether a certificate completed in the way you think most appropriate might allow registration.

However, on receiving this advice, the doctor should not initial the certificate to indicate that the coroner has been informed. If it is initialled, the death cannot be registered without the coroner's authority, which could then result in the very delay that the doctor hoped to avoid.

This page was correct at publication on 26/07/2022. 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.