Of the 539 calls to our medical advice line from foundation year doctors during a recent five-year period, one of the top three reasons for calling was for help after receiving a request from the coroner. In the first instance, these were usually requests for statements, although far less commonly, the first contact was a request for the member to attend an inquest to give evidence.
Being informed that a patient you have cared for has died can be upsetting and stressful. As part of their inquests, coroners will often need written reports from those involved in the care of a deceased patient. Such requests can make an already distressing time even more stressful for the clinicians involved.
The England and Wales coroners' statistics show that 32,000 inquests were opened in 2020, up 7% compared to 2019. 2020 also saw the highest number of inquests since 1995. Inquest cases represented 16% of all the deaths reported to coroners in 2020. Given these figures, it is understandable that most doctors will have to produce at least one written report for the coroner during their career.
The purpose of an inquest is to establish the circumstances surrounding the death. They are inquisitorial rather than adversarial and the coroner will want you to provide a comprehensive, factually accurate report which is easy to read by everyone, not just other medics.
The following steps can help guide you through responding to a request from the coroner for a statement.
The coroner needs your help in understanding what happened and what your role was. Their request does not necessarily mean there is any specific concern about your input into the case, just that you may be best placed to describe an episode during the patient's care.
Make sure you are fully informed
In order to write an accurate statement, you will need the relevant records to make sure they are consistent with what you submit to the coroner. Don't just rely on your recollections; they may be incomplete or inaccurate by the time you are asked for your account.
It is important that your statement is in line with the GMC's expectation of doctors when they provide evidence for legal processes, namely:
71. You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must make sure that any documents you write or sign are not false or misleading.
a. You must take reasonable steps to check the information is correct.
b. You must not deliberately leave out relevant information.
Discuss the case with your clinical or educational supervisor to obtain feedback and support. Even if you do not feel vulnerable to criticism, they can help reassure you and offer guidance on your statement.
Of course, they may identify learning points that you had not thought of, and the earlier you are made aware of these the better. If it is the case that you should have done something differently, they can help you reflect on this and advise you on how to best remediate.
Cooperate with the request
Whether the request has come straight from the coroner, as often happens in primary care, or via the trust legal team, it is important to note any deadline and respond to the request as promptly as possible.
If you are an employee of the hospital trust, you are indemnified by the trust. They will usually support and guide you through a coroner's process too, so you will be advised by the MDU to liaise closely with the team.
Read the request carefully in case there are any specific issues you have been asked to address.
Before you write
It is in your best interests to include all information requested and by doing so, it may be possible to avoid attending the inquest to give evidence. The more comprehensive and clear your statement, the less likely it is that you will be asked for a supplementary statement or to attend the inquest just to clarify any information that is unclear from your statement.
Points to cover
- Include your full name and qualifications (Bachelor of Medicine rather than MB).
- State the nature of the contact with the patient; for example, that you were the junior doctor on call for medicine overnight.
- Include a brief sentence indicating that you have prepared your statement at the request of whoever wrote you the letter, be it the coroner or one of their officers. You should also state the sources of information that you have relied upon for your statement; this is likely to be the clinical records of which you have a copy, any recollections you may have of this case and your normal practice in a certain situation.
- Outline the history that you obtained from the patient. The history should be written in full sentences and should include negative as well as positive findings. For example, rather than say 'Ptnt been SOB for 1/52' you should write 'Mr X gave a one week history of shortness of breath.'
- Approach the examination findings, if you did examine the patient, in a systematic way in your report, followed by a paragraph on the management plan at the time of your involvement. Again, do this in full sentences, avoiding any medical jargon or explaining it in lay terms afterwards.
- Explain how your involvement with the patient's care ceased.
- Address any particular issue that the coroner may have raised in their request.
Other points in style
- When mentioning any drug, include the name and dosage as a minimum.
- Do not paste sections of the notes into the report or rely on the reader having access to supporting documents. Assume the reader is a lay person with no prior knowledge of the case and no access to the records. In other words, your statement should be able to stand alone.
- When referring to other staff, include their name and job title if possible - the coroner may wish to contact them also as the investigation progresses.
- Write in the first person using an active voice. For example say, 'I reviewed the chest X-ray and it was normal' rather than 'The patient had a normal chest X-ray.'
Seek advice on your report
Your medical defence organisation can advise you not only on what information it might be helpful to include, but also on the style and formatting of the report. When a member contacts us about writing a statement for the coroner, we usually suggest that they send their draft report to our advisory department along with the relevant entries in the medical records and the request for the statement.
We would request that all these documents are anonymised, in keeping with data protection law.
If you work within a hospital trust, the trust should see your draft too before it is submitted to the coroner. It's important to attend any meetings the trust arranges to discuss the inquest.
If you are asked to attend an inquest hearing as a witness to give oral evidence, remember you can contact your medical defence organisation for support throughout the process.
See our other guidance on coroners, inquests and writing reports.
This page was correct at publication on 02/06/2021. 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.