As part of their inquests, coroners will often need written reports from those involved in the care of a deceased patient. Most doctors will have to produce at least one written report for a coroner during their professional career.
The Coroners and Justice Act 2009 introduced a power to require a witness to provide a statement. A good report is worth the effort; it can minimise the risk of the coroner asking for clarification, meaning you don't have to attend the inquest. Your report could then be read out at the inquest in your absence.
A good coroner's report requires different skills to producing a report for clinical purposes.
The report should be a detailed factual account, based on the medical records and your knowledge of the deceased.
- Include your full name and qualifications (Bachelor of Medicine rather than MB).
- Describe your status (eg, GP registrar or consultant surgeon for 10 years).
- Type your report on headed paper where possible.
What to include
Be specific about your contact with the patient. For example, did you see the patient on the NHS or privately? For clinical or forensic purposes? Or for a combination of reasons?
Where appropriate, say if you saw the patient alone or with someone else during each consultation. Give the name and status of the other person (eg, spouse, mother, social worker).
The report should stand on its own
Don't assume the reader has any knowledge of the case. Several people may have to read the report apart from the coroner.
Write in the first person
The reader should have a good idea of who did what, why, when, to whom, and how you know this occurred. Be precise and explicit.
- Example: instead of writing, 'The patient was examined again later in the day', it's more helpful to say, 'I remember asking my registrar, Dr Jane Smith, to examine the patient again later on the same day, and according to the notes she did so.'
Concentrate on your observations and understanding
Your understanding of a case will be influenced by the history the patient gave you, but don't simply quote what the patient told you happened.
A description of the presenting symptoms is important, but will mainly be used to put the interpretation of your examination into context – it's less likely to be relied on by the coroner.
This emphasis contrasts with a good clinical report, where the history is central to any consultation.
Avoid jargon or medical abbreviations
All medical terms are best written in full. If you mention a drug, give an idea of what type of drug it is. Give the full generic name, dosage and route of administration.
- Example: many lay people might be familiar with abbreviating blood pressure to 'BP'. But 'SOB' for 'shortness of breath' is less common, and could be misinterpreted as something else.
Give a factual chronology of events as you saw them, referring to the clinical notes whenever you can. Describe each and every relevant consultation or telephone contact in turn and include your working diagnosis or your differential diagnoses.
Outline any hospital referrals, identifying the name of the relevant practitioner or consultant.
The coroner will often require disclosure of the whole medical record. Take a full copy for your own files before disclosing or returning the records, including a physical copy of all information held digitally.
Even when not asked, it's often helpful to disclose a copy of the contemporaneous clinical notes. You might need to provide a word-for-word, typed transcript with any abbreviations written out in full. It's also useful to give the exact dates spanned by the notes, as this isn't always obvious from the entries.
The absence of an entry may be important. Just as negative findings are often important in clinical reports, with a coroner's report it's important to think about what's not included, as well as what is.
- Example: you're reporting on a case of a child who has died. The pathologist finds healed fractures at post-mortem, but the notes don't indicate that the parents sought medical advice for these injuries. This raises the question of non-accidental injury, and could have serious and immediate implications for surviving children in the family.
Say what you found, but also what you looked for and failed to find. If you failed to put yourself in a position to make an adequate assessment, your evidence could be challenged. If your report clearly demonstrates that your history and examination were thorough, you are less likely to be called to explain your evidence at an inquest.
Specify what the different details of your account are based on. This could be your memory, the contemporaneous notes you or others wrote, or your usual or normal practice. A coroner won't expect you to make notes of every last detail, or to remember every aspect of a consultation that at the time appeared to be routine. It's perfectly acceptable to quote from memory, making it clear that this is what you're doing.
If you cannot recall the details of a case, then state what your usual or normal practice would have been in the circumstances of the case.
Identify any other clinician involved in the care of the deceased by their full name and professional status. Describe your understanding of what they did and the conclusions they reached on the basis of your own knowledge or the clinical notes. You should not, however, comment on the adequacy or otherwise of their performance.
Our medico-legal advisers can review a draft of your statement before you submit it, to make sure it's as complete and appropriate as possible. If you need to, contact us here.
I have been asked by a policeman for a report about a recently deceased patient. Can I comply with the request?
The duty of confidentiality extends beyond the grave. It is important to find out whether the policeman is, in fact, the coroner's officer. If he is making inquiries on the coroner's behalf, it is appropriate to co-operate with him. Any other police officer making inquiries into the circumstances of a person's death would need the consent of the executor of the estate or the personal representative before such information could be released, unless you believe the situation justifies a breach of confidentiality (ie. it is in the public interest).
The coroner has asked me to produce a statement and to send him my patient's original medical records. Can I do this without the consent of the family?
Yes. The coroner, or procurator fiscal in Scotland, is obliged by law to investigate the circumstances of certain deaths. The originals of medical records and relevant information about the deceased must be disclosed to the coroner or the coroner's officer on request. Make sure that you keep copies of anything you send. The MDU can assist members with the preparation of a statement to the coroner.
This guidance was correct at publication 19/03/2018. It 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.