As part of their investigations, coroners frequently request written reports from those involved in the care of a deceased patient. For most doctors, preparing at least one report for a coroner will be an inevitable part of their career.

Under the Coroners and Justice Act 2009, coroners have the power to require a witness statement, so it's essential to approach this task with care.

A well-crafted report is worth the effort. It can clarify key details, reduce the likelihood of follow-up questions, and might even save you from having to attend the inquest in person. In many cases, your report might simply be read out in your absence, provided it meets the necessary standards.

This guide applies to England and Wales only.

General principles

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), including the year.
Describe your status at the time you saw the patient (for example, 'GP registrar' or 'consultant surgeon for 10 years').
Type your report on headed paper where possible, using full, grammatically correct sentences.
Divide your report up into clear paragraphs. Numbering paragraphs makes it easier to refer to sections of your report if you're asked to give oral evidence.

What to include

Be specific about your contact with the patient. For example, did you see the patient on the NHS or privately?

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 (for example, spouse, mother, social worker, chaperone).

Style

The report should stand on its own

Don't assume the reader has any knowledge of the case. Several people might have to read the report apart from the coroner and they might not have access to or be able to interpret the medical records.

Write in the first person and refer to patient by name

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. It is better to use the patient's name rather than refer to them as 'the patient'. The family may read the report and using the patient's name gives it a more personal tone.

When sending your draft report to the MDU for review, redact the patient's name and remember to replace this before submitting your final report to the coroner.

Example: instead of writing, "Mr X was examined again later in the day," it's more helpful to say, "I remember asking my registrar, Dr Jane Smith, to examine Mr X again later on the same day, which, according to the notes, she did at [time]."

Concentrate on your observations and understanding

Provide a detailed account of your interaction with the patient including the history you were given, what examination took place and what your clinical findings were.

Include any relevant negative findings. Give an account of your differential diagnosis, management plan and any safety netting advice that was given.

Avoid jargon or medical abbreviations

Your report will be read by those with no medical knowledge. All medical terms are best written in full, avoiding abbreviations and technical language, if possible.

If you have to use abbreviations or medical terms, explain these. If you mention a drug, give an idea of what type of drug it is and why it was prescribed. 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.

Clinical notes

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 phone contact in turn and include your working diagnosis or your differential diagnoses.

Outline any hospital referrals, identifying the name of the hospital referred to and the relevant practitioner or consultant and speciality.

The coroner will often require disclosure of the whole medical record. You should also ensure you have had access to the full medical record when preparing your report and that your report is consistent with these.

The absence of details can be just as significant as the information included. Much like negative findings in clinical reports, it's important to think about what's missing in a coroner's report to provide a full and accurate account.

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, for example, by including relevant negative findings, 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 or explaining what your normal practice would be under those circumstances.

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 based on 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.

Q&A

The coroner has asked me to produce a statement and to send them my patient's original medical records. Can I do this without the consent of the family?

Yes. The coroner is obliged by law to investigate the circumstances of certain deaths. The original 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 if this is requested in addition to the records.

I've been told that if something 'isn’t written down, it didn’t happen' and should not go into a statement. Is that true?

No. It's appropriate to include details from memory, as long as you're clear where the detail comes from with phrases like, "In the notes I recorded that..." or "I also remember that…"

It's not possible to document every detail of every consultation. The purpose of a coroner's report is to assist the investigation, so if what you remember is relevant to the death, include it.

Writing a report for the coroner

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