How to write a coroner's report - general principles

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. The Medical Council's Guide states that it should be relevant and accurate (paragraphs 51 and 52).

Include your full name and qualifications (eg, Bachelor of Medicine rather than MB).
Describe your status (eg, 'GP trainee' or 'consultant surgeon for 10 years').
Type your report on headed paper where possible.

What to include in a coroner's report

Be specific about your contact with the patient. For example, did you see the patient on a publicly funded basis 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).

Style

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 happened. 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 GP trainee, Dr Jane Smith, to examine the patient again later 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.

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

Outline any hospital referrals, if you are a GP, identifying the name of the relevant practitioner or consultant.

The coroner will often need the whole medical record to be disclosed. Make a full copy for the coroner if requested, including a physical copy of all information held digitally, and retain the original files for your own records before disclosing or returning the records to the coroner.

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 did not find. If you failed to put yourself in a position to make an adequate assessment, your evidence could be challenged. But if your report clearly demonstrates 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, as long as you are making it clear that this is what you're doing.

If you cannot recall the details of a case, state what your usual or normal practice would have been in the 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 on the basis of your own knowledge or the clinical notes.

You should not, however, comment on the adequacy or otherwise of their performance.

How can the MDU help?

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.

For more advice, read our guide to attending a coroner's inquest.

Writing a report for the coroner in the Republic of Ireland

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