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, and reduce the possibility of having to attend the inquest. Your report could then be read out at the inquest in your absence.
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).
- Describe your status at the time you saw the patient (eg, 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 may make it easier to refer to sections of your report in case you're asked to give 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 (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 and they may not have access to or be able to interpret the medical records.
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, 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 relevant practitioner or consultant.
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.
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 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 here.
Q&A
I've been asked by a police officer for a report about a recently deceased patient. Can I comply with the request?
The duty of confidentiality extends beyond death. It's important to find out whether the police officer is, in fact, working as a coroner's officer. If the police are making inquiries on the coroner's behalf, it is appropriate to cooperate. 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 - for example, in the public interest.
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.
This page was correct at publication on 21/07/2022. 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.