Advice for doctors on attending coroners’ inquests

There has been widespread media coverage recently regarding the Inquest into the death of Emma Stones, a 12-year old girl with cerebral palsy who died of septicaemia at Tameside General Hospital in February 2011. On Monday the South Manchester Coroner, John Pollard, delivered a narrative verdict declaring that the standard of care provided to Emma was lacking to such a degree that it played a part in her death.

All healthcare professionals are likely to attend or provide evidence to a Coroner’s Inquest at some stage during their career.  The purpose of this article is to explain the inquest process and assist with preparation should you be required to attend an inquest.

Who is the coroner and what is their function?

The coroner is an independent judicial officer and must be a qualified doctor or lawyer of at least five years standing. Coroners operate on a local level and their duty is to investigate and adjudicate upon any death in their area which is sudden, unexplained or cannot be registered by the Registrar of Births, Deaths & Marriages.

When is an inquest required?

In 2011, 46% of all registered deaths in England & Wales were reported to a coroner. Of these, inquests were opened in respect of 30,981 deaths (about 14% of all deaths reported to the coroner). The coroner is required to hold an inquest where:

– There is reason to suspect the deceased died a violent or unnatural death;

– The cause of death is unknown;

– The deceased died in prison or otherwise in the custody of the State, for example whilst detained under the Mental Health Act.

What questions will the inquest answer?

An inquest is a public hearing directed solely at determining who the deceased person was and how, when and where they died. In certain circumstances, for example where the deceased died in prison, the scope of the Inquest can be widened to include a more detailed examination and commentary on the circumstances of the death. Coroner’s verdicts are forbidden from including any opinion on criminal or civil liability, for example allegations of clinical negligence. This does not, however, prevent the coroner from recording conclusions of unlawful killing or neglect when appropriate.

As a healthcare professional, it is important to remember that inquests are inquisitorial, meaning they are an exercise in fact-finding and not an exercise in apportioning guilt.

Preparing for an inquest

Prior to the inquest, the coroner will request statements from relevant witnesses and this will almost always include healthcare professionals. If you are drafting a statement yourself without legal assistance, make sure it is an honest, chronological account of your involvement in events. Include details of your background, qualifications and experience and refer to key entries in the medical records. Stick to the facts and avoid including your opinions, or comments on the actions of others.

Once the coroner has received all the witness statements, he/she will decide who is required to give oral evidence at the inquest. If your statement is thorough and covers all the issues, or if your involvement was only peripheral, the coroner may conclude that your statement can simply be read at the Inquest and you do not need to attend in person.

If the coroner asks you to attend the inquest it is advisable to do so. Should the coroner actually issue a witness summons, then it is compulsory for you to attend the inquest and not attending could result in proceedings for contempt of court.

Prior to attending the inquest you should read over the witness statement you provided to the coroner, review the deceased’s medical records and request copies of key documents such as the post-mortem report and any SUI reports prepared following the death. If recommendations were made in any SUI reports, or if you have identified any learning points yourself, it is important to try and implement these – coroners wish to see evidence of learning from mistakes.

Attending an inquest

At an inquest, you can expect to see the coroner, the coroner’s officer, interested persons (for example, the relatives of the deceased) and legal representatives. Inquests are public hearings and members of the public or press may also be in attendance.

As a witness, you will be escorted to the witness box by the coroner’s officer and then invited to swear an oath or make a statutory affirmation to tell the truth. You will usually read your witness statement aloud and then be given an opportunity to expand on or clarify any points. The coroner examines, or questions, each of the witnesses and conducts the inquiry. Interested persons or their legal representatives also get an opportunity to question the witnesses. You are not obliged to answer any questions tending to incriminate you and the coroner will give you a warning if such questions are asked.

It is helpful to bear in mind when giving evidence that you should direct your comments to the coroner, take your time (speaking slowly and clearly) and feel free to say so if you don’t understand a question or don’t know or remember the answer to a question. Take time to consider your answers and try to be concise.

After you have given evidence you will be released by the coroner and are then either free to leave, or stay and listen to the rest of the inquest.

Once all the evidence has been heard and any legal submissions made, the coroner will deliver his findings, often called the verdict.  There are a number of short-form verdicts, including ‘natural causes’, ‘suicide’, and ‘industrial disease’. More and more often coroners tend to record narrative verdicts, where they summarise the evidence heard at the Inquest and explain their conclusions in some detail. If the coroner has identified a particular risk of other deaths or considers that particular action needs to be taken he can write to an appropriate body, such as the General Medical Council or Health & Safety Executive with recommendations.  This is known as a Rule 43 letter.


Most Inquests are routine and do not need to be feared. The key to reducing any anxiety you might feel is (i) good preparation and (ii) seeking the right advice and assistance at an early stage when you do need professional help.

Andrea James is Head of Healthcare Regulatory at George Davies Solicitors LLP, former in-house solicitor to the General Medical Council and specialises in advising healthcare professionals. Click here for further information.

Event: GMC Fitness to Practise – Legal, Insurance & Financial Perspectives

George Davies Solicitors are pleased to invite you to a free evening seminar for doctors covering: the GMC fitness to practise process; the insurance risks of the fitness to practise process; and managing your finances during the fitness to practise process.

Details: 19 September, 18.30-21.00, The De Vere Whites Hotel at Bolton Reebok Stadium

To reserve a space please contact [email protected] or call 0161 236 8992

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