Coroners’ investigations – your questions answered

Medical Defence Union Medico-Legal Adviser Dr Ed Farnan explains what to do if you are asked to write a report for the coroner or give evidence at an inquest.

When a loved one dies unexpectedly, their families want and deserve to know what happened and doctors have an important role in that process. In the context of the Covid-19 pandemic, it is no surprise that the coroner service’s caseload has increased in the last two years. According to the coroner’s annual returns for 2021, there were more than 25,400 cases last year compared with just over 17,800 in 2019. 

Unsurprisingly, the Medical Defence Union (MDU) has received more calls from members seeking advice about coroners’ inquiries during the last two years. Most want to clarify their ethical and legal duties and may be nervous about writing a report for a coroner or being asked to attend an inquest. 

The first thing to say is that the vast majority of coroners’ cases do not result in an inquest. In fact, the number of inquests (virtual and in-person) recorded in the annual returns for 2021 was less than before the pandemic (2,101 compared with 2,225). The core function of the coroner is not to apportion blame, but rather to investigate sudden or unexplained deaths so a death certificate can be issued. 

As a doctor, you should co-operate with coroners’ inquiries and respond professionally. This MDU advice should help. 

If you are asked to write a report 

In line with the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (para 40.2), the reports you write “must be relevant, factual, accurate and not misleading”. Here are some do’s and don’ts: 

> Do include your details and qualifications 

State your full name and qualifications (eg, Bachelor of Medicine rather than MB) and status (eg, ‘GP trainee’ or ‘consultant surgeon for 10 years’). 

> Do be specific about your contact with the patient 

For example, did you see them on a publicly-funded basis or privately? Did you see them alone or with someone else during each consultation? If so, give the name and status of the other person. 

> Do not use jargon or medical abbreviations 

Write medical terms in full and when mentioning drugs, give an idea of what type of drug it is, the full generic name, dosage, and route of administration. 

> Do not criticise other clinicians 

Identify any other clinician involved in caring for the patient by their full name and professional status, eg, if you made a hospital referral. Describe your understanding of what they did and the conclusions they reached on the basis of your own knowledge or the clinical notes, but do not comment on their performance. 

The first thing to say is that the vast majority of coroners’ cases do not result in an inquest 

> Do give a factual chronology of events with reference to the clinical notes 

Your report should stand on its own and not assume the reader has any knowledge of the case. 

Write in the first person, describing each relevant consultation or telephone contact and include your observations, working diagnosis or your differential diagnoses. Say what you found, but also what you looked for and did not find. 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. 

> Do specify what your account is based on 

This could be your memory, the contemporaneous notes you or others wrote, or your usual or normal practice. A coroner will not 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 is perfectly acceptable to quote from memory, as long as you are making it clear that this is what you are doing. 

If you cannot recall the details, state what your usual or normal practice would have been in the circumstances. 

> Do not forget to copy the records 

The coroner will often need the whole medical record to be disclosed so take a full copy including a physical copy of all information held digitally. Even when not asked, it is often helpful to disclose a copy of the contemporaneous clinical notes. It is also useful to give the exact dates spanned by the notes, as this is not always obvious from the entries. 

> Do seek advice 

Your medical defence organisation (MDO) can review a draft of your statement before you submit it. 

If you are asked to attend an inquest 

The law on inquests is set out in the Coroners Act 1962 and its later amendments. Here are the answers to some of the most common queries from members: 

Why is it necessary to hold an inquest? 

The purpose of an inquest is to determine who has died and when, where and how the person died, and – to the extent the coroner considers necessary – establish the circumstances in which the death occurred. 

Possible verdicts include accidental death, misadventure, medical misadventure, suicide, natural causes, open verdict or a narrative verdict. A verdict of unlawful killing can also be returned, but this would not be expected in an inquest relating to the medical care of a patient. Coroners or juries can also make recommendations of a general nature to help prevent future deaths or in the interests of public health or safety. 

How should I prepare? 

If you have never attended an inquest before, you may find it helpful to do so as member of the public. It is useful to see first-hand the layout of the court and how witnesses are questioned by the coroner and other representatives. 

This guidance from the Department of Justice may also help. 

Do I need legal representation? 

In most cases it would not be necessary to have legal representation and it can even send the wrong signal to the family of the deceased. Considerations include whether the deceased’s family are legally represented, whether you may be criticised and whether there is a jury. It may be helpful to have a discussion with your MDO and/or the coroner if you are called to give evidence. 

Your hospital legal services manager may liaise with the coroner and arrange legal representation. Keep in mind that there might occasionally be a conflict of interest between you and the hospital. The hospital’s legal advisers will normally let you know if such a conflict arises and you can contact your MDO. 

What can I expect when I give evidence? 

As a witness you will be asked factual questions about your involvement in the deceased’s care. Your responses to questions should be polite, factual, and not omit relevant information. If you do not know an answer to a question, explain your difficulty rather than speculate. Avoid giving an opinion, disparaging colleagues or trying to answer questions that are beyond your expertise or experience. 

Can I be criticised? 

The purpose of an inquest is not to apportion blame, but it is possible for a doctor to be criticised about their involvement in the patient’s care. Seek advice from your MDO if this happens. 

MDU membership is open to consultants and hospital doctors not currently in training posts working in public hospitals. To find out more information, visit www.themdu.com/ ireland or follow us on Twitter @the_mdu