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Receiving a letter from the Coroner’s office or the Trust legal team requesting a statement for an inquest is likely to cause some apprehension in many doctors. In 2019 in England and Wales 40% (210,900) of registered deaths were reported to the Coroner and in the same year an inquest was opened in 14% (30,000) of deaths. It is common for doctors (to some extent depending on their speciality) to have some professional involvement in an inquest at least once in their career. The following article will explain the role of the Coroner, the process of an inquest and the obligations and responsibilities of a doctor involved in a professional capacity.
The office of Coroner was first introduced in England in 1194 shortly after the Norman conquest. Their original role was a pecuniary one to ensure that any taxes owed to the Crown were identified and collected. The coronial duties included investigation of deaths due to suicide, as the assets of the deceased were then owed to the King, and Treasure trove, (which remains within a coroner’s role today).
In current times the Coroner’s role is more focussed on investigating deaths when the deceased’s body is found within their jurisdiction. There are certain circumstances of a death which will obligate a Coroner to open an inquest, including a suspected violent or unnatural element to the death, a death that occurs in state custody, including detention under the mental health act, and when the cause of death is unknown following a post-mortem examination.
There is a statutory duty for a doctor to refer a person’s death to the Coroner when there is reason to believe that any of the above circumstances exist. The Notification of Death regulations (2019) sets out this obligation and includes a list of circumstances where a death must be referred for the Coroner’s consideration.
Following a referral to the Coroner there are several actions that the Coroner may take:
Should a post-mortem reveal a natural cause of death and there are no concerns, the investigation may conclude at that stage without an inquest hearing.
An inquest may be opened when no post-mortem has been conducted in a situation where the cause of death can be established without a post-mortem but there remains another reason for the death to be investigated by the Coroner. In 2019, 41% of inquests did not involve a post-mortem.
A death from apparent natural causes may be deemed unnatural if the Coroner has reason to suspect that an element of care or treatment contributed to the death and particularly if there is a suspicion of culpable human failure in the care of the deceased. This extends beyond medical professionals and may apply to carers or other professionals such as the police or an employer.
When the Coroner opens an investigation, they will gather the information required to establish the answer to four questions: Who died; Where they died; When they died; and how they came about their death. The focus of the investigation and subsequent inquest is the last of these four questions. How the deceased came about their death is not simply the medical cause of death but by what means the person came to their death.
When there is reason to suspect that a death resulted from the State breaching its duty to protect the deceased against a known human threat or other risk, an Article 2 (referring to the European Convention of Human Rights; Article 2 being the right to life) or an enhanced inquest will be heard. This will often but not always require a jury. The circumstances in which a jury is mandatory are set out in guidance from the Chief Coroner. The scope of an Article 2 inquest is wider and includes the broader circumstances leading to the person’s death.
The Coroner also has a role in improving patient safety and must identify and report any problems with systems or processes that continue to exist and risk future deaths or harm. While the Coroner does not apportion blame, in exceptional circumstances, they may also report a practitioner to their regulator if they have serious concerns about the practitioner’s involvement in the care of the deceased or concerns about the practitioner’s conduct at the inquest itself.
The information the Coroner gathers include the medical records, a statement from the family of the deceased, statements from the treating clinicians and any other professionals such as the police or ambulance staff. The Coroner may instruct an expert to opine on the facts of the case, particularly where they are complex.
A statement for the Coroner should be a factual account of a doctor’s involvement in the care of the deceased, set in the context of their medical history. The Coroner will usually give a reasonable time frame in which to provide a statement, on average 6 weeks.
Doctors have a professional obligation to assist the Coroner with their inquiry as set out in Good Medical Practice, paragraph 73. “You must cooperate with formal inquiries and complaints procedures and must offer all relevant information while following the guidance in Confidentiality.”
The Coroner has statutory powers within the Coroners and Justice Act (2009) to compel a doctor to provide a statement or give evidence. Failure to do so without reasonable explanation can result in a referral to the GMC or criminal prosecution, although the latter is highly unusual.
There are some general points to consider when writing a statement for the Coroner:
In some inquests the Coroner will hold a Pre-Inquest Review Hearing (PIRH). This is an opportunity for the Coroner to hear representations from the parties involved, establish the scope of the inquest and confirm the witness list. The PIRH is usually attended by the interested persons (see below) or their legal representatives.
When issuing a summons to attend an inquest the Coroner’s officer will usually notify witnesses of their status at the inquest.
A Witness of Fact attends to give a factual account of their involvement in the care of the deceased. A Witness of Fact cannot question any of the other witnesses, is not entitled to legal representation at the hearing and does not receive advance disclosure of the evidence available to the Coroner.
An Interested Person (IP; formally referred to as Interested Party) is an individual or an organisation who the Coroner believe has sufficient interest in the outcome of the Inquest, or whose involvement is pivotal to the case. An IP may question other witnesses, has the right to legal representation and is entitled to receive advance disclosure. The family of the deceased are usually recognised as an IP.
There are advantages to being granted IP status; however it may also indicate that the Coroner has a particular interest in an individual professional, or they may have contributed to the death, which could result in a criticism surrounding the care the practitioner or organisation provided.
As a professional witness, a doctor’s role is to set out the facts of their involvement in the care. When giving evidence the Coroner will usually take the witness through their statement asking questions or points of clarification. Following the Coroner’s questions the witness will be asked questions by all other IPs including the deceased’s family or their legal representative. As an IP, a witness’s own legal representative will usually be the last to ask questions. This will be an opportunity to cover any relevant points which have not been clearly addressed beforehand or clarify any areas of contention.
The GMC have set out relevant guidance within Acting as a witness in legal proceedings - GMC (gmc-uk.org). All doctors should be aware of their professional obligations when involved in an inquest.
The Coroner has the statutory power to compel a witness to give evidence at the hearing. If a doctor is too unwell to attend or is unavailable for another unavoidable reason, they should notify the Coroner’s office/Trust legal team as soon as possible.
An inquest is a public hearing and as such may be attended by members of the press depending on the nature of the case. The prospect of giving evidence often induces apprehension in doctors, particularly if they are unfamiliar with judicial proceedings. However, an inquest is not an adversarial process, there is no prosecution or defence. That said, anxiety is a natural response, there are some practical steps that a witness can take to place them in the best position at the inquest hearing:
Once the evidence has been heard, the Coroner will determine the facts and reach a conclusion. This can be a short form conclusion such as natural causes, accident or suicide, but the Coroner may also provide a narrative to explain the circumstances by which the death came about.
A Coroner can add a rider of neglect to an inquest conclusion. Neglect has a narrow definition in law and does not have the same meaning as negligence.
Following the inquest hearing the Coroner can write a Prevention of Future Deaths Report in cases where the evidence suggests that further avoidable deaths could occur and that, in the Coroner’s opinion, preventative action should be taken. The report will be sent to the person or authority which may have the power to take the appropriate steps to reduce the risk and they have a mandatory duty to reply within 56 days. These reports are now routinely published.
The Coroner is not permitted to make any determination of civil or criminal liability. An inquest conclusion however may contain a neutrally worded criticism of a professional. For example, “the GP did not examine Mr A when he complained of abdominal pain”.
A doctor is obliged to inform the GMC of criticism received during the course of an inquest as set out in paragraph 75 of Good Medical Practice:
“You must tell us without delay if, anywhere in the world:
a. you have accepted a caution from the police or been criticised by an official inquiry….”
The GMC clarifies within its guidance that “official inquiry” includes an inquest and a doctor should inform the GMC of such criticism that calls their fitness to practise into question. In some instances the criticism is unambiguous and the decision for a doctor to refer the matter to the GMC is straightforward. However this is not always the case and discussion with the legal team or the doctor’s MDO may be helpful.
Involvement in an inquest should be discussed within a doctor’s appraisal. It is wise to reflect on the case and the inquest hearing itself. Many doctors are concerned about the consequences of documenting detailed reflections. The recording of a doctor’s reflection within an appraisal can be restricted to broad themes of learning and should not contain patient identifying information.
An understanding of the inquest process and a sound knowledge of the relevant professional obligations will place doctors in a better position when involved in a Coroner’s investigation. Support from colleagues and expert medicolegal advice from the practitioner’s MDO can ease the burden of stress as well as reduce the risk of an adverse outcome for a doctor assisting the Coroner.
Publication Date: Thursday 14th May 2020
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