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Inquests – how can we help?

09 September 2021

Dr Rachel Birch, Medicolegal Consultant at Medical Protection, looks at how inquests work and why you need Medical Protection assistance.

Medical Protection is frequently contacted for advice in relation to inquests, be that writing a statement for the coroner or attending an inquest to give evidence. In this article we look at the potential risks and how to mitigate against them, which are important points to consider following a request for a report or a summons to attend an inquest.  Most GPs are familiar with contacting the coroner to report a sudden death or discuss the likely cause of death of a patient. However, some GPs may not have been asked to provide a factual statement for the coroner, and even fewer will have attended an inquest in a professional role. It can be daunting facing such scenarios, especially if the patient’s death was unexpected. Your role in this situation is to assist the coroner in an inquest into a patient’s death by offering all relevant information.  

The coroner’s inquest

An inquest is a fact-finding exercise and is inquisitorial rather than adversarial in its process. The coroner does not aim to establish blame, culpability or liability; rather, the purpose of the inquest is to establish: 

• “(a) the identity of the person in relation to whose death the inquest is being held.
• (b) how, when and where the death occurred, and 
• (c) to the extent that the coroner holding the inquest considers it necessary, the circumstances in which the death occurred, and to make findings in respect of those matters (in this Act referred to as ‘findings’) and return a verdict”

The coroner’s role is not to consider or investigate questions of civil or criminal liability at the inquest. 

In providing a written statement, or giving oral evidence at an inquest hearing, a doctor’s (or other healthcare professional’s) role is to provide factual information to assist the coroner in concluding the process and answer the above questions.

The coroner will usually collect statements from individuals who have been involved in the care of the patient, often including a close relative of the deceased, and those clinicians and agencies who were involved in the care of the deceased prior to their death. 

Factual statement

If the coroner requests you to provide a written statement regarding the patient’s medical history, you should ensure that you have sufficient knowledge of the patient. It would usually be appropriate for you to provide a statement if you have been involved in the patient’s care, especially most recently, or alternatively if you are the patient’s registered GP.  

The Medical Council advises in Guide to Professional Conduct and Ethics for Registered Medical Practitioners: “Reports must be relevant, factual, accurate and not misleading.”
Therefore, it would be prudent to take reasonable steps to ensure that the information in your statement is accurate, and you should include all information that is likely to be relevant to the coroner’s investigation.

Medical Protection’s guidance on Report Writing may be of assistance in the preparation of a factual statement.  

Your opening paragraph should generally include your qualifications, a brief description of your experience, your current role (and role at the material time if this was different) and the time in post. 

As the statement is highly likely to be read by the family of the deceased, it is appropriate to offer condolences before moving on to the body of the report. 

The level of detail will vary depending on the contact(s) you or the practice had with the patient, but the sources relied on to write the report should be given – for example, the medical records, recollection of the consultations and usual practice. Where other clinicians were involved in the care of the patient, those clinicians should be given an opportunity to review the aspects of the report detailing their involvement, and to consult their own indemnity provider as necessary.

An overview of the patient’s past medical history and medications should be provided, and the statement written in chronological order. Each relevant consultation should be described such that it is clear what history was obtained from the patient, and what the findings of any examination were, along with the working diagnosis and the rationale for reaching that diagnosis. The management plan should be explained and any medical terminology defined in lay language. If blood results or observation readings are provided, the normal values and the units of these should also be provided.

If specific questions have been asked by the coroner, then these should be addressed. 
It should be made clear when the practice’s or an individual clinician’s involvement with the patient ended, and it is appropriate to end the statement with an offer to provide further information or clarification should it be required. 

The final version of the statement should be signed and dated. 

It is not usually appropriate to simply provide a copy of the relevant medical records, and this may be more likely to result in a summons to attend the inquest in order to explain the entries and provide additional information. 

If you are asked to provide a statement for the coroner, please do not hesitate to contact Medical Protection to request advice on your statement prior to its submission. 

Giving evidence

You may be called to attend an inquest as a factual witness. The coroner may either ask you to read your statement in court or may take you through it asking relevant questions. The family may also have questions that they wish to ask you. If the family of the deceased patient are legally represented, then their legal representative will also be provided with the opportunity to ask you questions.

It is helpful to know, prior to the inquest, whether the family are going to be legally-represented and, in particular, whether they have raised any complaints or concerns with respect to your individual involvement (or that of the practice). If you have any concerns that you may be subject to criticism about the care you provided to the patient, then it would be important to discuss your concerns with Medical Protection. In some circumstances we may arrange for you to have legal representation at the inquest, if there is any medicolegal vulnerability.    

When giving evidence you should ensure that you are familiar with your written statement and the medical records, and have these to hand. If you are attending to give evidence in person, you should ensure you attend the court in good time.  If you are providing evidence remotely, it is recommended that you have undertaken a test run with the court in advance and that you have a quiet private room to give evidence from where you will not be disturbed. Unless you have permission from the court, you must be alone when you give your evidence. 

When speaking to the coroner or answering questions from other parties, you should speak clearly and ensure any medical terms are explained. You should ensure that you answer any question openly and honestly, but do not try to predict what the coroner might ask next and answer pre-emptively – the coroner will seek further information as required. 

If there is a pause after you have finished speaking, do not be alarmed or leap to fill the silence. The coroner may require a brief period of time to make notes or consider their next question. In the event you do not understand the question or you do not know the answer, state this.

At all times your tone of voice should be explanatory and non-confrontational, and you should not speculate on the actions of others. 

The verdict

At the end of the inquest the coroner will reach a conclusion, referred to as the verdict. This may be of a short form; for example, the death was due to natural causes, suicide, or accidental death. Alternatively, the coroner may provide a more detailed narrative conclusion, which contains more information about the circumstances in which the death occurred. They may also make recommendations for actions they consider necessary to prevent further deaths or to protect public health or safety.

There may be potential risks to individual doctors involved in an inquest, even if that doctor is there to represent the practice as a whole. If the coroner is concerned that the standard of care provided to the patient contributed to their death, they may make reference to this in their comments. This could potentially trigger a complaint, from the family, to the Medical Council. 

Therefore if you identify any potential areas in the care that could be subject to criticism, we recommend that you discuss the care, as a practice, and consider and put in place  any actions, systems or protocols in order to reduce the risk of future similar occurrences.

Case study

Dr S, a GP partner, was requested by the coroner to provide a statement detailing the past medical history, medications and relevant consultations of Mr A, a 45-year-old patient who had recently been found deceased at home. She had been the last GP to see Mr A, two weeks prior to his death. 

The coroner did not provide a copy of the autopsy report, but did let Dr S know that the cause of death as determined by the pathologist was codeine toxicity. Dr S was also advised that the family had expressed concerns that Mr A had been requesting his medications early, and that this had allowed him to accumulate a substantial quantity of codeine. 

Dr S had consulted with Mr A on a number of occasions during the year prior to Mr A’s death, mostly relating to his mental health and back pain. 

Dr S considered that the medical records were adequately detailed to satisfy the coroner’s request, and provided a printout of these, along with a medication list. Dr S could see, during her review of the records, that Mr A had been requesting codeine earlier than would be expected. However, she did not consider that there was any particular significance to this finding, as she recalled that she had previously discussed the risks of dependence and the patient had been insistent the medications were necessary to manage his symptoms. 

Dr S was subsequently informed by the coroner that she would be required to give evidence at the inquest. Further, specific questions were asked about the patient’s use of codeine and diazepam, and how frequently these medications had been prescribed by the practice.

It was at this point she contacted Medical Protection for assistance.

How we helped

A medicolegal consultant (MLC) reviewed the patient’s records and then discussed the matter with Dr S. The patient had been requesting codeine up to 14 days earlier than would be expected for several months prior to his death, and these prescriptions had been provided by a number of GPs with no further contact with the patient. On one occasion, Mr A had told the receptionist that he had lost the previous prescription; on a separate occasion he said that he was requesting the medication early as he was due to go away on holiday. 

Although Mr A had attended for a number of consultations with Dr S during this time period, the use of codeine did not appear to have been discussed in any of these, although the ongoing diazepam use had been noted. 

The MLC assigned to the case considered there were risks that the practice and Dr S may be criticised by the coroner at the inquest for the continued early prescribing of codeine, and what appeared to be a lack of discussion of this with the patient, especially as her consultation notes were minimal.  

The MLC sought consent from Dr S to instruct a solicitor, which Dr S provided. 
In conference with the MLC and instructed solicitor, it was agreed there was a possibility that the coroner may criticise Dr S as an individual clinician regarding a failure to document any assessment of the patient’s mental health and a failure to address the patient’s codeine use at the time of his consultations; and the practice (and therefore Dr S as a partner) more generally for a failure to identify and act on the repeated early requests for medication. 

It was also possible that the family might make a complaint to the Medical Council, given their concerns about the medication prescribed. 
It was concluded that a more detailed statement provided to the coroner would be beneficial, and also that the practice should conduct an investigation of the patient’s care, as a significant event analysis (SEA), and review its policy with respect to repeat prescribing. 

The coroner was approached for permission to submit a further statement and this was granted, albeit with a very short time frame. 

Dr S, with assistance from Medical Protection, produced a comprehensive and considered statement regarding her consultations with the patient, setting out her recollection of the discussions regarding the use of codeine and diazepam in more detail, and the assessments she had made of the patient’s mental health. She also ensured that the practice did conduct a SEA, and changes were made to ensure there was a mechanism in place for checking whether medications were requested early, and to prompt a discussion with the patient about this prior to prescribing the medications. 

At the inquest, although the coroner did raise some concerns about the sparse consultation records of Dr S, and that the initial statement provided had simply been a printout of the records, they acknowledged that the subsequent statement submitted and the oral evidence provided by Dr S was of a high standard. Dr S was not criticised in the narrative conclusion provided by the coroner.

Furthermore, the coroner was satisfied with the practice’s SEA and the clear changes made as a result of Mr A’s death. The family felt that the practice had taken appropriate steps to improve patient care, and they did not make a subsequent complaint to the Medical Council. 

If you are requested to provide a statement to the coroner, it is advisable to contact Medical Protection as soon as possible so that we can provide an objective review of your statement and consider any possible risks and their mitigation at an early stage, which may reduce the risk of criticism by the coroner at the inquest itself. 

 

If you are requested to provide a report or to attend an inquest, please contact Medical Protection for further advice.   

 

1Section 18A of the coroners Act 1962 as amended by the coroners (Amendment) Act 2019
2Medical Council. Guide to Professional Conduct and Ethics for Registered Medical Professionals
3Medical Protection. Report writing factsheet.