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Behind the scenes of a coroner's inquest

Post date: 25/06/2019 | Time to read article: 4 mins

The information within this article was correct at the time of publishing. Last updated 25/06/2019

An inquest is a fact-finding exercise that is conducted by the coroner and, in some cases, in front of a jury.The purpose of an inquest is to find out who died – when, where, how and in what circumstances. It is intended to be inquisitorial rather than adversarial, and as such, there are no formal allegations or pleadings.

An inquest is opened by the coroner for a range of different reasons, including if a death does not appear to have been caused by natural causes or occurred in other suspicious circumstances. Inquests are also held when a person has died whilst in prison or police custody, whilst detained under the Mental Health Act, whist subject to a Deprivation of Liberty Safeguard, and in rare circumstances, when the cause of death is still uncertain after a post-mortem examination.

It is usual for the coroner to hold an inquest when a death occurs within 24 hours of admission to hospital or a surgical procedure, although this is not mandatory. If there is a possibility that a medical procedure contributed to or caused the death, it should be discussed with the coroner, regardless of the timescales involved. You should record the details of referral to the coroner in the patient’s records.

The coroner may also hold an inquest if the death was due to natural causes and an inquest is considered by the coroner to be in the public interest.

Doctors should report deaths to the coroner if they appear to be unexplained, unexpected, violent or unnatural (such as an accident or suicide), or if they occurred whilst the individual was in custody, as a result of potential medical mishap, or in a circumstance which may require investigation.


The first contact you are likely to have from the coroner is a request for a medical report, to assist them in their investigation of the patient’s death.

As soon as you are contacted by the coroner it’s a good idea to get in touch with Medical Protection. Our medicolegal experts can assist you in writing your report, help you prepare for the inquest and arrange legal representation for you on the day if required.


The General Medical Council (GMC) advises that doctors must disclose relevant information about a patient who has died to help a coroner with an inquest. If the coroner requests copies of the patient’s clinical records, as part of an investigation, then these should be provided.

Additionally, GPs may also be asked to provide a report for the coroner.

A good report should be detailed and factual, based on existing medical records and knowledge of the deceased. It should be able to serve as a ‘standalone’ document, providing the coroner with the relevant information without having to refer to the medical records.

The report should have a clear title, outlining that it was prepared for the coroner. It is helpful to provide the coroner with some background information, such as where the patient was seen, and how well the patient was known to the practice.

Whilst the report will be primarily based on the contemporaneous medical records, if GPs are referring to their recollection of events or their usual practice then they should say so.

When using medical terms, they should be explained insufficient detail for those persons reading the report that do not necessarily have a medical background. If referring to other healthcare professionals within the report, they should be identified by name.


If the report is clear and factual enough, it may be that the doctor does not need to attend an inquest and the report can be read out on their behalf. If you are is asked to attend an inquest then it is important you are thoroughly prepared. You need to carefully look through all the patient’s medical notes and bring any guidance or information with you that can help explain and justify your actions.

Before the inquest, make sure you read through your report again and have all the facts you need at your fingertips – sometimes an inquest can be more than a year after the death, so it can take a while to re-familiarise yourself with the situation. It can be helpful to talk through the report with your medicolegal adviser, to prepare yourself further forgiving evidence.


As a GP, your role at an inquest is to provide impartial factual evidence that can assist the coroner in making a decision. As a witness, you will have to provide evidence under oath,meaning you have a legal obligation to tell the truth. When you are called up to the witness box you should remember to speak slowly and clearly. Avoid using jargon that the family may not understand and explain any technical terms you may have to use.

The coroner may ask you to read through your statement or may take you through the statement in court. Therefore it is prudent to have as much detail as possible in your statement before it is submitted.

You are giving evidence to the coroner, so ensure that you face them when answering a question. Listen carefully to each question. Make sure every answer is open, honest and fair.

If you don’t know the answer, or understand the question, say so, and ask for it to be rephrased.

‘Interested persons’ are permitted to ask questions and it is likely that the coroner themself will have questions for you. If the patient’s family are legally represented, then their counsel may also ask you questions.

Do not become flustered or lose your patience with any opposing counsel (if present) and try to remain neutral and focused. You can appeal to the coroner if you feel that a question is improper, or if you would like to expand on your answer.

Remember to take as much time as you need for each answer.


Once the inquest is over, the coroner will sum up their findings and make a conclusion in a Record of Inquest. If there is a jury involved, the coroner will summarise the essential facts and findings, and advise them of any applicable laws.

A decision on how the person died will be determined in view of the evidence given. The coroner can add a rider of “neglect” to the verdict if they feel that there was a missed opportunity or gross failure to provide medical attention. It could be due to a breakdown in communication rather than a deliberate act.

The coroner can also refer the doctor to the regulatory body should they feel it would help to prevent a future recurrence of the incident that led to the fatality.


A coroner’s inquest is something many GPs are likely to experience at some point in their career. Usually evidence giving will be relatively easy and straightforward, but getting expert advice is still important.

The GMC expects doctors to self-refer if they have been subject to criticism at an inquest, so talking to us for advice as soon as possible is an important step in reducing the prospect of being criticised.

Prevention of a problem is ultimately a lot less stressful than dealing with a problem. Medical Protection courses can help you avoid problems occurring or escalating in future.

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