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Inquests – how can we help?

Post date: 08/09/2021 | Time to read article: 9 mins

The information within this article was correct at the time of publishing. Last updated 06/04/2022

Dr Heidi Mounsey, 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. 

What is your role in an inquest?

You are there to assist the coroner in an inquest into a patient’s death by offering all relevant information. You are permitted to remain silent only if commenting may lead to criminal proceedings being taken against you. 

As a doctor, you have a number of professional obligations with respect to producing a statement for the coroner (or in other circumstances such as for a serious incident investigation), and these are set out in the GMC’s Good Medical Practice at paragraph 711, which states:

You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must make sure that any documents you write, or sign are not false or misleading.

a. You must take reasonable steps to check the information is correct.
b. You must not deliberately leave out relevant information.

In addition, paragraph 75 of Good Medical Practice highlights your requirement to inform the GMC without delay if you are criticised by an official inquiry; this would include criticism from a coroner in relation to an inquest.

What is an inquest?

An inquest is a fact-finding exercise and is an inquisitorial rather than an adversarial process. The coroner does not aim to establish blame, culpability or liability but rather to answer four questions. These are:

• Who died?

• Where did they die?

• When did they die?

• How did they die (or sometimes “in what circumstances” the deceased came by their death)?

The main focus of an inquest is usually the last of these questions.

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

If requested to provide a written statement, you can review our guidance on report writing2. In addition to this, the following aspects should be considered: 

• The 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, 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. 

Factual witness or interested person?

In the event you are requested to attend an inquest, you may be called as a factual witness or as an interested person (IP).

An IP is either a government body responsible for the care of a patient (for example, an NHS trust or a prison), or any individual whom the coroner believes is pivotal to the case or has sufficient interest in the inquest, such as the practice or an individual GP. A patient’s family would normally be an IP, for example. 

A factual witness attends to give evidence and can be questioned by any of the IPs or their representatives. A factual witness does not have a right to see all the other documents relevant to the inquest, cannot question other witnesses and does not have a right to legal representation. 

An IP has the right to full disclosure of all the documents relating to the inquest and also has the right to legal representation. An IP (or their legal representative) may ask questions of any of the witnesses giving evidence at the inquest.

Consequently, if you are requested to attend an inquest it is helpful to know from the outset on which basis you have been asked to attend. 

What happens during the inquest?

During an inquest itself, the coroner will question the witnesses, followed by questions from any IPs, including the family of the patient or their legal representative. The coroner may either ask you to read your statement in court or may take you through it, asking relevant questions. As mentioned, an inquest is inquisitorial rather than adversarial; however, many healthcare professionals understandably find it stressful being questioned in these circumstances.

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. 

At the end of the inquest the coroner will reach a conclusion. 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 as to how the patient came about their death.

Inquest risks – how Medical Protection can help

There are potential risks to an individual doctor 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 could add a neglect or poor care comment to the conclusion. 

Less frequently, the coroner may also produce a Regulation 28 Report (Prevention of Future Deaths) if they believe that this is necessary. If a doctor is criticised during a coroner’s conclusion, they must refer themselves to the GMC (as noted above) and to NHS England under regulation 9 of the Performer’s List. It is also important to note that failure to comply with a request to attend as a witness at a coroner’s inquest can result in the order of a fine for contempt of court and a complaint to the GMC.

Therefore, if you identify any potential areas in the care that could be subject to criticism we advise that practices meet as soon as possible to undertake a robust SEA, and put in place any actions or changes to practice in order to reduce the risk of future 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. 

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. 

The coroner did not provide a copy of the postmortem, but did set out that the cause of death as determined by the pathologist was codeine toxicity. Further, the family had 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 seen Mr A on a number of occasions during the year prior to Mr A’s death, with most of these consultations 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 noted during his review of the records that Mr A had been requesting codeine earlier than would be expected, but did not consider that there was any particular significance to this finding, as he recalled that he 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 he was an Interested Person and would be required to give evidence at the inquest. It was at this point he contacted Medical Protection for assistance. 

A medicolegal consultant (MLC) reviewed the patient’s records and discussed the matter with Dr S. The patient had been requesting codeine up to 14 days earlier than would be expected for a number of months, and these prescriptions had been provided by a number of clinicians with no further contact with the patient. On occasion, Mr A had set out that he had lost the previous prescription or 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 some mention was made in relation to ongoing diazepam use. 

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 the consultation notes of Dr S 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 explained to Dr S that should he be criticised by the coroner, he would be obliged to self-refer to the GMC. Further, the coroner may issue a Prevention of Future Deaths (PFD) report if they considered that the death was avoidable. This would require the practice to make changes according to the coroner’s recommendations. Both PFD reports and the responses are sent to the chief coroner and usually published on the Courts and Tribunals Judiciary website3

It was concluded that a more detailed statement provided to the coroner would be beneficial, and also that the practice should conduct an 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 timeframe. 

Dr S, with assistance from Medical Protection, produced a comprehensive and considered statement regarding his consultations with the patient, setting out his recollection of the discussions regarding the use of codeine and diazepam in more detail, and the assessments he had made of the patient’s mental health. He also ensured an SEA was conducted, 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 and his Medical Protection team did not feel that the comments made by the coroner to Dr S during the inquest amounted to criticism such that self-referral to the GMC was required. Further, the coroner was satisfied with the practice’s SEA and the clear changes made as a result of Mr A’s death, and concluded that it was not necessary to issue a PFD. 

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 reduces the risk of criticism by the coroner at the inquest itself. 

1Good Medical Practice 
2Report writing - England
3Reports to Prevent Future Deaths, Coroners and Justice Act 2009

















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