Preparing to go to a coroner’s court

Following a report of a death to the coroner, it may be necessary to attend an inquest. In the first of two articles, Dr Gabrielle Pendlebury advises on what to expect and how to prepare for an inquest.

The purpose of an inquest

A Coroner must investigate deaths that are violent, unnatural or unexplained and those that occur in state detention. A preliminary investigation may clarify that a death was natural; but if not, the Coroner will proceed to a formal investigation and open an inquest when necessary.  

Ultimately, a coroner’s inquest must answer four questions: 

  1. Who died;
  2. Where;
  3. When;
  4. How or in what circumstances the deceased came by their death.

To answer these questions, the coroner may require information from a number of sources. This can include opinion evidence from experts such as a pathologist or toxicologist and evidence from factual witnesses, including clinicians involved in the care of a deceased patient.  

An inquest hearing is held in public and is a formal court proceeding. There is no defence and prosecution, as it is not a function of the coroner to apportion blame – the coroner’s court is one of investigation and inquiry; it is not adversarial. 

Notification of involvement in an inquest

In most instances, the doctor will hear from the family or other healthcare professionals that a patient has died. However, on occasion, they will find this information out directly from the coroner either in writing or through a phone call. 

If the coroner has decided an inquest is necessary to investigate the death, one must be opened as soon as practicable after a reportable death and the process should, where possible, be concluded within six months.  

In complex cases, the coroner may hold a Pre-Inquest Review Hearing (PIRH) with interested persons to decide on the scope of the investigation, identify witnesses and to plan the inquest date and duration.

As soon as you are aware of an inquest, it is sensible to contact your defence body, as it can then liaise with the coroner on your behalf if they believe that this is necessary.

A request for a report

Your medical defence body can also assist in the preparation of a report, if one has been requested by the coroner, by reviewing and editing the proposed report and also by gaining relevant information from the Coroner. It is at this stage that the coroner may also alert the doctor to the need for a PIRH.

It is often helpful to call your defence body in anticipation of writing a report, as this will prevent procrastination but also allow you to talk through the case and consider how best to structure the report.

Preparation is key when it comes to preparing the report. The production of a comprehensive, clear and preferably concise report can have a number of positive outcomes:

 Aid the coroner in his or her understanding of events;

 Give closure to the family by answering questions they may have;

 Provide some catharsis for the clinician. It is very rare for a clinician to not have doubts about their practice, or if issues/errors are identified, it allows time to remediate and address these issues prior to the inquest;

 A well-prepared report is excellent preparation for giving evidence. The clinician while writing the report will be drawn to areas of ambiguity and confusion, which can be addressed first at this stage rather than alighted upon at the inquest.  

A common error is to be over-inclusive, thus producing an unwieldy report that is difficult to read. It is good to keep in mind American humourist Mark Twain’s quote: ‘I apologise for such a long letter – I didn’t have time to write a short one.’1 

However, it is better to provide too much information than too little. If you are struggling to write a targeted report, your defence body can review and edit. 

We know the process can be terrifying and it is easy to lose sight of what information is necessary and important.

The report should be based on the medical records, your own recollection and your usual practice.

See the text boxes for what to include, what to do and not to do and report writing tips.

Supplementary report

Sometimes it is necessary to make a supplementary report to deal with issues that come to light after you have written your original report. 

Before doing this, make sure that you review your report, the medical records and any new documentation.

Dr Gabrielle Pendlebury (right) is a medico-legal consultant at Medical Protection