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Five tips for writing a report for the coroner

Receiving a letter from a coroner requesting a report for an inquest can be stressful. Here is some advice for producing a high quality report that assists the coroner and reduces the chance of your needing to attend court.

When the coroner is involved

The coroner must be informed when deaths are: unexpected, unnatural, the result of self-harm or suicide, related to the deceased’s occupation or of a person in custody or other state detention (including those under mental health legislation or a Deprivation of Liberties Safeguarding Order).

The coroner should also be notified if no doctor is able complete the Medical Certificate of the Cause of Death (MCCD), which may happen if the deceased was not attended to in the 14 days prior to death.

When concerns have been raised regarding circumstances leading up to the death, including concerns about the care provided, the coroner may be asked to investigate. It is worth remembering that inquests are inquisitorial, not adversarial. The ultimate aim is for the coroner to establish the facts that led up to a person’s death, and to form a conclusion (formerly called a verdict) as to the cause.

The GP’s report

A GP’s report represents an opportunity to provide information that the coroner may be unaware of, and a well-drafted statement may mean that you do not need to attend the Inquest in person, as it may be read out in court without you present.

Doctors have a professional duty to provide information to an inquest, as outlined by the GMC in Good Medical Practice (2013). Any failure to supply a report following a coroner’s request could result in a doctor being compelled to do so by way of court order. When care does not go according to plan it is important to be open and honest, rather than making light of any difficulties or trying to cover up errors, as a report that is deliberately misleading could lead to the doctor facing a charge of perverting the course of justice.

Your report should provide factual information from your knowledge of the patient in primary care, although it will inevitably include information regarding secondary care.

Here are some tips for providing your report:

1. Provide your report promptly

The coroner may request a deadline if there is an inquest pending, but other than that, you should get the report to them as soon as possible. If there’s likely to be a delay in getting the report to the coroner, you should contact them to seek an extension.

2. Include an opening statement and appropriate background

Include an opening statement that states your full name, professional qualifications and experience, and your role at the time of your involvement in the patient’s care.

State the basis of your report (i.e. whether it has been drafted from your recollection of events, and/or with reference to the medical records).

Bear in mind that your report may be shared with interested persons, including the family. It is therefore good practice to express your condolences early in the report.

3. Detail the care provided

Provide a chronological summary of the care provided by you and the practice. Try to make the report thorough without being overly detailed, as there is a risk is that important events are ‘lost in the detail’. As a professional witness (of fact) your report should be ‘clear and concise.’

As far as possible, your report should be based on facts that you experienced directly. However, inquests do allow ‘hearsay’ evidence if it is relevant and may assist the coroner.

Be specific regarding dates and times, and name the healthcare professionals that provided any care that you refer to in your report. Using the passive voice when describing care that you have provided appears evasive and may lead to you being called to give oral evidence in court.

Remain factual, and avoid any temptation to make assumptions or inferences – that is the role of the coroner.

Avoid appearing critical of other professionals, and beware of stepping outside your area of expertise. You are being asked to provide a statement of fact, not an expert opinion. If you do express any opinion, you should state the basis of that opinion, and why you feel qualified to provide it.

4. Summarise

You may wish to conclude your report with a brief summary of the case, a further expression of condolence to the family, as well as an offer to provide the coroner with any further information or assistance that is required.

5. Check your language

Explain any complex medical terminology. A good rule of thumb is that your report should be understandable by a lay person.

Finally, you should ensure that you have checked your report thoroughly for any typographical or grammatical errors prior to submitting it.

Dr Ewen Ross is a medicolegal adviser at Medical Protection