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.
An inquest 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 (PIR) with interested persons, to decide on the scope of the investigation, identify witnesses, and to plan the inquest date and duration.
Ultimately, a coroner’s inquest must answer four questions: Who died? Where? When? And 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.
Why a GP would need to attend an inquest
A comprehensive report from the deceased patient’s GP may provide all the information the coroner needs to have a clear understanding of the primary care provided. However, if the coroner feels that further clarification or explanation is required, then the GP will usually be called to attend the inquest in person as a witness of fact to explain the care provided by themselves or the practice.
In certain circumstances you may be asked to attend as an interested person, which affords you certain rights, such as being legally represented and having access to the court documents before the hearing. This does not necessarily mean that you are vulnerable to criticism but we would suggest you contact your defence organisation to seek further advice if you are named as an interested person. There are several reasons why a party may be given interested person status. As a GP, section 47 f) of the CJA Act 2009 is of relevance as the coroner may wish to explore whether you are ’a person who may by any act or omission have caused or contributed to the death of the deceased.’
What to expect at court
In most courts the coroner sits at the head of the chamber, with the witness box to one side. The advocates’ bench is in front of the coroner, and behind that is general seating. Inquests are held in an open (public) forum and some will generate media attention so reporters may be present, often sitting at the back of the court. All inquests are now audio-recorded, and this forms the court record.
When called, you will be asked to ‘swear in’ by reading an oath on a holy book, or a non-denominational statement of truth. After this point any failure to tell the truth would amount to perjury.
Each witness will be questioned by the coroner and then by interested persons, including the family.
When the coroner has heard all the evidence, they will ‘sum up’ and deliver their conclusion. This can be in ‘short form’ or a narrative verdict. Whilst the purpose of an inquest is to establish the facts of a death and not to apportion blame or liability, a coroner also has a duty to prevent future deaths. The coroner may therefore issue a ‘Regulation 28 Report’ to a person or organisation if current systems or practices could result in a similar death in future if not addressed. If a GP is criticised in this report, or during an inquest, they are required to inform the GMC without delay, and in certain circumstances may be required to inform NHS England.
It is advisable to seek the support and assistance of your defence organisation to ensure you are fully prepared for an attendance at the coroner’s court, or to get advice on any concerns that you have arising from the inquest.
What to do if you are called to an inquest
- Be prepared. This is not a test of recall and reading statements that you have submitted and any other relevant documents will refresh your memory of events. You may take case documents into the court room, and refer to these while in the witness box. Consider marking or highlighting important sections in advance for ease of reference on the day.
- Dress smartly. This is a formal occasion and a suit or other business attire is considered appropriate.
- Arrive on time. Register your arrival with the coroner’s officer or clerk. You will be shown in to the courtroom and be seated ready to be called to take the witness box.
- Switch your mobile phone off.
- Be polite and remember it is fine to give your condolence to the family if you see them at court.
- Direct your answers to the coroner, whom you should address as ‘Sir’ or ‘Madam’.
- Answer the question you have been asked, not the one you wanted to be asked. If you are unsure of the question, seek clarification.
- Keep your answers brief and factual.
- Use non-technical language whenever possible. Ideally you should answer in lay terms.
- Keep calm. The tendency is to speed up when nervous, but make sure you speak clearly and slowly.
What not to do when attending an inquest
- Don’t discuss the facts of the case outside the courtroom as this could be seen as interfering with the inquest process.
- Don’t be tempted to fill gaps in proceedings by speaking. The coroner may be making notes from the evidence, or preparing their next question.
- Don’t stray into the remit of an expert unless you are qualified to give such an opinion. Remember that a witness of fact should confine evidence to facts within their direct experience.
- Don’t leave court unless the coroner releases you.
Dr Ewen Ross is a medicolegal adviser at Medical Protection