Podcast: An introduction to inquests for the primary care sector

In the latest episode of our GP podcast series, primary care partner Justin Cumberlege talks to Sam Wright, a senior solicitor in our healthcare advisory team, about the role of GPs in the inquest process.

Listen to the episode below:

Episode summary

In this episode, Justin and Sam discuss:

00:16 – Introduction

01:36 – What is an inquest?

02:49 – What should/shouldn’t you say in an inquest?

05:00 – Can inquest evidence be cited in a subsequent clinical negligence case?

05:54 – Quality of evidence

07:47 – Do GPs need to attend inquests in person?

11:36 – Who can support GPs throughout the inquest process?

12:53 – Potential adverse outcomes of inquests



Hello and welcome to the latest episode of Hempson’s primary care podcast. This podcast is about an introduction to inquests, particularly for GPs and the primary care sector. I’m Justin Cumberlege, a partner in the primary care team and I’m joined by my colleague Samantha Wright, who advises NHS Trusts and others about inquests. Today we are therefore going to be discussing how to prepare for an inquest and what you should do if you receive that letter from the Coroner’s court. So I’m now just going to hand over to Samantha, just to introduce herself.


Hi. Yes. So I’m Sam Wright and I work in the advisory team in Manchester at Hempsons. As Justin quite rightly said, they’re advising NHS trusts, care organisations and other healthcare professionals on inquests, providing representation at inquests when necessary, and any advice and guidance around the inquest process itself, as and when necessary.


Great. Thank you, Sam.

Sam, just explain what an inquest is, please.


Okay, so an inquest is a fact finding exercise that the Coroner will conduct, whereby if a Coroner is made aware that a body of a deceased is within the Coroner’s area, he has the duty then to conduct an investigation into that person’s death where it’s suspected that that person has died a violent or unnatural death, or where the cause of death is unknown, or where the deceased died while in custody or otherwise in state detention.

It’s really important, really, to point out that an inquest in itself whilst takes place in a court of law and it is a Coroner’s court where an inquest takes place, it is an effect finding exercise and not a method of apportioning, guilt or blame. It should never be forgotten that there are no parties. So with an inquest, there’s no claimant and defendant like you see in the civil courts or a defendant in the criminal court, it’s non adversarial and there’s no indictment, there is no prosecution and there’s no defence. Like I say, it’s merely a fact finding exercise.


Yeah, but you say that, but I know people go to inquests to listen to them and they use the information at the inquest in a subsequent case. So shouldn’t you be a bit careful about you say there?


From a clinical perspective, if I have clinical witnesses and I’m advising them in advance of an inquest, I always say the best policy is to be as open and honest as you possibly can with your evidence. If there’s any questions that you can’t answer, it’s a case of simply saying you can’t answer those or maybe deferring to another clinician who they feel is best placed to answer those questions. And similarly, if any questions are asked that the clinician isn’t quite sure of what is being asked of them, at inquest, we’d always say to ask for a question to be repeated. I’d never advise a witness to watch what they say.

I feel like some witnesses that I have had the benefit of speaking to sometimes can feel a little anxious around the inquest process, feel a little bit unsure, especially if, say, for instance, they’re worried about something that they might say that may, for want of a better phrase, drop their colleague in it. But what I would always say is be as honest as possible in terms of your opinion and your practise and that’s following out your duty as a clinician at Coroner’s court.

Yes, depending on the outcome of the inquest, the evidence may be used in support of, say, for instance, a clinical negligence claim. But what we have to remember is a clinical negligence claim is something that is brought in a separate arena altogether that’s the civil courts and quite separate from the inquest process itself. But in terms of providing evidence at inquest, the best policy is to be as honest and open as you possibly can on the information that you have in front of you and within your clinical expertise.


Yes. So it seems to me though, that what is said in a Coroner’s court can then be used in a subsequent negligence case. I mean, it can be cited, can’t it, that information?


It can be cited. I mean, what we have to remember is that the Coroner records within his narrative conclusion that he keeps to factual language and doesn’t stray outside of that. And that’s why representation is important because it’s for the advocates then to remind the Coroner of the type of language that can and cannot be used at inquest during that narrative conclusion. So, yeah, it’s absolutely important that the Coroner sticks to the factual language as opposed to straying into the realms of ambiguous wording, if you like-


Maybe opinions? I don’t know.


Yes, absolutely.


So the other thing is that you say stick to the evidence. Sometimes the notes are pretty bad and it might have been a locum or somebody who is not often at the surgery or even somebody you can’t track down now and the notes they’re given are rubbish. So what happens then?


So in those circumstances, and it’s quite often the case that a GP may be asked to provide a witness statement on a period of care of the deceased, but it might be that particular GP isn’t the one that completed the attendance with the deceased. And quite often we do have clinicians covering periods of care that weren’t their period of care. And it’s always difficult because, of course, you’ve only got what’s in front of you in terms of the clinical notes. What we would always advise in those circumstances is just give as much as you can from the clinical notes. Don’t try to stray into opinions of what you think might have been the thought process of someone else, because I guess you possibly can’t say unless you can 100% say that was the case, then, of course, provide your evidence.

But I guess with where we have a locum that has seen a patient and you’re providing an account of what’s within the medical notes, make it clear in your witness statement that that is based solely on the medical notes and that you haven’t had the benefit of assessing the patient or seeing the patient yourself and that the witness evidence that you’re providing is an account of what you can see in the medical notes. That’s when we would usually see a witness statement that is quite brief in the sense that it’s a rehearsal, if you like, of what’s in the medical notes and the observations taken and the conversations which took place.


Right, thank you. If a patient dies in hospital who’s been referred by the GP practice there, is it likely that the GP would be required to go to the Coroner’s court, or will it focus on the consultants and people at the hospital?


It really depends on the circumstances. More often than not, GPs will always be asked to provide a report for the benefit of an inquest. I guess whether they would be called to provide evidence orally. So there’s just two ways a Coroner can deal with evidence from a GP or any other party to witness to an inquest. They can either admit the witness evidence under Rule 23 of the Coroner’s Rules, which means that their evidence will be read out into court and there would be no need for them to attend. Or alternatively, they can ask the witness to attend to provide evidence orally.

Generally speaking, if the Coroner makes a decision to admit evidence onto the court record, as opposed to having someone attend to provide the evidence orally, it’s because whatever is in that witness statement is enough and the Coroner doesn’t need to hear or ask any further questions of that witness. We’ll usually see that where, for instance, like you say, if someone has died in hospital, but as part of their condition, it might be that on the cause of death, COPD say, for instance just as an example. Whilst there may not be any particular concerns in terms of the GP’s practise and care, it might be that the Coroner needs a witness statement from the GP just evidencing what the issues were throughout the deceased’s life and for how long? Or up to a certain period with COPD itself just to have a broad overview of what the comorbidities were of that particular patient.

And in those circumstances, it might be that the GP provides a witness statement just advising on the number of different attendances, say over a period of twelve months or even two years, depending on what the Coroner is asking for, And the Coroner may be satisfied with that and doesn’t really have any further questions over and above what he’s got in front of him within that witness statement. And in those instances, the witness evidence may be admitted into court and read out by the Coroner, as opposed to have the GP attend.

However, in other circumstances it might be that the GP is called to provide evidence orally. And those circumstances might be, say, for instance, whereby the patient visited his GP two days before, a week or so before the death, and then went to hospital three days before, so two days after the GP attendance. And it turns out that actually there’s some real issue around the patient’s condition, something that the GP didn’t pick up, that potentially should have picked up, and the Coroner may want to ask further questions around that assessment and period of care. So like I say, it completely depends on the circumstances as to whether a witness will be called to provide oral evidence or not, but quite usual for GPs to be involved in the inquest process from one perspective or another.


Right, good. And so who can support me, I mean, if I’m summoned to come to Coroner’s Court to give evidence, is anybody who can support me during that process and who pays for the support?


We would expect GP Practices and GPs themselves to be signatories to maybe a medical defence union that might be able to provide advice and support around the inquest process. It’s a case of probably checking the terms and conditions of the policy that they have as to whether representation at inquest itself will be something that could be offered if it’s felt that that is needed.

There’s also the CNSGP provided by the NHSR, although as I understand it, the CNSGP scheme is limited to claims and doesn’t provide any cover, if you like, financial cover towards representation at inquest. The practice may also want to check any of the overarching insurance policies that they may have to see what type of assistance can be gleaned from those policies as well.


Yeah, that’s a good point, because you always just think about your MDUMPS type policy. But there are other policies which cover legal costs which may help. I suspect you can also extend them to cover it if you want.

Good. So that’s really been helpful, Samantha, and it shows that one ought not to be too fearful if you receive a letter to go to an inquest. But it’s important to be well prepared and also to have support if you have to attend in person. But often it seems that you might just be able to send in a report and that’s all that the Coroner requires from you. So that wouldn’t be too onerous.


Yeah, absolutely. I mean, more often than not that is the case and witness statement may be all that’s required and no attendance necessary. I guess one thing to highlight really, is that there are adverse outcomes that can come out of a potential inquest, something that I do feel that the primary care sector need to have an awareness of, just so they know that an inquest can have potential adverse outcomes in certain situations.

Now, when we talk about those adverse outcomes, we’re talking about things like the Coroner having the duty to issue Prevention of Future Deaths reports, otherwise known as PFDs or Regulation 28 orders. They also have it within their gift to issue neglect riders against healthcare professionals where they feel that there has been a failure to provide basic medical treatment. In certain circumstances there’ll be referrals to the CQC if the Coroner feels it warranted and necessary. And of course we already know that clinical negligence claims may arise out of circumstances surrounding the inquest investigation. And in the most serious situations there can also be referral to the police for investigation. Now, these adverse outcomes are the most serious of inquests and inquest conclusions, but nonetheless, being aware that they are potential issues that can arise out of inquest is always good knowledge to have.

Now, what we offer at Hempsons, certainly within our team, is the Hempson’s Inquest Management service. And what we tend to do with a lot of our NHS trusts is offer this. It’s a free service whereby if any of our healthcare professionals have any concerns about potentially being involved in the inquest process itself or have any anxieties in relation to it or just want to sound off the situation that they’re in. We’re quite happy to take any queries by email or by phone, just to give one off advice in terms of where the risk might lay, if there is potential risk. Because like we said, there’s not always risk, but there are some potential adverse outcomes that can arise out of inquest that it’s always good to have a little bit of extra knowledge around that and just to see where you stand, really.


Yeah, that’s a very important point. Good. Thank you, Samantha. I think it’s very interesting and helpful for those people who might be called to attend an inquest. And if you would like to know more about it or if you would like support, I’m sure Samantha will be very happy to help you. So do contact her or any of the people at Hempsons on our health advisory team for a bit of support in those circumstances. There’s also a wealth of other information on our website and other podcasts, so please do browse through them and contact us if there’s anything there that’s important to you which we can help you with. Thank you very much for listening and I hope it’s been helpful.

Our podcasts are provided free of charge and for information purposes only. Please obtain professional legal advice before applying this information to your specific circumstances. 

Visit our GP page for more information about our dedicated legal support for general practitioners. For more information about how we can support you during an inquest, visit our inquests page.