What happens when you’re called to an inquest?

In this three-part series, inquest solicitors from Hempsons explain how the inquest process relates to independent practitioners. This month, Clementine Robertshaw shows how to prepare for giving evidence to an inquest in writing and if called to attend in person.

Anyone who works in medicine may be involved in an inquest at some point in their career. It can be a nerve-wracking experience, particularly for independent practitioners. 

Inquests are very different to other types of legal proceedings you may have experienced as a doctor, as the process is effectively an investigation led by a judge and each case can run very differently.

If you are asked by a coroner to provide evidence for an inquest, either a request for a report or witness statement or to attend court to give evidence in person, it’s important to react quickly. 

Your role will vary depending on whether you were providing a key service related to the cause of death, involved shortly before the death occurred or had a more tangential or direct role in care. 

Generally, you should inform your indemnity insurer, medical defence organisation or legal team for advice and support through the process.

As a witness, your role is to provide the evidence you can to help the coroner answer four key questions: who died, where they died, when they died and how they came by their death.

The family and friends will often have wider questions, but the coroner will seek to focus the inquest process on those matters which will help them understand the nature of the death. 

Gathering evidence

As a witness, you are not expected to provide all the answers, because the coroner will be gathering evidence from a range of people and organisations.

In preparing a witness statement, you should bear in mind that it will be key in whether the coroner decides to call you to attend the hearing. You are less likely to be called if it is clear that you have provided all the evidence you can in your statement and that it answers any obvious questions. 

So make sure you review relevant records, explain key terms and acronyms, and explain your role and your service. You should make clear what role you personally played in the care, what information comes from your memory or mainly from the records and what is the context which you weren’t involved in but helps your evidence to make sense.

It is very useful to bookend your evidence with confirmation of your first and last direct involvement – or that of your team – so the coroner can see that you have included everything relevant. 

As the coroner’s focus is on the details, nature and cause(s) of the death, the narrative should end at the death, other than to offer condolences to the family.

Keep in mind that the family are very likely to read your statement, so while it is factually clear, ensure it is also appropriately sensitive. Details such as spellings must be accurate to reflect the care you take in your work and how seriously you take the family’s loss.

The coroner has a second duty alongside investigating specific deaths: to consider whether an inquest brings to light issues with care which could risk other deaths in the future. 

So it can be prudent to reflect on the events and whether there should be any changes in your individual practice or in the systems involved in the deceased’s care. 

Improvements in care

If so, do include that in your statement, along with any action being taken to enact improvements in care. If you have changed role since the relevant time, make sure you include that, so the coroner knows you aren’t able to comment on current process.

If you are called to attend and give evidence at an inquest, you should alert your defence body or solicitor for individual preparation and advice. The request will come through the coroner’s officer and they will be able to give guidance on when the hearing will happen, how long it is listed for and other practical details. 

This will be handled by your representative, if you have one for the hearing, and you will only need a lawyer with you at that point if you are an ‘interested person’, which is usually only for family and those individuals or organisations most relevant to the care or the death. 

Attending remotely 

Many coroners remain flexible in allowing evidence to be given remotely where this will allow less disruption to clinical care, so you can ask if the hearing will be remote or if your evidence can be.

There are advantages and disadvantages to attending remotely rather than in person. There is less travel time and it is easier to review medical records should the coroner want confirmation of a specific detail in your evidence. But we have all learnt of the dangers of accidentally leaving a camera or microphone on at the wrong time.

You should have your witness statement with you when you give evidence, which is another reason to ensure it is comprehensive. The coroner will explain the process and will lead the questioning. 

They will take you through your statement, sometimes also asking questions based on the medical records, evidence of the family or other witnesses or on other reports. 

The family may then also ask questions, either directly or through a legal representative. If they are unrepresented, the coroner will usually help them frame their queries into questions that you can answer. 

If there are others involved in the inquest, they may also have a representative who might ask you questions, and finally your own representative – if you have one – can do so. 

It is a good rule of thumb to answer the question put to you and then to stop, allowing the questioner to ask for more detail only if they need it.

In a statement and in court, you should not speculate or go beyond your expertise. Remember that you will be giving evidence under oath, so it is important to understand the questions put to you. 

You can ask for them to be repeated or explained and if the honest answer is ‘I don’t know’ or ‘I don’t remember’, then that is a perfectly acceptable answer. 

Help the coroner 

Clinicians deal with a lot of patients, and coroners understand you won’t have perfect recollection of every detail so as long as you are clear that you can explain that you do not remember an event in that specific instance but you can explain the usual process.

Above all, remember that you are called to help the coroner with those four key factual questions, and not to justify yourself or because you are in any way being blamed for the death. 

You probably spend a good amount of time explaining care and decision-making to patients or families, and it is that skillset, although in an unfamiliar setting, that you need in the coroner’s court. 

While you might want to give word-perfect answers, it can be more important to demonstrate your professionalism and compassion to the family and coroner through how you answer the questions.

Finally, remember that support is always available, including from solicitors, to guide you through the process and support in the hearing if necessary.

First published in Independent Practitioner Today in September 2022.