When you’re asked to go to an inquest

In the first of a new three-part inquest series, Thorrun Govind explains the inquest process and what happens if you are called to attend – with additional material from James Down.

As front-line healthcare professionals – and I write this as a pharmacist myself – we are very much focused on the care we are providing and working in the challenging environments that we do. 

Legal correspondence can therefore feel like an unnecessary distraction from the day job and feel very far removed from our role caring for patients. However, our work can have life and death implications. 

The prospect of engaging with court proceedings is very daunting, no matter how long you have been qualified. Here at Hempsons solicitors, we have supported numerous clinicians through the coronial process. 

We have a duty of candour. As registered persons, we must act in an open and transparent way with relevant people in relation to care and treatment provided to service users in carrying on a regulated activity. 

Seek answers

Our engagement with the coronial process is therefore an important part of helping the bereaved seek answers and closure. It is as much a component of our role as keeping up to date with the latest NICE guidelines or making sure a patient is fully informed about their latest immunisation.

Inquests are coroner-led legal proceedings with the family at centre of process. They are non-adversarial, in that there are no ‘sides’ and all those involved in the case work together to assist the coroner to establish the facts. 

In simple terms, it is an inquisitorial fact-finding investigation with the aim of answering four questions: Who died? Where did they die? When did they die? And how did they come by their death?

Coroners are independent judicial officers appointed by the local authority who have a statutory duty to establish who the deceased was, as well as how, when and where they died when the cause is unknown or where there is reason to suspect the death may not have been due to natural causes. 

Duty to assist

Inquests are prompted by concerns raised by family, clinicians, pathologists, circumstances that give rise to concerns and for deaths in custody, such as in prison or a secure mental health unit.

When you are initially contacted to assist the coroner, it is likely that you will be corresponding with the coroner’s officers, rather than the coroner themselves. 

You have a duty to assist the court and should let your defence or insurance providers and legal team know you have been contacted so they can guide you through the process.

You may be asked to provide information or to write a statement, and the time spent gathering this will depend on what exactly has been requested. Do not be tempted to put it off. 

The coronial process begins with information-gathering to narrow down the issues for the coroner to consider and to set the scope of the inquest. You could be asked to provide patient medical records as well as communications with other healthcare professionals and internal policies. 

If you do not have the documentation requested, it is better to be honest and up-front as soon as possible, rather than delaying the coronial process. You also have a duty to provide ‘full and frank’ disclosure, which includes documents that are not helpful to your position, but relevant to the investigation.

Coroners have been sympathetic to the pressures on healthcare professionals during the pandemic; however, a simple unwillingness to engage is not acceptable. They also have a wide discretion to require evidence to be given or produced.

This can include the power to require witnesses to attend court and in certain situations they can impose criminal sanctions – including a fine or imprisonment.

Provide clarity 

Once the coroner has received all the relevant information, they will decide who will be called to give oral evidence live in court and what parts of the evidence can simply be read into the court record. This is usually reserved for uncontroversial elements. 

Providing a clear detailed statement can therefore prevent the requirement to attend court to give oral evidence and if your legal team are asking you to provide clarity, you would do well to heed this advice.

At the inquest, if you are called to provide evidence, you will do so under oath: a reminder that your duty is to the court and not to the parties. The coroner and other parties – formally recognised and known as Properly Interested Persons (PIPs), such as the deceased’s family – will have the opportunity to ask you questions. 

While doctors and healthcare professionals are well-versed in talking to patients, it is important to prepare for attending the coroner’s court as a witness. This includes the formalities of addressing the coroner as ‘Sir’ or ‘Ma’am’. 

It is important to give a good impression, so smart clothes are a must and do not forget to have your mobile phone on silent, with your notes, statements and documentation easily accessible. 

Attend remotely

Courts are increasingly allowing witnesses to attend remotely and you should consider your location as an extension of the court room. Legal support will make the process less daunting.

The coroner’s court also plays an important part in preventing future deaths and the coroner may ask you about your current practices and ways of working. 

The coroner must make a Prev­ention of Future Deaths report where the investigation they have been conducting reveals something which gives rise to a concern that there is a risk of deaths in the future. The coroner will suggest that action should be taken to eliminate or reduce that risk, although coroners cannot recommend what that action should be.

You may have wondered how the coroner’s courts have dealt with Covid. As it is a naturally occurring disease, it is therefore capable of being a natural cause of death and therefore Covid does not automatically prompt an inquest. 

There may, of course, be additional factors around the death which mean a report of death to the coroner and subsequent inquest is necessary – for example, where the cause is not clear.

First published in Independent Practitioner Today in July 2022.