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General / Advisory Publication

The MDU’s Guide to

INQUESTS
a practical medico-legal guide
The MDU . Inquests

Contents

Introduction 2
Role of the coroner 3
Who refers a death to a coroner? 4
Types of cases to be reported to the coroner 5
Investigation 6
Statement for the coroner 7
Legal representation 8
The hearing 9
The verdict 10
Scotland - fatal accident inquiry 11
Publicity 12
After the inquest 13
Fees and expenses 13
Judicial review 13
Questions and answers 14
References 16
Bibliography 16

1
Introduction

This booklet is intended to help MDU members who are


asked to assist the coroner with inquiries into a person’s
death. An inquest is a fact-finding inquiry and not a trial. It is
held by the coroner when he decides that a death may not
be due to natural causes. Doctors may be asked to submit
statements to the coroner about the care and treatment they
have given their patients and if necessary attend inquests as
witnesses.

Inquests can be a distressing experience for a number of


reasons. The coroner is inquiring into the nature of a death,
which may be violent or sudden. The police - who, in some
areas, are described as coroners’ liaison officers - are often
involved, acting as intermediaries between the witnesses and
the coroner. When the hearing is finally called, the inquest is
in public. This means that the press can attend and
occasionally there is a jury sitting. The family of the deceased
are often present and this can cause considerable concern to
the doctor.

Producing a statement and giving evidence at an inquest are


usually straightforward and The MDU deals with an average
of 500 inquiries a year from members seeking advice or
assistance with inquests. We are available to advise members
at each stage of the inquiry process, from the production of
the statement to legal representation at the inquest itself, if
that is necessary.

The MDU’s medico-legal advisers are always happy to


discuss any issues of concern and are available 24 hours a
day, 7 days a week for advice. We hope you will find this
booklet helpful and reassuring.

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The MDU . Inquests

Role of the coroner

The Coroners Act 1988 details the circumstances in which a


coroner should hold an inquest and in some situations
summon a jury. These are where the coroner has reasonable
cause to suspect that a person has died a violent, unnatural
or sudden death and the causes are unknown, or where a
person has died in prison or in such circumstances as to
require an inquest under any other act. The proceedings and
evidence at an inquest are directed solely to determine:

● who the deceased person was

● how, when and where he came by his death

● the details of the death, which the registration acts


require to be registered

The coroner’s court is not concerned with matters of civil or


criminal liability. Its sole purpose is to determine who died,
where, when and how.

From 1194 to 1888, county coroners were elected by the


county freeholders. They reached the peak of their eminence
in the 13th and 14th centuries, when the coroner’s post was
held by a knight ‘possessed of lands’. In 1235, the Statute of
Westminster declared that ‘none but the lawful most wise,
discreet knights should be chosen’. At that time, the coroner
had jurisdiction in criminal courts and one of his duties was to
ensure that the Crown received all it should when an
individual died.

Until the late 1800s, the coroner’s court was held in a public
place and he issued a general summons to all who knew the
facts to come forward and give evidence. These public
places included licensed premises - a practice which has
since ceased!

Coroners are now appointed by county authorities. Since


1926, they have had to be registered medical practitioners,
barristers or solicitors of at least five years’ standing. They or
their deputies should be ‘always available’.

Although it has been said that the coroner’s post is one of the
few with lifelong security of tenure, a coroner may have to
retire at a certain age, if asked to do so by the appointing
county or other authority. The Lord Chancellor can remove a
coroner from his post for misconduct in discharge of his duty
or for neglect of duty.

3
Who refers a death to the coroner?

The coroner receives notifications from a number of sources,


including doctors, the police, medical referees and the
registrar of births, deaths and marriages. Of these, only the
registrar is obliged to refer a death to the coroner, by virtue of
Regulation 41 of The Registration of Births and Deaths and
Marriages Regulations 1987 which say the death should be
reported if it is one:

● ‘In respect of which the deceased was not attended


during his last illness by a registered medical
practitioner; or

● In respect of which the registrar


i) has been unable to obtain a duly completed certificate
of cause of death, or
ii) has received such a certificate with respect to which it
appears to him, from the particulars contained in the
certificate or otherwise, that the deceased was not seen
by the certifying medical practitioner either after death or
within 14 days before death; or

● the cause of which appears to be unknown; or

● which the registrar has reason to believe to have been


unnatural or to have been caused by violence or neglect
or by abortion or to have been attended by suspicious
circumstances; or

● which appears to the registrar to have occurred during an


operation or before recovery from the effect of an
anaesthetic; or

● which appears to the registrar from the contents of any


medical certificate of cause of death to have been due to
industrial disease or industrial poisoning.’

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The MDU . Inquests

Types of cases to be reported to the coroner

Doctors are not legally obliged to report a death to the The following list is not exhaustive. Doctors may need to refer
coroner, though in practice they should do so if there is any the case to the coroner where they have any doubt about the
doubt or suspicion. A doctor can issue a death certificate on cause of death and feel that they cannot complete the death
the basis that ‘...they will only sign statements they believe to certificate.
be true. This means that you must take reasonable steps to
verify any statement before you sign a document.’ This ● abortions - other than natural or therapeutic
guidance is produced by the General Medical Council in the
● accidents or injuries if in any way contributing to the
publication, Good Medical Practice1. If you feel that you
cause of death
cannot comply with this, you may need to refer the matter to
the coroner. ● alcoholism - chronic or acute

● anaesthetics and operations - either death during an


The registrar of deaths must notify the coroner if the operation or before full recovery from anaesthesia or after
deceased person was not seen by a certifying medical operations performed for trauma injury (in any event a
practitioner during the 14 days before death, or at any time death within 24 hours of operation should be referred)
afterwards. If a death is one to be reported by the registrar to
● a death which has occurred within three months of an
the coroner, the doctor should do the same. All individuals
invasive operative procedure
have a common law duty to notify the coroner if the
deceased person may have met his death by violent or ● death connected with crime or suspected crime
unnatural means, or if there is a sudden death of unknown
● ill treatment - starvation or neglect, even if self inflicted -
causes.
including death that may be due to lack of medical care
or lack of nursing care

● drug abuse or therapeutic mishap and also if death may


be related to a medical procedure or treatment whether
invasive or not

● industrial disease or toxicity, arising out of the deceased’s


employment

● infant deaths, if cause obscure

● persons receiving disability pensions (a war or industrial


disability) - if death is or may be connected with
pensionable disability

● persons in legal custody, including deaths in hospital while


sentence is being served

● poisoning from any cause - occupational, therapeutic,


accidental, suicidal, homicidal and also food poisoning

● septicaemia, where originating from an injury

● still births where there is a possibility that the child may


have been born alive, or there is cause for suspicion.

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Investigation

Inquiries are usually carried out by the coroner’s officer (a The coroner decides which witnesses to summon. This can
plain-clothed policeman). While doctors are advised to co- be by voluntary agreement, after ‘due notification’ by a formal
operate with the coroner’s office, they should contact the summons, or by a Crown Office subpoena. If a witness fails
MDU if they need assistance in drafting their statement or if to comply with the coroner’s summons or to answer
they feel that any aspects of the care and treatment they questions, this may result in a fine of up to £1,000 or
have given the patient may be criticised. imprisonment for contempt of court.

A doctor would normally need the consent of a deceased The coroner may decide - after considering the results of
patient’s executors, or the next of kin, before disclosing interviews with relatives, doctors and healthcare workers -
information to a third party. However, the coroner (procurator that no further investigation is necessary. Alternatively, he may
fiscal in Scotland) is obliged by law to investigate the order a post mortem. He will then select a pathologist who in
circumstances of certain deaths. To help the coroner decide some circumstances will have forensic experience. Where
whether an inquest should be held, clinical notes and relevant there is any criticism of the medical or nursing care provided
information about the deceased must be disclosed to the by a particular hospital, it is usual for a pathologist from a
coroner or coroner’s officer on request. different site to carry out the post mortem. This is usually a
Home Office appointed pathologist.
The coroner may also ask for information about living
patients, when this is relevant to his inquiry, but the doctor
may not disclose this without the patient’s consent, unless
ordered to do so by the coroner during a public inquest.

With a suspected murder or manslaughter, the coroner will


pass the investigation of the death to the police. A doctor
may then disclose the deceased person’s medical notes
directly to the police (though preferably at the behest of a
senior officer, such as a detective superintendent), or to the
Home Office pathologist. If the police are considering
prosecuting somebody for murder or manslaughter, then the
inquest is deferred until after any criminal prosecution has
taken place, or a clear decision has been made by the Crown
Prosecution Service not to prosecute.

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The MDU . Inquests

Statement for the coroner

A doctor making a statement for the coroner should provide


a detailed, factual account, based on knowledge of the
patient and the medical records. It should be a chronological
record of the doctor’s role in the clinical sequence. It is helpful
to include, where relevant, dates and times that the patient
was seen. Details should be given about the history, the
findings on examination, diagnoses, investigations and the
treatments ordered. Other doctors or healthcare workers
involved in the clinical sequence should be identified,
because the coroner may also want to seek their comments.
The coroner will need to see the deceased patient’s medical
records.

The statement should include the following:

● full name, qualifications and practice address of doctor

● full name, address if known and date of birth of the


deceased

● for whom the report is produced

● detailed summary of past medical history with dates

● recent illness or event leading to the death, including


dates seen, history taken, examination, differential
diagnosis and treatment - with a brief outline of any
hospital referrals, identifying the name of the relevant
practitioner or consultant.

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Legal representation

It is rare for doctors and healthcare workers to have legal


representation at inquests. In general, it should be avoided
unless relatives or others - who may themselves be
represented legally - have made specific criticisms of the care
given to the deceased.

Where the patient has died in hospital and the relatives are
critical of the treatment given, the practitioner involved must
discuss the need for legal representation with a senior
administrator. MDU members can of course continue to seek
advice from the MDU about the wording of the statement
which they will submit to the coroner and about their
presentation of evidence.

If the relatives of the deceased person are represented legally,


they may view the inquest as an opportunity to seek evidence
for possible use in a civil claim.

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The MDU . Inquests

The hearing

The evidence given at an inquest is intended to answer


questions put by the court. Witnesses are not called to give
evidence in support of a particular case. Most doctors who
are called have been in charge of the care of the patient; they
are not there in any expert capacity. Each witness takes the
oath or affirms and is then examined by the coroner, who
may elicit evidence in different ways. Doctors are often asked
to read out their statements, or the coroner may ask them
questions based upon it. It is advisable for them to re-read
statements before the inquest. After witnesses have been
examined by the coroner, they may also be questioned by
other interested persons or their representatives and, if
necessary by the witness’s own representative.

Giving evidence at an inquest is usually straightforward.


Witnesses should reply in an audible and concise manner.
Medical jargon should be avoided if at all possible. The family
of the deceased sometimes attend inquests and it is best
that they hear a clear, factual account of the care and
treatment given to their relative.

Doctors who are questioned in a manner aimed at suggesting


that they have committed a crime may decline to answer the
questions put to them. They cannot be obliged to answer any
questions which may incriminate them. If they feel their
professional conduct or competence is called into question,
then they may seek an adjournment of the inquest from the
coroner and contact the MDU for advice. This is an unusual
occurrence and practitioners will normally have already
sought advice so that they are prepared, if they feel they may
be subject to any criticism in relation to the care and
treatment given to the deceased.

The coroner may sit alone or with a jury. He is bound to have


a jury where the death was in custody or it occurred at work
or on a railway or in circumstances thought to be prejudicial
to the public’s health or safety. Members of the jury may
question a witness to help clarify any matters they do not
understand.

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The verdict

At the end of a jury hearing, the coroner must sum up the


evidence which has been given and direct the jury on any
points of law that arise. The jury’s findings will cover the
matters which are the concern of the inquest. The question of
how the person died should be answered by a brief summary
of the circumstances leading to the death, as determined by
the jury, in view of the evidence given.

When the coroner sits alone, he will summarise and record


his own findings and conclusions on the inquisition form (the
formal record of the inquest). The following words may be added, where appropriate: ‘and
the cause of death was aggravated by neglect/self neglect’.
The verdict comprises:
“Neglect”, “lack of care” and “self neglect” may, in some
● the deceased person’s name circumstances, be used as free-standing conclusions.
Doctors should be aware that these terms do not amount to
● the injury or disease causing death
a finding of negligence: indeed the Coroners Rules state that
● the time, place and circumstances in which no verdict should be framed in such a way as to appear to
the injury occurred determine criminal or civil liability. The completed inquisition
● the conclusion as to death form is signed by the coroner and, where there is a jury by
those jurors who agree with it. The jury consists of between
● the registration particulars
seven and eleven people and majority verdicts are acceptable
as long as the minority is of no more than two.
The following is a comprehensive list of suggested (though
not compulsory) verdicts given in note (4) to the prescribed When the inquest is finished, it must be closed formally. The
form of inquisition in the Coroners Rules 1984. coroner’s officer calls ‘silence’ and asks everyone present in
the court to stand as the coroner leaves the bench.
● natural causes

● accident/misadventure

● industrial disease

● sentence of death

● dependence on drugs/non dependent abuse of drugs

● lawful killing

● open verdict

● want of attention at birth

● unlawful killing

● suicide

● still birth

● attempted/self-induced abortion

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The MDU . Inquests

Scotland - fatal accident enquiries

There is no coroner’s office in Scotland. Instead, the


procurator fiscal investigates all sudden, suspicious,
accidental, unexpected and unexplained deaths.

Under Section 1 of the Fatal Accidents and Sudden Deaths


Inquiry (Scotland) Act 1976, the procurator fiscal should hold
a public inquiry before the sheriff. This includes all deaths
occurring in custody or in the course of employment or
deaths which are sudden, suspicious or unexplained or give
rise to serious public concern. The inquiry is held in public
and the proceedings are transcribed in shorthand.

Doctors can be compelled to attend and give a statement,


known as a precognition, to the procurator fiscal. They can
also be ordered to give evidence at the fatal accident inquiry
and must answer the questions put to them, except those
which might point to their being guilty of a criminal offence.
The sheriff then issues a final report (known as the sheriff’s
determination) which includes the place and cause of death,
occupational hazards resulting in death and the reasonable
precautions by which death might have been avoided. The
procurator fiscal is only obliged to arrange for a post mortem
if he considers that the circumstances justify this.

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Publicity

Inquests are held in public (e.g. a coroner’s court or


magistrate’s court) unless they involve national security. The
press may attend and will report any inquest deemed
newsworthy, for example, because of the manner of death or
if the deceased was a celebrity. Doctors who are contacted
by the press are advised not to comment, as they have a
duty of confidentiality to the deceased patient. The MDU has
a press office which can assist members with such inquiries.
It can be contacted 24 hours a day via the freephone
advisory help line number.

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The MDU . Inquests

After the inquest

Fees and expenses


Immediately after the inquest, the coroner should pay the fees
of every medical witness and reimburse all reasonably
incurred expenses. These fees are set by the Home
Secretary. Doctors are advised to contact the coroner’s officer
or the clerk to the court after the hearing to arrange for
suitable reimbursement.

The coroner will pay an expert witness a fee according to the


nature and difficulty of the case and the preparatory work
involved in giving evidence. An expert witness may also be
entitled to a travel allowance.

Judicial review
In rare cases, where anyone with a ‘sufficient interest’ is
dissatisfied with the way in which an inquest has been
conducted or with the coroner’s decision not to hold an
inquest, he or she may apply for judicial review or make an
application under the terms of Section 13 of the Coroners Act
1988. This may result in an inquest being held or in a new
inquest with a new coroner sitting.

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Questions and answers

1 Q I have been asked by a policeman for a report about 3 Q The relatives of my deceased patient are to be
my recently deceased patient. Is it all right to legally represented at a forthcoming inquest. Their
comply with the request? solicitors have asked for copies of the records. I
have retained a copy set as the originals are with the
A The duty of confidentiality extends beyond the grave. It coroner. Am I obliged to disclose the records?
is important to find out whether the policeman is, in fact,
the coroner’s officer. If he is making inquiries on the A The coroner should be informed of this request. The
coroner’s behalf, it is appropriate to co-operate with him. Access to Health Records Act 1990 entitles the patient’s
Any other police officer making inquiries into the representative to have copies of any medical records
circumstances of a person’s death would need the made on or after 1 November 1991. Access to these
consent of the executor of the estate or the personal records of a dead patient can, however, be withheld if
representative, before such information could be you believe the information was provided by the patient
released, unless you believe the situation justifies a in the expectation that it would not be disclosed to the
breach in confidentiality. applicant. This caveat should be noted on the records.
The MDU provides advice in the booklet Can I see the
2 Q The coroner has asked me to produce a statement records? which is free to members.
for him and also to send him my patient’s original
medical records. Am I entitled to do this without the 4 Q I am due to go on holiday in three weeks, but have
consent of the family? been asked to attend an inquest during the period
that I will be abroad. Can the coroner compel my
A Yes, the coroner, or procurator fiscal in Scotland, is attendance?
obliged by law to investigate the circumstances of
certain deaths. Medical records and relevant information A Yes. The coroner has power to compel the attendance
about the deceased must be disclosed to the coroner or of witnesses under pain of fine or imprisonment for
the coroner’s officer on request. The MDU is always contempt. Depending on how crucial your evidence is,
happy to assist a member with the preparation of a or how central to the case, the coroner may well look
statement to the coroner. It is always helpful if you sympathetically at receiving your evidence simply in the
enclose copies of the relevant medical records when you form of a statement. Alternatively, he may consider
send us your draft report. You may wish to take a copy postponing the inquest. He has the authority to compel
set of the medical records, so that you have access to you to attend, regardless of any inconvenience, but this
them to produce the report, if the coroner requests the is rarely exercised.
originals.
5 Q I recently attended an inquest into the death of one
of my patients. The coroner was very critical of my
management and said so quite bluntly. To my mind,
his comments were inappropriate. I feel that I have
been defamed and I would like to take legal advice.

A The coroner is entitled to judicial immunity regarding civil


proceedings and in connection with words spoken while
exercising his judicial duty, except where the words are
in excess or without his jurisdiction. In the circumstances
that you describe, it would not be advisable to seek to
pursue an action for defamation.
The decisions of a coroner can be subject to judicial
review where the verdict is not justified by the facts in
the evidence.
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The MDU . Inquests

Questions and answers

6 Q My patient, a woman in her 60s, died recently. She 8 Q I am a transplant surgeon and we have permission
had only been on my list for six months and I saw from relatives to harvest the kidneys of the patient
her on one occasion three months before her death. who has died as a result of injuries suffered in a
I was aware from her notes of a problem with road traffic accident. Because of the cause of death,
alcohol abuse and her relatives now tell me that she the coroner has been notified. I want to proceed to a
was neglecting herself. In short, I do not know transplant as soon as possible. Is this all right?
whether I could sign a death certificate. Should I ask
the coroner’s permission? A The body of any deceased person who came by his
death suddenly or violently belongs to the coroner by
A The coroner cannot give you authority to sign a death common law. Transplant surgeons should abide by the
certificate. A doctor attending the deceased patient in her recommendation of the code of practice Cadaveric
last illness is required by statute to complete a death Organs for Transplantation, drawn up in 1983 by a
certificate, giving the cause of death to the best of his working party set up by various UK health departments.2
knowledge and belief. If, as it appears, you feel you are They should seek consent from the coroner for the
without the knowledge and belief to complete the removal of specific organs before removing any from the
certificate, then it can be completed to show that the death body. He will ensure that inquiries are instigated by the
has been reported to the coroner. The registrar cannot duty pathologist and will give his assent or refusal based
register the death until the coroner has finished his inquiries. on these inquiries. Failure to seek the coroner’s assent
Doctors may seek to avoid delay by reporting a death for the removal of organs could be an offence under the
informally to the coroner and seeking reassurance to Human Tissue Act 1961.
issue a death certificate. However, on receiving this
reassurance, the doctor should not initial the certificate
to indicate that the coroner has been informed. If this is 9 Q After the inquest on one of my patients who died
done, the death cannot be registered without the tragically at the age of two, I spoke to the parents to
coroner’s authority, which produces the very delay that express my condolences. It was rather awkward, as
the doctor sought to avoid. during the inquest they had criticised my
management. I wonder whether I have compromised
7 Q I am a casualty officer and have been asked to myself by doing this, if they try to sue me. Have I in
attend the inquest of a 48-year-old man. I sent him some way admitted liability?
home from A&E where he presented with chest pain.
I formed the view that he had reflux oesophagitis A Expressing sympathy to the family is not in itself an
and advised accordingly. He was brought in dead admission of liability. It is a common courtesy that
two hours later. His widow is very critical of me and I anyone would wish to extend to relatives who have been
fear she may sue the hospital as she has three bereaved recently.
young children to bring up alone. The GMC’s guidance to doctors, Good Medical Practice
states: ‘If a patient under 16 has died you must explain,
A The MDU will be happy to advise you on the preparation to the best of your knowledge, the reasons for, and the
of your report for the coroner. You will probably have circumstances of, the death to those with parental
already discussed the case with your consultant. The responsibility.’
unit general manager should also be notified of the
forthcoming inquest. The hospital may face litigation and
may need to instruct solicitors to appear on its behalf.
Since you are a junior doctor, your consultant may well
wish to be available to attend the inquest with you. Any
claim of negligence in this case will be made against the
hospital, and the hospital and their legal advisers will
answer it in its entirety under NHS indemnity.
15
References and Bibliography

References
1. Good Medical Practice, Duties of a Doctor, para 55, GMC,
July (1998)

2. Cadaveric Organs for Transplantation: a code of practice


including the diagnosis of brain death, DHSS, (1983)

Bibliography
Coroners’ Inquiries - a Guide to Law and Practice, Burton
JDK, Chambers DR and Gill PS, Longman Law Tax and
Finance, London (1989)

Jervis on the Office and Duties of Coroners, Matthews P and


Foreman JC, Eleventh edition, Sweet & Maxwell, London
(1993)

Can I see the Records? MDU, London (2001)

Confidentiality, MDU, London (2001)

Good Medical Practice; Duties of a Doctor, GMC (1998)

For further guidance on inquests or other medico-legal


and ethical matters, members can call our advisory
helpline on Freephone : 0800 716646

Our advisers will be pleased to help.

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