Assisting the coroner

Ms Claire Cregan provides information and guidance on dealing with requests made by, or on behalf of, the coroner

The Coroners (Amendment) Act 2019 (the ‘Act’) sets out the powers available to coroners in the investigation of reportable deaths, which include deaths occurring in a violent or unnatural manner, by misadventure, as a result of negligence, misconduct, or malpractice, and deaths occurring while in state custody/detention. A complete list of reportable deaths is set out in the Act.

Post-mortem examination

The Act sets out specific circumstances (which mirror the list of reportable deaths) where “it shall be the duty of a coroner to direct that a post-mortem examination” be carried out to determine cause of death. In other circumstances, the coroner has discretion to direct a post-mortem examination, unless they receive a written request to do so from certain individuals or institutions specified in the Act.

Post-mortem report requests

Family members of a deceased patient often contact their treating doctor and request a copy of the post-mortem report. The Act states that the coroner must provide a copy of the post-mortem report to a family member if requested, unless doing so could prejudice criminal proceedings, instituted, or being considered. It is therefore prudent for the doctor to advise family members to make direct contact with the coroner to request a copy of the post-mortem report, or for the doctor to contact the coroner to confirm they can release a copy directly to the deceased patient’s family.

Of note, paragraph 46.6 of the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (ninth edition), provides: “After the death of a patient, you should be available to speak with the bereaved family if that is what they wish. You should, as far as possible, explain the circumstances of the patient’s death to the family in an open and sensitive way unless the patient previously expressed an objection to such information being given.” 

Subject to the above, it is appropriate for a doctor to meet with the deceased patient’s family to discuss the content of the post-mortem report, and explain medical terminology, should the family wish to do so.

Releasing patient information

The coroner will gather relevant evidence from a number of witnesses and they often write directly to doctors seeking a copy of the deceased patient’s medical records or a medical report. The Coroner’s Court is a court of law, and this request has a similar legal basis to a court order. It is therefore not necessary for the doctor to seek additional consent; for example, from the deceased patient’s legal personal representative, prior to releasing patient information to the coroner.

Members of An Garda Síochána will often request information from a doctor in their capacity as agent for the coroner. In such cases, it is important to clarify that the gardaí are acting on the direction of the coroner. It is best practice to seek a written request from the gardaí and to retain this document on the deceased patient’s clinical file. If there is any ambiguity surrounding the exact nature of the request, or if the request is time-sensitive, the doctor should seek clarification directly from the coroner prior to releasing any patient information. 

Medical report

Doctors are regularly requested to provide written reports to the coroner and may be requested to attend at an inquest to give evidence, based on the content of their report/statement/medical records. It is therefore vital to ensure that all relevant information has been included and that the report is factual and accurate. The report may be read into evidence in the presence of the deceased patient’s family, or their family may see a copy of the report.  The language used in the report should be measured and condolences offered where appropriate.

When drafting a report, the first step is to carefully review the medical records. The coroner may come from a legal background rather than a medical background, and it is helpful to avoid using acronyms or shorthand medical terms in the report, to ensure it can be easily understood. There is no prescribed format for drafting a report, but we suggest it is helpful to include the following information:

▶ Details of the doctor;

▶ Details of the deceased;

▶ Condolences to the deceased’s family;

▶ Deceased’s medical history;

▶ Clinical concerns and prescribed medications at the time of death;

▶ Summary of recent relevant attendances with the deceased;

▶ Summary of deceased’s final illness and any comments about the likely cause of death, if known and appropriate to do so.

If the doctor previously provided a statement directly to An Garda Síochána, the medical report can be based on the information already given in that statement.

Inquest

A coroner’s inquest is an inquiry into the circumstances surrounding a sudden, unexplained or violent death, to establish the identity of the deceased person and to determine how, when, and where their death occurred. It is not intended to determine civil or criminal liability, but to establish facts for the public record. An inquest is held in public, and the coroner has broad powers to make any necessary direction, including the production of any document or article in a person’s possession, power or control, the taking of an oath/affirmation by a witness and directing a witness to answer questions.

Where a doctor is requested to attend at an inquest to give evidence, they will usually be given a minimum of two weeks’ notice. The doctor should bring a copy of the deceased patient’s clinical notes and a copy of any statement/report previously provided to the gardaí/coroner. The doctor may be asked to read out their statement/report and should be prepared to clarify any inaccuracies or contradictions. If there is any sensitive information that the doctor feels may be inappropriate to read publicly, they should discuss this with the coroner in advance of the inquest. 

The coroner decides who is classified as an “interested person” at an inquest. Such persons may include the family of the deceased, or representatives of a board or authority in whose care the deceased was at the time of their death, eg, hospital, prison, or other institution. Such interested persons may be legally represented by a solicitor or a barrister who can ask questions on their behalf. Questions asked by or on behalf of interested parties may be challenging and can often be confrontational and it is important to remain composed when answering. We strongly recommend you contact your indemnifier for guidance and support through this process.   

Verdict

The coroner (or jury if present) returns their findings and verdict in relation to how the person’s death occurred, together with any recommendation(s) to prevent a similar death in the future. The range of verdicts includes:

▶ Accidental death;

▶ Misadventure;

▶ Suicide;

▶ Natural causes;

▶ Unlawful killing;

▶ Narrative verdict;

▶ Open verdict – meaning that there is insufficient evidence to decide how the death occurred; the matter is left open should further evidence come to light.

As mentioned above, the purpose of an inquest is not to determine civil or criminal liability, but to establish facts for the public record.

Conclusion

A request to assist a coroner or to attend at an inquest can cause stress and worry to a doctor. It is important to remember that the purpose of an inquest is not to apportion blame, but to establish how the person’s death occurred and to provide answers to family members who have lost their loved one.

It is important to remember that the purpose of an inquest is not to apportion blame, but to establish how the person’s death occurred

Prior to releasing a statement/report to the coroner, or giving evidence at an inquest, we recommend seeking advice and guidance from your indemnifier, particularly if there is any possibility of civil proceedings being initiated or a complaint to the Medical Council arising from the treatment afforded to the deceased patient. In our experience, doctors find it very beneficial and comforting to have support from their indemnifier to assist with a report and to guide them through the inquest process.