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Coroner’s inquests: A guide for doctors

By Ms Maria Campbell - 08th Oct 2023

inquests

Ms Maria Campbell outlines what medical professionals should know about giving evidence at inquests

 A coroner’s inquest is an inquiry into the circumstances surrounding a death.  Medical practitioners can be asked to assist in the inquest process by providing a report to a coroner or by attending an inquest to give evidence in relation to the death of their patient.

What is the purpose of an inquest?

An inquest is held in circumstances where the death was sudden, unexplained, or violent. The purpose of an inquest is to establish the identity of the deceased person and to determine how, when, and where the 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 is conducted by a coroner. A jury is required at an inquest in specific circumstances such as deaths relating to murder, when they occurred in prison, or where the death resulted from a road traffic accident. Prior to holding an inquest, the coroner gathers evidence from those witnesses who may be of assistance. This often includes the clinicians who had been treating the patient in the time leading up to their death, even if their involvement with the patient was quite limited.

Role of medical practitioner

As a medical practitioner, you may have had some involvement with a coroner by reporting a sudden, unexplained or violent death, as legally required. You may, however, also be asked to assist the coroner by providing a report or by attending an inquest to give evidence. It can be daunting when faced with this prospect, but it is important to remember that your role as a witness is to provide honest, impartial evidence to assist the coroner in reaching their verdict.

Releasing patient information

The coroner’s court is a court of law and as such, where a report is requested, patient consent to release personal information is not necessary as a coroner’s request has a similar legal basis as a subpoena/court order and cannot be ignored.

Sometimes, An Garda Síochána will act as the agent for the coroner, and will request or collect the report from the medical practitioner. It should be clarified with the Garda that the report has in fact been requested by the coroner, and where any doubt exists a written request from the coroner can be sought.  In most cases, best practice would be to seek the request in writing from the coroner. If there is any confusion about what the coroner has requested (medical records, report etc) you can ask the coroner for clarification.

Drafting a coroner’s report

Doctors may be requested to provide a written report to a coroner in relation to a deceased patient.

The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners provides a helpful starting point in relation to the provision of medical reports. Paragraph 40.2 states that:

“Reports must be relevant, factual, accurate, and not misleading. Their content must not be influenced by financial or other inducements or pressures.”

If you are called as a witness you will be required to swear the oath/affirmation regarding your report so it is important to ensure all relevant information has been included and that the report is factual.

The first step is to review the deceased’s medical records carefully. If you have already given a statement directly to An Garda Síochána in relation to the patient, you can base your medical report on the information already given in this statement. There is not a prescribed format for a report, but as a starting point it is recommended that you include the following:

  • Details of the doctor;
  • Details of the deceased;
  • Past medical history;
  • Medical problems and medications at the time of death;
  • Summary of recent relevant attendances with the patient; and
  • Summary of patient’s final illness and any appropriate comments about the likely cause of death if known.

It is important to note that a coroner may come from a legal background rather than a medical background, and therefore it is helpful to avoid using acronyms or shorthand medical terms so your report can be easily understood. It is also important to bear in mind that the deceased patient’s family members are likely to see a copy of your report or hear your report being read out at an inquest and you may want to offer your condolences to the family.


If you have already given a statement directly to An Garda Síochána in relation to the patient, you can base your medical report on the information already given in this statement

Attending an inquest

As a medial practitioner, you may also be requested to attend an inquest to give evidence. In normal circumstances you will be given two weeks’ notice to attend the scheduled inquest hearing. 

You should bring a copy of the patient’s notes and a copy of the statement you provided with you to refer to.  You may be asked to read out the statement you have provided and be prepared to clarify any inaccuracies or contradictions.  If there is sensitive information that you feel is inappropriate to be read publicly, discuss this with coroner in advance and they will advise you on how to proceed.

Tips for giving evidence

Giving evidence at an inquest may feel intimidating. Some advice to help you prepare is provided below:

  • Remember to dress professionally.
  • You should address the coroner as “Sir/Madam”.
  • Be confident when taking the oath and if you are asked to read your report out in full – speak slowly and clearly.
  • Always consider your response before speaking.
  • If the answer to a question is “yes” or “no” and if you feel that to simply state “yes” or “no” would be misleading, advise that you would need to clarify a “yes” or “no” answer.
  • Be careful not to give an opinion unless it can be factually backed up.
  • Do not get into an argument with the coroner or any solicitor/barrister who may be questioning you.
  • If you are not sure of the answer to a question, you should say so. If a question is outside your area of expertise you should explain this to the coroner.
  • If you are comfortable to do so, it is generally appropriate to offer your condolences to the family of the deceased before giving your evidence.

Will I be questioned?

Any person who has an interest in the inquest may personally ask you or any other witness questions and they may be legally represented by a solicitor or a barrister who can do so on their behalf. The coroner decides who is classified as an “interested person”, but such persons may include the family of the deceased, or the representatives of a board or authority in whose care the deceased was at the time of death, eg, hospital, prison, or other institution. The family may have legal representation present and they may question you.

Questions asked by or on behalf of interested parties such as family members of the deceased, may be challenging and confrontational. It is important to remain composed in these circumstances and to remember that a coroner does not have the power to make a finding of clinical negligence. However, there are circumstances in which the phrase “aggravated by lack of care” can be added to the verdict by the coroner. Such a finding could result in a referral of the matter to the Medical Council by the coroner, although this does not often occur.

The coroner has broad powers to make any direction deemed necessary for the proper conduct of an inquest, including directing the taking of an oath/affirmation by a witness, directing a witness to answer questions, directing the production by any person of any document or article in the possession, power, or control.

Verdict

A verdict will be returned in relation to how the death occurred. The range of verdicts open to the coroner (or jury, if one is present) include:

  • Accidental death;
  • Misadventure;
  • Suicide;
  • Natural causes;
  • Unlawful killing;
  • Open verdict – meaning that there is insufficient evidence to decide how the death occurred – the matter is left open in the event that further evidence comes to light.

Where an inquest is held with a jury, the jury returns the findings and verdict together with any recommendation designed to prevent a similar death occurring.

Conclusion

Losing a patient is a difficult time for a doctor, particularly where you have a good relationship with the patient or the death is unexpected. Receiving a request to assist in the inquest process can add to a doctor’s worry at this time. It is important to remember that the purpose is not to apportion blame, but to establish how the death occurred and provide answers to family members who have lost their loved one. 

We recommend seeking advice from your indemnifier if you have any queries or concerns regarding any request to assist a coroner.

References available on request

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