Guidance on Attending a Coroner’s Inquest

Introduction

Witnesses may agree to attend voluntarily or may be served with a summons. Failure to answer a summons can result in a fine for contempt of court.

It is important to clarify in what capacity the GP is being called. This would usually be as a professional witness.

A coroner’s inquest is there to establish the fact around the death and the mode and circumstances that led to the death and as such it is not concerned with ‘blame’ or ‘fault’ though it can highlight its findings and lawyers may well use the evidence from an inquest in any civil case that follows.

Coroner’s Inquest

(taken from ‘Going to Coroner’s court. James Brooks. BMJ 12/1/12)

A Coroner’s inquest is a fact-finding inquiry. It is not a trial. The scope is limited to establishing who died, when, where and how. The Coroners court is not a court of blame; it is a court of fact.

Providing a medical Report for the Coroner

From time to time, it may be necessary for the coroner to request a short factual report from the GP, as a professional witness, detailing the circumstance of the last illness and death, details of the last contact with the attending GP, the past medical history and medication. If the author feels able then it may be appropriate to offer a cause of death.

The report may enable the coroner to avoid a postmortem. It may also remove the need for a GP to attend an inquest in person and so it is in your interest to ensure that the report contains as much relevant information as is possible. Just attaching a printout summary of the patient record is unlikely to provide the coroner with sufficient information and as such you are more likely to be called to court as a formal witness.

It should be noted, however, that the report can be used as evidence in court and as such you may wish to seek guidance from your MDO before sending it to the Coroner’s Office.

It is recommended that the report is written in the first-person singular, active voice:

‘I, John Smith, on 4 June at 10am visited the patient at home and saw this and did that,’ etcetera.

The LMC has agreed with the Coroner’s Office that GPs will not charge for this short report, especially as it may negate the need for the coroner to request formal attendance of the GP at court in person.

The coroner is not expecting GPs to spend excessive amounts of time producing lengthy reports.

A report may be requested as opposed to just a computer printout because the family can request copies of any notes sent to the coroner and medical record print outs can sometimes generate more questions than answers.

We advise that providing basic medical information for a Coroner’s Report is your duty. However, a more detailed report may be asked for. There is nothing in the Coroners Act that clearly stipulates a fee for reports where payment is not being offered. The BMA advises doctors to complete the report otherwise they may face being summonsed.

Coroners are entitled to request medical information that is relevant and necessary to their enquiries.

The GMC sets out clearly in Good Medical Practice that ‘You must assist the coroner or procurator fiscal in an inquest or inquiry into a patient’s death by responding to their enquiries and by offering all relevant information. You are entitled to remain silent only when your evidence may lead to criminal proceedings being taken against you.’

HEE have produced the following guidance: Coroners’ Inquests – Writing a statement

The MPS have produced a good template here: Coroners report template

Doctors as Witnesses

Doctors appearing as witnesses fall into one of three categories:

Ordinary witnesses (called to give evidence in a capacity unrelated to their work as doctors);
Professional witnesses (of whom the deceased would have been a patient);
Or expert witnesses (doctors with advanced knowledge of a specific field relevant to the case).

Doctors attending Coroners court as a professional witness are entitled to claim travel expenses and an attendance allowance.

The GMC gives the following advice for Doctors acting as a witness in legal proceedings: Coroners’ court fees and allowances

Duties of all Witnesses

Doctors play an important role in the justice system by contributing evidence both as expert witnesses and as witnesses of fact.
Whether you are acting as a witness of fact or an expert witness, you have a duty to the court and this overrides any obligation to the person who is instructing or paying you. This means you have a duty to act independently and to be honest, trustworthy, objective and impartial. You must not allow your views about a person to affect the evidence or advice you give.
You must understand your role as a witness throughout the court process. You must cooperate with case management, making sure you meet the timescales for producing reports and going to conferences, meetings or court hearings.
You must make sure that any report you write, or evidence you give, is accurate and not misleading. This means you must take reasonable steps to check the accuracy of any information you give, and to make sure that you include all relevant information.
People who do not have a medical background may rely on your advice and evidence to help them make decisions. Where it is possible to do so without misleading anyone, you should use language and terminology that people who are not medically qualified will understand. You should explain any abbreviations and medical or other technical terminology you use. Diagrams with explanatory labels can be useful.

In general terms doctors may find it helpful to bear in mind that a low threshold to seek advice from their medical defence organisation is to be encouraged. In particular, MDO advice is going to be most effective when it is given before a doctor provides a statement to the coroner. Where the doctor has been criticised about care they gave the deceased, or where the coroner is aware of such criticism (but the doctor is not) then this is a strong prompt to seek MDO advice at the earliest opportunity. It follows from that that doctors should feel able to speak to coroners directly to seek such information and, in addition to ascertaining whether there has been criticism, it can be very useful to find out if the family of the deceased are to be legally represented. (If they are it strongly suggests that they are not happy with the circumstances of death and can be an indication that the doctor may need legal representation too.)

Finally, there may be something about the nature of the death that suggests early liaison with the doctor’s MDO is necessary or prudent. This could include circumstances where there is to be a jury inquest, where the deceased had been detained in custody, where they had apparently taken their own life, where they had been under psychiatric care or where the deceased was a child or vulnerable person. Note that this list is not exhaustive and the important point is for the doctor to speak to their MDO where experienced MLAs can give further advice and/or assistance.

Information on the MDU’s page can be found here: Coroners – The MDU

Information from the MPS can be found here : Behind the scenes of a coroner’s inquest (medicalprotection.org)

The MDDUS also has a number of articles that are publicly available and the links are below:

MDDUS – Taking the stand

MDDUS – Coroner’s inquests

MDDUS – Coroner’s inquests PART 2

The BMA gives the following more general advice for any doctors attending court proceedings (not necessarily a coroner’s inquest).

Attending Court

If you are summoned to the court after providing a report you should:

Familiarise yourself with the report or statement you provided
Speak to the lawyers involved about any other documents you need to read in preparation
Inform the solicitors about any mistakes or omissions in your written evidence
Practice your points so they are clear and concise
Agree a place to meet on the day with the barrister or solicitor
Do some information gathering on the opposition’s counsel if possible

How to Present Yourself

If you are inexperienced at giving oral evidence, practice taking the oath.
In court, speak as slowly as possible. If you do not understand a question, you should ask the judge to ask the barrister to rephrase it.
You should always face the judge and also direct all your answers to him or her. In observing the judge, keep an eye on their pen and allow the judge to either finish writing before continuing or to ask you to continue.
You should always be ready to explain your area of expertise to the court.

Also, it is important that GPs in this situation contact their MDO for individually tailored advice and assistance.