Inquest proceedings can be unpredictable and stressful, and support with managing requests from the Coroner are not included in the England and Wales state indemnity schemes.
Medical Protection has a wealth of experience in coronial law and can assist and advise members with inquest proceedings from the outset, by advising on your draft statement to the Coroner.
The Coroner presides over the inquest hearing. They are responsible for seeking evidence to answer four questions: who died; when they died; where they died; and how they came about their death. If you are asked for a statement by the Coroner, it is highly likely to be in relation to that final question.
Many Coroners set out what they want the doctor to cover in the statement - for example, consultations relating to mental health or prescriptions of controlled drugs - and many doctors write statements without the input of a medical defence organisation and without consideration of possible consequences, believing this to be a straightforward request.
Medical Protection advice
Why our advice is important:
We can assist in identifying those aspects the Coroner may consider to be particularly relevant. In writing a statement the Coroner usually wants a chronology of the relevant appointments, but it is also common for the Coroner to delve into matters further by asking pertinent questions, for example, what was the policy for giving repeat prescriptions and conducting medication reviews for a patient who overdosed and died?
We can guide you in writing your statement so that it comprehensively addresses issues which we think the Coroner will be particularly interested in. Based on our extensive experience, we can read between the lines and see how the nuances might play out at a hearing.
We can assess whether there is a need for a Significant Event Analysis to address any learning points. This might sound counter-intuitive, but it is advisable to get ahead of potential criticisms which might come out at the inquest hearing. The reason to do this early is to be in a position to say to the Coroner, “We have talked about this case and identified what we did well, what we could have done better and what we will do in future.” Reflection and remedial action is key.
If the first time any learning points are identified is from the witness box, there is a risk the Coroner could issue a Regulation 28 report for the Prevention of Future Deaths. This is a matter of public record and there is an obligation to respond within a timeframe prescribed by the Coroner. It is preferable that if there are learning points arising from the care, the family and the Coroner are able to read about this in advance, thus potentially avoiding a difficult line of questioning.
Should there be criticism by the Coroner of the care provided, we also advise doctors following inquests on their self-referral obligations pursuant to the General Medical Council’s Good Medical Practice guidance. This sets out the circumstances under which a doctor must self-refer to the GMC, and includes being criticised by an official inquiry, which would include inquests.
Coroners will sometimes ask you to speculate on what may have happened had the sequence of events been different – for example, would the deceased have survived if they had been referred to hospital earlier? Or they may ask you to speculate on the actions of others, which can lead to incredibly difficult questions at the time of the inquest. This is straying into the territory of a medicolegal expert witness and should be avoided. We are alert to such requests and where a clinician may have inadvertently overstepped their remit when replying.
Medical Protection is able to request that the Coroner places less weight on certain aspects of a statement, if it has been injudiciously submitted before our involvement, but ensuring the first statement provided to the Coroner is the definitive document, is our priority.
In addition, there have been cases where Coroners have called the clinician as a witness simply because their statement was not detailed enough – again, a situation that could be avoided if a doctor is able to request support early. Of course, a doctor may still be called to give evidence even in the face of a detailed statement, but a well-written, comprehensive statement will put you in the best starting position possible.
Finally, but of no less importance, we can help you set the tone of the statement. It is important to bear in mind it will be read by a grieving family (who will be able to ask questions of you about it), and sensitivity over particularly difficult matters is key.
If you receive a letter from the Coroner asking you for a statement and/or summonsing you to give oral evidence at the inquest, it is important to be able to request appropriate support early. The sooner you can seek help, the better. We can assist with your statement, write to the Coroner where necessary, liaise with other parties and gather in relevant documents.
You must not ignore any correspondence you receive from the Coroner – a failure to cooperate may lead to a fine, imprisonment, or both.
We can ease the burden for you, and help to put you in an optimal position, so our advice is to ensure you have professional protection in place which enables you to request support with inquest proceedings.
Not yet a member?
Visit: www.medicalprotection.org/uk/join
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