The MDU’s Guide to

a practical medico-legal guide

INQUESTS

General / Advisory Publication

1

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

Contents

The MDU . Inquests

Introduction

2

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.

Role of the coroner

The MDU . Inquests

3

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.

4

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.’

Who refers a death to the coroner?

Types of cases to be reported to the coroner

5

Doctors are not legally obliged to report a death to the

coroner, though in practice they should do so if there is any

doubt or suspicion. A doctor can issue a death certificate on

the basis that ‘...they will only sign statements they believe to

be true. This means that you must take reasonable steps to

verify any statement before you sign a document.’ This

guidance is produced by the General Medical Council in the

publication, Good Medical Practice1. If you feel that you

cannot comply with this, you may need to refer the matter to

the coroner.

The registrar of deaths must notify the coroner if the

deceased person was not seen by a certifying medical

practitioner during the 14 days before death, or at any time

afterwards. If a death is one to be reported by the registrar to

the coroner, the doctor should do the same. All individuals

have a common law duty to notify the coroner if the

deceased person may have met his death by violent or

unnatural means, or if there is a sudden death of unknown

causes.

The following list is not exhaustive. Doctors may need to refer

the case to the coroner where they have any doubt about the

cause of death and feel that they cannot complete the death

certificate.

● abortions - other than natural or therapeutic

● accidents or injuries if in any way contributing to the

cause of death

● alcoholism - chronic or acute

● anaesthetics and operations - either death during an

operation or before full recovery from anaesthesia or after

operations performed for trauma injury (in any event a

death within 24 hours of operation should be referred)

● a death which has occurred within three months of an

invasive operative procedure

● death connected with crime or suspected crime

● ill treatment - starvation or neglect, even if self inflicted -

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.

The MDU . Inquests

Investigation

6

Inquiries are usually carried out by the coroner’s officer (a

plain-clothed policeman). While doctors are advised to co-

operate with the coroner’s office, they should contact the

MDU if they need assistance in drafting their statement or if

they feel that any aspects of the care and treatment they

have given the patient may be criticised.

A doctor would normally need the consent of a deceased

patient’s executors, or the next of kin, before disclosing

information to a third party. However, the coroner (procurator

fiscal in Scotland) is obliged by law to investigate the

circumstances of certain deaths. To help the coroner decide

whether an inquest should be held, clinical notes and relevant

information about the deceased must be disclosed to the

coroner or coroner’s officer on request.

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.

The coroner decides which witnesses to summon. This can

be by voluntary agreement, after ‘due notification’ by a formal

summons, or by a Crown Office subpoena. If a witness fails

to comply with the coroner’s summons or to answer

questions, this may result in a fine of up to £1,000 or

imprisonment for contempt of court.

The coroner may decide - after considering the results of

interviews with relatives, doctors and healthcare workers -

that no further investigation is necessary. Alternatively, he may

order a post mortem. He will then select a pathologist who in

some circumstances will have forensic experience. Where

there is any criticism of the medical or nursing care provided

by a particular hospital, it is usual for a pathologist from a

different site to carry out the post mortem. This is usually a

Home Office appointed pathologist.

7

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.

Statement for the coroner

The MDU . Inquests

8

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.

Legal representation

9

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.

The MDU . Inquests

10

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 verdict comprises:

● the deceased person’s name

● the injury or disease causing death

● the time, place and circumstances in which

the injury occurred

● the conclusion as to death

● the registration particulars

The following is a comprehensive list of suggested (though

not compulsory) verdicts given in note (4) to the prescribed

form of inquisition in the Coroners Rules 1984.

● 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

The following words may be added, where appropriate: ‘and

the cause of death was aggravated by neglect/self neglect’.

“Neglect”, “lack of care” and “self neglect” may, in some

circumstances, be used as free-standing conclusions.

Doctors should be aware that these terms do not amount to

a finding of negligence: indeed the Coroners Rules state that

no verdict should be framed in such a way as to appear to

determine criminal or civil liability. The completed inquisition

form is signed by the coroner and, where there is a jury by

those jurors who agree with it. The jury consists of between

seven and eleven people and majority verdicts are acceptable

as long as the minority is of no more than two.

When the inquest is finished, it must be closed formally. The

coroner’s officer calls ‘silence’ and asks everyone present in

the court to stand as the coroner leaves the bench.

The verdict

11

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.

The MDU . Inquests

12

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.

Publicity

13

After the inquest

The MDU . Inquests

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.

Questions and answers

14

1 Q I have been asked by a policeman for a report about

my recently deceased patient. Is it all right to

comply with the request?

A The duty of confidentiality extends beyond the grave. It

is important to find out whether the policeman is, in fact,

the coroner’s officer. If he is making inquiries on the

coroner’s behalf, it is appropriate to co-operate with him.

Any other police officer making inquiries into the

circumstances of a person’s death would need the

consent of the executor of the estate or the personal

representative, before such information could be

released, unless you believe the situation justifies a

breach in confidentiality.

2 Q The coroner has asked me to produce a statement

for him and also to send him my patient’s original

medical records. Am I entitled to do this without the

consent of the family?

A Yes, the coroner, or procurator fiscal in Scotland, is

obliged by law to investigate the circumstances of

certain deaths. Medical records and relevant information

about the deceased must be disclosed to the coroner or

the coroner’s officer on request. The MDU is always

happy to assist a member with the preparation of a

statement to the coroner. It is always helpful if you

enclose copies of the relevant medical records when you

send us your draft report. You may wish to take a copy

set of the medical records, so that you have access to

them to produce the report, if the coroner requests the

originals.

3 Q The relatives of my deceased patient are to be

legally represented at a forthcoming inquest. Their

solicitors have asked for copies of the records. I

have retained a copy set as the originals are with the

coroner. Am I obliged to disclose the records?

A The coroner should be informed of this request. The

Access to Health Records Act 1990 entitles the patient’s

representative to have copies of any medical records

made on or after 1 November 1991. Access to these

records of a dead patient can, however, be withheld if

you believe the information was provided by the patient

in the expectation that it would not be disclosed to the

applicant. This caveat should be noted on the records.

The MDU provides advice in the booklet Can I see the

records? which is free to members.

4 Q I am due to go on holiday in three weeks, but have

been asked to attend an inquest during the period

that I will be abroad. Can the coroner compel my

attendance?

A Yes. The coroner has power to compel the attendance

of witnesses under pain of fine or imprisonment for

contempt. Depending on how crucial your evidence is,

or how central to the case, the coroner may well look

sympathetically at receiving your evidence simply in the

form of a statement. Alternatively, he may consider

postponing the inquest. He has the authority to compel

you to attend, regardless of any inconvenience, but this

is rarely exercised.

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.

Questions and answers

15

6 Q My patient, a woman in her 60s, died recently. She

had only been on my list for six months and I saw

her on one occasion three months before her death.

I was aware from her notes of a problem with

alcohol abuse and her relatives now tell me that she

was neglecting herself. In short, I do not know

whether I could sign a death certificate. Should I ask

the coroner’s permission?

A The coroner cannot give you authority to sign a death

certificate. A doctor attending the deceased patient in her

last illness is required by statute to complete a death

certificate, giving the cause of death to the best of his

knowledge and belief. If, as it appears, you feel you are

without the knowledge and belief to complete the

certificate, then it can be completed to show that the death

has been reported to the coroner. The registrar cannot

register the death until the coroner has finished his inquiries.

Doctors may seek to avoid delay by reporting a death

informally to the coroner and seeking reassurance to

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

done, the death cannot be registered without the

coroner’s authority, which produces the very delay that

the doctor sought to avoid.

7 Q I am a casualty officer and have been asked to

attend the inquest of a 48-year-old man. I sent him

home from A&E where he presented with chest pain.

I formed the view that he had reflux oesophagitis

and advised accordingly. He was brought in dead

two hours later. His widow is very critical of me and I

fear she may sue the hospital as she has three

young children to bring up alone.

A The MDU will be happy to advise you on the preparation

of your report for the coroner. You will probably have

already discussed the case with your consultant. The

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.

8 Q I am a transplant surgeon and we have permission

from relatives to harvest the kidneys of the patient

who has died as a result of injuries suffered in a

road traffic accident. Because of the cause of death,

the coroner has been notified. I want to proceed to a

transplant as soon as possible. Is this all right?

A The body of any deceased person who came by his

death suddenly or violently belongs to the coroner by

common law. Transplant surgeons should abide by the

recommendation of the code of practice Cadaveric

Organs for Transplantation, drawn up in 1983 by a

working party set up by various UK health departments.2

They should seek consent from the coroner for the

removal of specific organs before removing any from the

body. He will ensure that inquiries are instigated by the

duty pathologist and will give his assent or refusal based

on these inquiries. Failure to seek the coroner’s assent

for the removal of organs could be an offence under the

Human Tissue Act 1961.

9 Q After the inquest on one of my patients who died

tragically at the age of two, I spoke to the parents to

express my condolences. It was rather awkward, as

during the inquest they had criticised my

management. I wonder whether I have compromised

myself by doing this, if they try to sue me. Have I in

some way admitted liability?

A Expressing sympathy to the family is not in itself an

admission of liability. It is a common courtesy that

anyone would wish to extend to relatives who have been

bereaved recently.

The GMC’s guidance to doctors, Good Medical Practice

states: ‘If a patient under 16 has died you must explain,

to the best of your knowledge, the reasons for, and the

circumstances of, the death to those with parental

responsibility.’

The MDU . Inquests

References and Bibliography

16

References

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

2. Cadaveric Organs for Transplantation: a code of practiceincluding the diagnosis of brain death, DHSS, (1983)

Bibliography

Coroners’ Inquiries - a Guide to Law and Practice, BurtonJDK, Chambers DR and Gill PS, Longman Law Tax andFinance, London (1989)

Jervis on the Office and Duties of Coroners, Matthews P andForeman 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-legaland ethical matters, members can call our advisoryhelpline on Freephone : 0800 716646

Our advisers will be pleased to help.