Inquests - England

What is an inquest?

An inquest is an official fact-finding inquiry following a death. This is carried out by a coroner and the purpose is to answer four questions:  

• Who died
• Where did they die
• When did they die
• How did they die (or sometimes in what circumstances the deceased came by their death). 

When is an inquest necessary?

An inquest is held in cases where the death was:

• Violent or unnatural
• The cause of death is unknown
• The deceased died while in prison, police custody or any other type of state detention.

It is usual for the coroner to hold an inquest when a death occurs within 24 hours of admission to hospital or a surgical procedure, although this is not mandatory. If there is a possibility that a medical procedure contributed to or caused the death, it should be discussed with the coroner, regardless of the timescales involved. You should record the details of referral to the coroner in the patient’s records.

The coroner may also hold an inquest if the death was due to natural causes and an inquest is considered by the coroner to be in the public interest.

What should you do if you receive a request from a coroner for a statement?

The GMC’s guidance Good Medical Practice specifies a doctor’s professional obligation to co-operate with formal inquiries and to be honest and trustworthy when writing reports and giving evidence to courts or tribunals (paragraphs 71-73).

A doctor’s role is to provide a factual account to assist the coroner in investigating the circumstances surrounding the death, ultimately allowing them to answer the four questions above during an inquest hearing. A statement should provide information regarding the treatment given to the deceased whilst under the practitioner’s care. This should cover an overview of the patient’s previous medical history, in addition to details of any relevant consultations.

Medical Protection can provide you with advice on the content and structure of your statement. If you are a hospital-based medical professional, your trust legal team can also assist you with this.

As part of the coroner’s investigation, statements will be obtained from all relevant parties. The coroner will then decide which witnesses are required to give oral evidence at the inquest. Under Rule 23 of the Coroners (Inquest) Rules 2013 your statement could be admitted into evidence if it is non-contentious, negating the requirement for you to attend the inquest hearing.

What should you do if you are called to appear as a witness at an inquest hearing?

An inquest hearing is held in public and is a formal court proceeding. There is no defence and prosecution as it is not a function of the coroner to apportion blame – the coroner’s court is one of investigation and inquiry; it is not adversarial. 

You can be called as a witness in two ways:

1. As a “Witness of Fact”: If one is called as a witness of fact, it would usually indicate that the coroner believes your involvement in the case to be peripheral. Your statement will form the basis of your oral evidence and you may be asked questions in order to clarify certain aspects.  
2. As an “Interested Person”: If one is called as an Interested Person (IP) it would indicate that the coroner believes you to be more centrally involved in the circumstances leading to death. If you are granted IP status you are entitled to have legal representation; receive disclosure of the documents that the coroner intends to rely upon at the inquest; and ask questions of other witnesses. 

Witness evidence is given under oath, which means that you are under a legal obligation to tell the truth at an inquest. Please see the Medical Protection factsheet on Giving Evidence. 

If you are a hospital employed doctor, the trust will likely represent your interests at an inquest. If you are self-employed, for example in general practice or in cases where there is a potential conflict between your interests and those of your employing trust, separate representation, if appropriate, can be provided through Medical Protection.

Jury inquests

There are certain circumstances in which it is mandatory for an inquest to be held before a jury. These include a death occurring: 

• in state detention (including under mental health section, police custody, prison) 
• as a result of a works accident
• due to notifiable poisoning or disease
• as a result of an act or omission of a police officer or a member of a service police force.

An inquest may also be held before a jury if the coroner thinks that there is sufficient reason for doing so.

Conclusions

The coroner (or a jury) will reach a conclusion once all of the evidence has been heard and considered. This includes the legal determination stating formally who died, and where, when and how they died. The coroner or jury may come to a ‘short form’ conclusion and use one of the following terms:

• Accident or misadventure
• Alcohol/drug related
• Industrial disease
• Lawful/unlawful killing
• Natural causes
• Open (used when there is insufficient evidence for any other outcome)
• Road traffic collision
• Stillbirth
• Suicide.

Alternatively, or in addition, the coroner or jury may make a brief ‘narrative’ conclusion setting out the facts surrounding the death in more detail and explaining the reasons for the decision.

The coroner’s conclusion can only be challenged by way of judicial review in the High Court. Legal proceedings must be initiated as soon as possible but no later than three months following the conclusion of the inquest.

Regulation 28 Reports – Prevention of Future Deaths (PFD)

Following the inquest, the coroner has a duty to make recommendations in cases where the evidence suggests that further avoidable deaths could occur and that, in the coroner’s opinion, preventative action should be taken. The coroner will prepare a report, which will be sent to the person or authority that may have the power to take the appropriate steps to reduce the risk; they have a duty to provide a response within 56 days of the date the report is sent. 

Notifying the GMC and NHS England

The GMC’s Good Medical Practice (paragraph 75) sets out the obligations for a doctor to inform the GMC (without delay) in circumstances when they have been criticised by an official inquiry (which would include a coroner’s inquest). The coroner can also refer a doctor or doctors to their regulatory body if they consider that it would prevent a recurrence of the incident that caused the death.

In England, a change to the National Health Service (Performers Lists) (England) Regulations 2016 places performers under an obligation to inform NHS England if the coroner has found that the performer’s actions have caused, or contributed to, the death of the deceased, or otherwise had their conduct brought into question at an inquest conducted as part of an investigation under the Coroners and Justice Act 2009.

If a doctor is concerned that they may be (or have been) criticised in the contexts of a coroner’s inquest, including in a Regulation 28 Report, then they should contact Medical Protection at the earliest opportunity to seek advice about the appropriate steps to take.  

Further information

• MOJ, A Guide to Coroners and Inquests 2010
• The Coroners Society of England and Wales
• The Coroners (Amendment Rules) 2008
• GMC, Good Medical Practice  
• GMC, Acting as a Witness in Legal Proceedings, explanatory guidance, Good Medical Practice (2013)