Coroners Inquests

This page includes information on:

  1. How to support a doctor in training attending a coroner's inquest
  2. A guide for doctors in training called to give evidence at a coroner's inquest

1. Supporting doctors in training attending a Coroner’s Inquest


A trainee being called to provide evidence at an inquest is an infrequent event however it can cause anxiety for doctors at the beginning of their careers. This paper details:

  • The support that doctors in training can expect locally and from HEE
  • HEE’s expectations regarding notification of instances where doctors in training will be or are likely to be attending an inquest
  • The role of the Postgraduate Dean in this process.

Local Support

Support for a doctor in training attending an inquest will come, in the first instance, from the doctor’s employer, whether the trainee is in primary or secondary care.

For trainees in secondary care the Trust’s Risk Management team (or equivalent) will usually co-ordinate the practical support for all Trust employees involved in an inquest. This will include providing access to the Trust solicitor (if appropriate); coaching and briefings on the process; and providing someone to attend the inquest with the doctor in training. Doctors in primary care should have access to similar support and advice. Doctors in training not covered by trust indemnity e.g. GP trainees on primary placements should ensure that their indemnity arrangements include involvement in cases referred to the coroner.

In all cases where a trainee is likely to be called to give evidence at an inquest, the doctor’s Educational Supervisor and Nominated Clinical Supervisor should be informed and should offer both practical and pastoral support to a trainee. The Educational Supervisor will also need to be mindful of any impact on the doctor’s training and progression.

Following a particularly distressing event, for instance a patient death, the trainee may want to seek psychological support through their employer (usually through occupational health), their GP or through their HEE local team’s Professional Support & Wellbeing services.

If the incident or matters in question are particularly contentious the doctor may also wish to inform, and seek support from, their medical defence organisation.

Notification to the HEE Local Team

Thresholds for notification of incidents to be escalated to HEE local teams are currently being reviewed and defined. However there is an expectation that if a doctor in training is expected to give evidence at an inquest then the HEE Local Team should be informed. The method of this escalation will be dependent on local processes.

Involvement of HEE Local Teams and the Postgraduate Dean

Once a notification of a doctor in training attending an inquest has been received the incident and surrounding circumstances should be reviewed by the Postgraduate Dean (or nominated deputy). The Postgraduate Dean (or nominated deputy) will:

  • Inform the doctor in training that the notification has been received. Share HEE guidance for doctors in training (see Appendixes)
  • Ensure that the trainee has been adequately supported locally and offer HEE Local Team support including access to the local Professional Support & Wellbeing services (or equivalent).
  • Offer meeting with the Head of Specialty (or equivalent) should the trainee want to discuss the incident or the support they are receiving.
  • Seek speciality advice (where necessary) from the Head of Specialty (or equivalent). The Postgraduate Dean should also ensure that the doctor’s training has been reviewed particularly if the issues may impact on progression in training. The specialty school will also need to ensure that the trainee has adequately reflected on the events in question.
  • In a very small number of cases the Postgraduate Dean will need to consider the impact that the issues may have on revalidation or fitness to practise.
  • Consider whether legal advice should be sought for HEE as an organisation (legal support for the doctor in training should usually come from their employer or through their medical defence organisation).
  • Consider whether the circumstance involved may result in local or national media coverage. If so then the local HEE communication lead should be informed. In such circumstances the Postgraduate Dean should also review the support for the trainee as such coverage can be very distressing for the doctors involved.
  • Share any learning across the Local team and consider if there are any quality implications.


2. A guide for doctors in training called to give evidence at a Coroner's Court

W Hiu Lam BMedSci (Hons) BMBS FRCA FRCP MSc (ML) is a Consultant at University Hospitals Plymouth, an Associate Postgraduate Dean and Head of Professional Support at Peninsula Deanery. He is also a Primary FRCA Examiner, member of the BJA Education editorial board.

Adam Malin PhD FRCP is a Consultant Respiratory Physician at Royal United Hospitals at Bath, an Associate Postgraduate Dean and Head of Professional Support at Severn Deanery. He is also the Honorary Secretary at NACT UK.

Ian Arrow BA is a Solicitor of the Supreme Court.  Admitted Solicitor in 1987.  Deputy Coroner 1993.  Appointed to own Coroner’s jurisdiction in the South West in 2003.  Now Senior Coroner for Plymouth, Torbay and South Devon area.



Being called as a witness at an inquest is an infrequent event, yet may cause anxiety and stress. These notes provide colleagues with information on how to prepare for an inquest and what support is available.

Background & process

A Coroner is an independent judicial officer whose jurisdiction has existed for many centuries. There are 88 Coroner areas in England and Wales with a is similar system in Ireland, but no Coroners in Scotland. However, a similar role in Scotland is undertaken by a Procurator Fiscal.  Coroners, supported by officers and administrative staff, are appointed by local authorities. Doctors are most likely to be in discussion with a Coroner’s Officer who assists the Coroner.

A doctor may report the death to a Coroner 1 if the:

  • cause of death is unknown
  • death was violent or unexplained
  • death was sudden and unexplained
  • person who died was not visited by a medical practitioner during their final illness
  • medical certificate is not available
  • person who died was not seen by the doctor who signed the medical certificate within 14 days before death or after they died
  • death occurred during an operation or before the person came out of anaesthetic
  • medical certificate suggests the death may have been caused by an industrial disease or industrial poisoning

Following the report of a hospital death, the Coroner’s Officer may contact the doctor about a written referral. Once a death is referred to the Coroner, the reporting doctor should not issue a Medical Certificate of Cause of Death (MCCD) to a family until formally agreed by the Coroner.

It is important to remember that for the family of the deceased an investigation can help with the grieving process, provide information and a setting in which their questions can be answered. The family usually wishes to see demonstration in changes in practice or procedures which may save future lives.

A referral to the Coroner’s Office normally results in one of the three outcomes:

1. The Coroner issuing a Certificate indicating no further investigation is required (Form A).

2. A direction by the Coroner that a Post Mortem examination should take place. If the post Mortem report provides a natural cause of death, the Coroner will then issue a Form B and no further investigation will take place.

3. In the event the death is unnatural or there are potential family fears to be allayed, then the Coroner will hold an Inquest. An Inquest is a formal hearing at which evidence is considered.


An Inquest produces a conclusion. It is not a trial. It is a fact-finding inquiry by a Coroner, with or without a jury, into the circumstances surrounding a death. The purpose is to answer four questions:

  1. Who was the deceased?
  2. When and where they died?
  3. How they came by their death?
  4. The details required by Registrar of Deaths to enable the death to be registered

Most Inquests are heard by a Coroner sitting alone. Only about 4% of inquests require a jury. A jury is required in:

  • Any death in custody
  • Any death involving the workplace and Health and Safety executive
  • Any death on a railway line
  • Where it would be in the public interest

The Inquest does not record who is responsible for a death. It is not the Coroner’s role to probe for any potential clinical negligence. It is however possible that the findings of an inquest may be influential in subsequent legal action as part of the prosecution or defence. The Coroner also has power under Regulation 28 to make a Report to an organization or individual which may prevent future deaths.

Preparation of statement

An Inquest Statement is one example of a professional statement you may be asked to provide throughout your career. The statement may be seen by:

  • Police
  • Coroner
  • Care Quality Commission/Health Ombudsman
  • Patients and their families
  • Solicitors and barristers
  • Secretary of State for Health

Therefore, it’s important to prepare this carefully and be aware of what is expected. When a request is made for a statement, it should be provided preferably within two weeks. A single comprehensive statement suitable for all possible investigations is recommended. It can be very helpful to ask an experienced colleague, or in some cases, a medical defence union, to give you impartial advice prior to formal submission.

Giving evidence

As a witness you are not on trial, you are there to assist the court. The Coroner decides which witnesses should attend, and in what order they are called. Normally they will hear the family’s evidence first, followed by the pathologist, then the treating clinicians/staff in chronological order. A witness must attend the Inquest following receiving a formal summons. The request of attendance may be submitted to the legal department of the organisation. Prior to the Inquest, it may be possible to be familiarized to the surroundings by attending a pre-inquest visit. This can usually be arranged by the hospital legal and human resources department in conjunction with the Coroner’s Office. The witness must remember to:

  • Arrive in good time
  • Dress appropriately (as if attending for a job interview)
  • Address the Coroner as Sir or Ma’am
  • Remember to turn off mobiles/bleeps
  • Be prepared to give your evidence under oath. If you wish to give an oath using a holy book other than a Bible, it is wise to give the Coroner’s Court advance notice.

The Coroner usually asks questions during and after hearing statements to clarify details. Following this clarification, the family or their legal representative can ask questions. The Coroner will ensure that no inappropriate questions or challenges are made. In some circumstances the Coroner will make a witness aware that they do not need to answer a question that could incriminate them. The proceedings in the Coroner’s Court are digitally recorded, and it is important that the witness’ replies are audible. In addition, they should avoid using medical jargon that the family may not understand.

There could be a significant time interval between the event and the Inquest being held, sometimes more than a year. The witness should prepare adequately and be re-familiarised with their statement, the medical records and any other relevant documents such as local or national policies. It is important for witnesses to have all the clinical facts at their fingertips. Muddled thinking, speaking or shuffling of papers never gives a good impression. The witness must concentrate and take time to speak clearly and slowly and aim to demonstrate honesty, reasonableness, professionalism and empathy.

The witness is normally free to leave after the evidence is given. However, you may wish to hear the conclusion at the end. Afterwards, you may feel tired and emotionally drained. Most Trusts will not expect you to return to work after a Coroner’s Court appearance. The media may be present at Inquests. Don’t be drawn into giving any comment to journalists. Media interests are managed by employer’s communication team and the press should be directed to them. Prior arrangement can be organised with court officials to depart from an alternative exit if necessary.

Representation at Inquest

This depends on the circumstances of each case. It is sometimes assumed that any contact with Inquests or litigation needs the involvement of your defence society. Most Inquests do not end with controversial or negative findings. The Coroner would find it unusual if a legal representative appears in the court for an individual witness for an uncontroversial investigation.


Being involved in an inquest creates understandable anxiety. It can be a distressing experience, for both witnesses and family. It is reassuring to know that most witnesses feel that their anxiety was overstated following reflection after the event.

The hospital trust’s legal department will usually coordinate statements and the date of the Inquest. They are familiar with the process and can offer advice. It is routine practice to have pre-Inquest meetings to review statements and offer advice on giving evidence and the process. They also frequently offer post Inquest debriefing.

Colleagues who may have given evidence in Court previously can be a useful resource to support the witness and would have insight into concerns. Acknowledging that Inquest is a stressful process, the witness can obtain support from Occupational Health and their GP. As a trainee, the educational team and Deanery Professional Support & Wellbeing service can offer additional support and advice.


1. [Accessed 2 March 2019].