Professional Documents
Culture Documents
INQUESTS
a practical medico-legal guide
The MDU . Inquests
Contents
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
1
Introduction
2
The MDU . Inquests
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!
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.
3
Who refers a death to the coroner?
4
The MDU . Inquests
Doctors are not legally obliged to report a death to the The following list is not exhaustive. Doctors may need to refer
coroner, though in practice they should do so if there is any the case to the coroner where they have any doubt about the
doubt or suspicion. A doctor can issue a death certificate on cause of death and feel that they cannot complete the death
the basis that ‘...they will only sign statements they believe to certificate.
be true. This means that you must take reasonable steps to
verify any statement before you sign a document.’ This ● abortions - other than natural or therapeutic
guidance is produced by the General Medical Council in the
● accidents or injuries if in any way contributing to the
publication, Good Medical Practice1. If you feel that you
cause of death
cannot comply with this, you may need to refer the matter to
the coroner. ● alcoholism - chronic or acute
5
Investigation
Inquiries are usually carried out by the coroner’s officer (a The coroner decides which witnesses to summon. This can
plain-clothed policeman). While doctors are advised to co- be by voluntary agreement, after ‘due notification’ by a formal
operate with the coroner’s office, they should contact the summons, or by a Crown Office subpoena. If a witness fails
MDU if they need assistance in drafting their statement or if to comply with the coroner’s summons or to answer
they feel that any aspects of the care and treatment they questions, this may result in a fine of up to £1,000 or
have given the patient may be criticised. imprisonment for contempt of court.
A doctor would normally need the consent of a deceased The coroner may decide - after considering the results of
patient’s executors, or the next of kin, before disclosing interviews with relatives, doctors and healthcare workers -
information to a third party. However, the coroner (procurator that no further investigation is necessary. Alternatively, he may
fiscal in Scotland) is obliged by law to investigate the order a post mortem. He will then select a pathologist who in
circumstances of certain deaths. To help the coroner decide some circumstances will have forensic experience. Where
whether an inquest should be held, clinical notes and relevant there is any criticism of the medical or nursing care provided
information about the deceased must be disclosed to the by a particular hospital, it is usual for a pathologist from a
coroner or coroner’s officer on request. different site to carry out the post mortem. This is usually a
Home Office appointed pathologist.
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.
6
The MDU . Inquests
7
Legal representation
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.
8
The MDU . Inquests
The hearing
9
The verdict
● accident/misadventure
● industrial disease
● sentence of death
● lawful killing
● open verdict
● unlawful killing
● suicide
● still birth
● attempted/self-induced abortion
10
The MDU . Inquests
11
Publicity
12
The MDU . Inquests
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.
13
Questions and answers
1 Q I have been asked by a policeman for a report about 3 Q The relatives of my deceased patient are to be
my recently deceased patient. Is it all right to legally represented at a forthcoming inquest. Their
comply with the request? solicitors have asked for copies of the records. I
have retained a copy set as the originals are with the
A The duty of confidentiality extends beyond the grave. It coroner. Am I obliged to disclose the records?
is important to find out whether the policeman is, in fact,
the coroner’s officer. If he is making inquiries on the A The coroner should be informed of this request. The
coroner’s behalf, it is appropriate to co-operate with him. Access to Health Records Act 1990 entitles the patient’s
Any other police officer making inquiries into the representative to have copies of any medical records
circumstances of a person’s death would need the made on or after 1 November 1991. Access to these
consent of the executor of the estate or the personal records of a dead patient can, however, be withheld if
representative, before such information could be you believe the information was provided by the patient
released, unless you believe the situation justifies a in the expectation that it would not be disclosed to the
breach in confidentiality. applicant. This caveat should be noted on the records.
The MDU provides advice in the booklet Can I see the
2 Q The coroner has asked me to produce a statement records? which is free to members.
for him and also to send him my patient’s original
medical records. Am I entitled to do this without the 4 Q I am due to go on holiday in three weeks, but have
consent of the family? been asked to attend an inquest during the period
that I will be abroad. Can the coroner compel my
A Yes, the coroner, or procurator fiscal in Scotland, is attendance?
obliged by law to investigate the circumstances of
certain deaths. Medical records and relevant information A Yes. The coroner has power to compel the attendance
about the deceased must be disclosed to the coroner or of witnesses under pain of fine or imprisonment for
the coroner’s officer on request. The MDU is always contempt. Depending on how crucial your evidence is,
happy to assist a member with the preparation of a or how central to the case, the coroner may well look
statement to the coroner. It is always helpful if you sympathetically at receiving your evidence simply in the
enclose copies of the relevant medical records when you form of a statement. Alternatively, he may consider
send us your draft report. You may wish to take a copy postponing the inquest. He has the authority to compel
set of the medical records, so that you have access to you to attend, regardless of any inconvenience, but this
them to produce the report, if the coroner requests the is rarely exercised.
originals.
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.
6 Q My patient, a woman in her 60s, died recently. She 8 Q I am a transplant surgeon and we have permission
had only been on my list for six months and I saw from relatives to harvest the kidneys of the patient
her on one occasion three months before her death. who has died as a result of injuries suffered in a
I was aware from her notes of a problem with road traffic accident. Because of the cause of death,
alcohol abuse and her relatives now tell me that she the coroner has been notified. I want to proceed to a
was neglecting herself. In short, I do not know transplant as soon as possible. Is this all right?
whether I could sign a death certificate. Should I ask
the coroner’s permission? A The body of any deceased person who came by his
death suddenly or violently belongs to the coroner by
A The coroner cannot give you authority to sign a death common law. Transplant surgeons should abide by the
certificate. A doctor attending the deceased patient in her recommendation of the code of practice Cadaveric
last illness is required by statute to complete a death Organs for Transplantation, drawn up in 1983 by a
certificate, giving the cause of death to the best of his working party set up by various UK health departments.2
knowledge and belief. If, as it appears, you feel you are They should seek consent from the coroner for the
without the knowledge and belief to complete the removal of specific organs before removing any from the
certificate, then it can be completed to show that the death body. He will ensure that inquiries are instigated by the
has been reported to the coroner. The registrar cannot duty pathologist and will give his assent or refusal based
register the death until the coroner has finished his inquiries. on these inquiries. Failure to seek the coroner’s assent
Doctors may seek to avoid delay by reporting a death for the removal of organs could be an offence under the
informally to the coroner and seeking reassurance to Human Tissue Act 1961.
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 9 Q After the inquest on one of my patients who died
done, the death cannot be registered without the tragically at the age of two, I spoke to the parents to
coroner’s authority, which produces the very delay that express my condolences. It was rather awkward, as
the doctor sought to avoid. during the inquest they had criticised my
management. I wonder whether I have compromised
7 Q I am a casualty officer and have been asked to myself by doing this, if they try to sue me. Have I in
attend the inquest of a 48-year-old man. I sent him some way admitted liability?
home from A&E where he presented with chest pain.
I formed the view that he had reflux oesophagitis A Expressing sympathy to the family is not in itself an
and advised accordingly. He was brought in dead admission of liability. It is a common courtesy that
two hours later. His widow is very critical of me and I anyone would wish to extend to relatives who have been
fear she may sue the hospital as she has three bereaved recently.
young children to bring up alone. The GMC’s guidance to doctors, Good Medical Practice
states: ‘If a patient under 16 has died you must explain,
A The MDU will be happy to advise you on the preparation to the best of your knowledge, the reasons for, and the
of your report for the coroner. You will probably have circumstances of, the death to those with parental
already discussed the case with your consultant. The responsibility.’
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.
15
References and Bibliography
References
1. Good Medical Practice, Duties of a Doctor, para 55, GMC,
July (1998)
Bibliography
Coroners’ Inquiries - a Guide to Law and Practice, Burton
JDK, Chambers DR and Gill PS, Longman Law Tax and
Finance, London (1989)
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