Completing a coroner's report - 5 tips for GPs

GPs are often asked to provide statements for the coroner. MDU medico-legal adviser Dr Nicola Lennard provides advice to help GPs prepare for writing a report or attending an inquest.

During 2014 25,899 coroner’s inquests were opened into the death of an individual in England and Wales. This means that 12% of cases reported to the coroner, are taken forward to an inquest.

In Scotland, procurators fiscal investigate around half of the 13,500 deaths reported each year, but only around 50-60 deaths result in a fatal accident inquiry.

As GPs have oversight of many aspects of a patient’s care they are frequently asked to provide statements for the coroner or to provide a statement or precognition (a verbal statement taken by way of questioning) to the procurator fiscal in Scotland. Doctors may also be called to attend these hearings.

Fatal accident inquiries differ in some significant ways from inquests and are often reported in the media. Your medical defence organisation can guide you if you are asked to provide a precognition or statement in relation to such an inquiry.

Although inquests (like fatal accident inquiries) are inquisitorial, rather than adversarial, the thought of being questioned by the relative of a deceased patient, or their solicitor, can be extremely intimidating. The following five tips are designed to help you prepare for writing a report or attending an inquest.

1. Get advice on your report

The coroner will want you to provide a comprehensive, factually accurate report which is easy to follow and written in language which can be understood by all. It is in your best interests to ensure that you include all information requested and by doing so, it may be possible to avoid the need to attend the inquest and give evidence.

Your medical defence organisation can advise you not only on what information it might be helpful to include, but also on the style and the formatting of the report. An inquest is open to the public and your report may be heard not only by the family of the deceased but also by the public and sometimes the media. 

2. Liaise with the coroner’s officer

Even if you do not feel vulnerable to criticism regarding the case, it may be that the deceased’s family have concerns that you are not aware of. It is possible to speak with the coroner’s officer and ask if any concerns or criticisms have been made about the care you provided.

This is particularly important if you have been called to give evidence, as you will also want to establish if the family of the deceased or any other interested parties are to be legally represented.

You will also wish to know if you have been made a ‘properly interested person’ (PIP). Your medical defence organisation will often liaise with the coroner on your behalf to establish this information. A PIP is an individual whose act or omission, may have caused or contributed to the death of the deceased.

If you are named as a PIP then you will be allowed legal representation at the inquest, and your representative can question the other witnesses. You will also be provided with copies of the statements of the other witnesses and relevant documents.

3. Know your statement well and keep replies short and factual

Significant time can elapse between providing a report and the inquest taking place, so refresh your memory of your statement the night before and remember to address the coroner as Sir or Madam.

The purpose of the inquest is to determine who the deceased was, when they died, where they died and how they died. When answering questions doctors have a tendency to provide detailed explanations, however in court you might want to limit your response so that you only answer the question that has been asked of you.

Your response should be factual and you should refrain from expressing expert opinion, unless you are asked to do so. When necessary it is appropriate to refer to your statement. It is also important to remember that although tensions may exist between you and the deceased’s family, offering your sincere condolences to them is to be encouraged.

4. Acknowledge if there have been shortcomings in the care provided

There are times when, with the benefit of hindsight, it is clear that the care provided to a patient could have been better.

If this is the case the coroner will want to see that there has been genuine reflection on the case, acknowledgement that matters could have been improved, an apology given where necessary and changes made to prevent a similar recurrence. This may not alter the verdict of the inquest, but may affect any criticism of you as a practitioner.

5. What to do when there is criticism of you

Paragraph 75(a) of Good Medical Practice indicates that you must tell the GMC without delay if you have been criticised by an official inquiry, which would include a coroner’s inquest. There is also a requirement to notify your performers’ list of such criticism.

The threshold for reporting such criticism is not always clear, and so you should seek advice from your medical defence organisation about the need for self-referral to the GMC at the earliest opportunity.

Photo: iStock

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