An inquest is not a trial, and nobody stands accused of anything. That is the law, and it can lead a doctor to arrive at an inquest underprepared. The coroner's findings are public, and the family's questions come to you in open court. What you say can travel to your employer and to the GMC. Where a death raises a question of criminal liability, it can also travel to the police. The rules on who takes part as an interested person are worth knowing before the hearing. So are the rules on what you can see and say.

What the inquest is for

Section 5 of the Coroners and Justice Act 2009 sets the purpose of the investigation: to ascertain who the deceased was and how, when and where they came by their death. Where the European Convention on Human Rights requires it, the question of how widens to the circumstances of the death. Section 10 then limits how the coroner or jury may frame the determination. It must not appear to decide criminal liability on the part of a named person, or any question of civil liability.

That protection is about the wording of the conclusion. It does not stop the coroner from finding facts about your care, and the coroner will record those facts.

When you are an interested person

Section 47 lists who counts as an interested person. The list includes family members, the personal representative and a medical examiner exercising functions in relation to the death. It also includes, at paragraph (f), a person who may by any act or omission have caused or contributed to the death. The same paragraph covers a person whose employee or agent may have done so. Paragraph (m) adds any other person the senior coroner thinks has a sufficient interest.

A doctor whose treatment is under scrutiny is likely to fall within paragraph (f). So is the trust that employs the doctor, through the words about an employee or agent. Being an interested person is a status that brings rights. It is not a finding that you did anything wrong.

What the status gives you

The Coroners (Inquests) Rules 2013 give interested persons two rights that matter most in practice. The first concerns disclosure. Under rule 13, where you ask for disclosure of a document the coroner holds, the coroner must provide it or make it available as soon as reasonably practicable. That duty is subject to the exceptions in rule 15. The rule names the post-mortem report and other reports provided to the coroner. The second right concerns witnesses. Under rule 19, the coroner must allow you, in person or through your representative, to examine any witness. But the coroner will disallow irrelevant questions.

Ask for disclosure early. The post-mortem report, the trust's serious incident or patient safety investigation and the statements of other witnesses tell you what the coroner is likely to explore. They also let you correct an error before the hearing rather than during it.

Your interests and the trust's

If the trust instructs lawyers for the inquest, their client is the trust. The evidence may point towards an individual failing rather than a system failing, and then the trust's position and yours can diverge. Ask early whether your interests align, and if they do not, take separate advice. Take a doctor in training with a concern about rota gaps, and a trust anxious to show that staffing was adequate. Those are interests that need separate voices.

Giving evidence

Good medical practice (2024) applies directly. Paragraph 98 requires you to cooperate with any formal inquiry, patient safety investigation or complaints procedure. It also requires you to provide all relevant information and to be open and honest. Paragraph 92 says that when giving evidence you must follow the GMC's guidance on honest communication. Under the same paragraph, you must make clear the limits of your knowledge and expertise. Paragraph 89 adds that you must not deliberately leave out relevant information and must not present opinion as established fact.

In practice that means a statement written from the records, with times and entries checked. It should separate what you remember from what the notes show, and say plainly where something sits outside your specialty. In court, listen to the whole question, answer it, and say when you do not know.

Rule 22 provides that no witness need answer a question tending to incriminate them, and that the coroner must tell you that you may refuse. A police investigation into the death may be possible. If so, take advice before you write your statement, not on the morning of the hearing.

After the inquest

Paragraph 99 of Good medical practice requires you to tell the GMC without delay if an official inquiry has criticised you. The GMC's guidance on reporting criminal and regulatory proceedings lists a coroner's inquest among its examples. It says the duty covers criticism of serious matters that would call your fitness to practise into question. The coroner may also make a report to prevent future deaths, which I deal with in a companion article.

If you are a nurse, dentist, pharmacist or other healthcare professional

Interested person status does not depend on your profession. Section 47 of the Coroners and Justice Act 2009 includes any person who may by any act or omission have caused or contributed to the death, so a nurse, midwife, paramedic or pharmacist whose care is under scrutiny can seek it on the same footing as a doctor, with the same rights to disclosure and to question witnesses under the Coroners (Inquests) Rules 2013. The regulator that follows the inquest differs, and our pages for nurses and midwives, pharmacists and HCPC professionals set out their processes.

Eloquia prepares doctors for inquests and supports them through the hearing on our inquests and NHS disciplinary track. We help you decide whether to seek interested person status. We then prepare your statement with the records in front of us and prepare you to give evidence. For each inquest you pay a fixed fee, stated plus VAT, which we quote once we have seen the papers. That fee includes a specialist barrister whom we involve from the outset. Advocacy at the hearing itself, where your case needs it, comes through a regulated law firm we work with, because conducting a case before a coroner is a reserved legal activity. Our fees and funding page explains how staged payment works.

If you have heard that the coroner will hold an inquest into the death of a patient you treated, ask the coroner's officer whether the coroner will treat you as an interested person. Request disclosure of the post-mortem report and investigation documents. Then draft your statement from the records before memory and hindsight blur together.

Sources

  1. Coroners and Justice Act 2009, section 5: Matters to be ascertained
  2. Coroners and Justice Act 2009, section 10: Determinations and findings to be made
  3. Coroners and Justice Act 2009, section 47: Interested person
  4. Coroners (Inquests) Rules 2013, rule 13: Disclosure of documents at the request of an interested person
  5. Coroners (Inquests) Rules 2013, rule 19: Entitlement to examine witnesses
  6. Coroners (Inquests) Rules 2013, rule 22: Self incrimination
  7. GMC, Good medical practice (2024), Domain 4: Trust and professionalism
  8. GMC, Reporting criminal and regulatory proceedings within and outside the UK