How To Prepare For Coroner's Court

"It can be a stressful process and you may feel very emotionally drained at the end of it."

Using insights from their own experience, an anonymous writer, explains how you can best prepare yourself for a coroners court summons and what you can expect from the process.

Being asked to attend a coroner’s inquest can be anxiety provoking and stressful, especially if is it something you have never been asked to do before. This document aims to give an insight to the experience, but also to provide guidance in terms of the process and how you might best prepare yourself.

It’s a scary prospect to be called to give evidence but it is common if a patient has been in receipt of care.

The Initial Process

It is possible that you will be notified of a patient’s death long before you are requested to attend a coroner’s inquest.

If you have been working with a patient, it is likely that a family member, your colleagues, or your organisation will inform you of a patient’s death beforehand. It is also likely that your organisation will launch their own internal review into the sequence of events prior to a patient’s death.

This will be in relation to the clinical care and support that was given. In essence, to gain an overview of the patient’s healthcare journey, if there were any omissions in terms of care provided and any future learning to be considered.

My Experience

The first I heard of my summons was in the form of an email from my line manager to indicate that a patient I had been supporting sadly had passed away.

I was also notified at the same time of the coroners request for a statement from me in terms of my role and involvement with the patient. This immediately instilled a sense of fear into me, and it was hard at this stage, not to overthink.

I was preoccupied with questions such as “Why do they want to talk to me?” “Have I done something wrong?” “Should I have done something different?”

It is reasonable to think like this initially, even if you are a confident practitioner and are certain that you have provided the appropriate care. It is still a daunting prospect to think that your practice will be scrutinised by the coroner and others.

Equally as a health care professional, you work hard to preserve a patient’s wellbeing and you constantly strive for good outcomes. We remain in the privileged position of looking after people and to provide the best care / treatment as far as possible, within the resources we have available.

We often come to know our patients well and become invested in their recovery. So, to hear the news that a patient has sadly passed in a manner that is unpleasant such as a suicide or where it is unknown / unclear, it is always difficult to hear.

Your thoughts will also jump to the family and how they might be coping with the loss, especially if it was unpredicted.

Even if you have followed good practice and done everything within the realms of your knowledge and expertise, it will still cause alarm and fear.

It is not unusual to feel this way because if you have been asked to provide a statement then you may be asked to attend the coroner’s inquest in person. Although we are constantly self-regulating, we are not used to others judgement upon our practice in such circumstances.

But try to think of it as aiding the enquiry process and the opportunity to provide your professional perspective rather than worrying that it will become a fault-finding exercise.

Exploring the sequence of events leading up to a patient’s death, will likely include the collaboration of several different services and professionals alike. The coroner will have to unpick the detail and salient points within the clinical information that will have been provided, in the form of witness reports.

Anyone that might have been involved in a patient’s care can be asked to provide a report/ witness statement and /or attend the inquest, if the coroner believes it can aid the process.

Role Of The Coroner

To investigate the sudden death of a patient / person to which the cause is unknown.

In England, Northern Ireland and Wales, a Coroner’s inquest will be undertaken when someone dies of unnatural causes or in custody or state detention. A Fatal Incident Inquiry (FAI) is the equivalent in Scotland.

Common factors might be:

• An unnatural death or death in suspicious circumstances.

• Death due to an accident, violence, neglect, abortion, or any kind of poisoning.

• Where the cause of death is unknown.

• If there has been a lack of medic attending the deceased during their last illness.

This list is not exhaustive but will provide an illustration of why a Coroner might be alerted. It might feel that they are there to apportion blame, but this is not their role.

They are however able to make recommendations in terms of future care provision.

A Coroner will need to establish the following:

• Who was the deceased

• When, where or how a person came by their death.

Purpose Of The Inquest

The inquest can help the family by assisting with the grieving process and it can provide the chronology of events that may not be known to the family members.

Importantly it is a factual account of what has happened to their loved one and it can be a forum where family can ask questions to all the health professionals involved.

It can also give reassurance of future learning and onward action if it felt that an omission of care occurred.

Why Have I Been Asked To Give Evidence?

There are a variety of reasons why you might be asked to give evidence. In my situation, my statement raised additional questions for the coroner, and I was asked to provide clarification around care that was given.

Any number of people can be involved in an inquest, this can range from family members, doctors, and other health care professionals, who might have been involved in the care of the deceased. It could also be someone who witnessed events such as an accident.

Some will be classed as “interested parties.” This designation will be the decision of the coroner and the status of an interested person means that they are required to be an active participant in the process.

As an interested person you have right to ask questions of all witnesses called (in person or via a legal representative), but it can also mean that you might be challenged or criticised on the care you have given.

An example of an interested person may be family member or healthcare trust that may be seen to have contributed through an act or omission to the death of the deceased.

If you have been asked as a witness to attend Coroners court, your role will be limited to attending for the purpose of giving evidence. If you have been asked to attend as an interested person, you will need to seek legal advice and or utilise the support of your trust’s solicitors in terms of how you should be represented at the inquest.

If you work for a trust, your trusts solicitors will be well versed in the field of law. You may be among several differing health professionals that have been called to give evidence.

If the coroner believes the behaviour of a clinician raise’s questions of professional misconduct, he can make a referral to the regulator such as the General Medical Council, Nursing and Midwifery Council or Health and Care Professionals.

It is important to also note that you may find yourself in a direct conflict of interest with your employer and will therefore need to seek out your own legal representative. You are more than likely to find out via your employer that you have been asked to give evidence.

You employer will have a process and policy for this eventuality. I was fortunate to have an employer who provided ample support throughout the whole process from initially learning that I would need to complete a report right through to attending and giving evidence.

The Initial Statement

You are required to complete a statement / report around your role and involvement only. You will have your clinical notes to guide you in terms of what you did at the time.

Remember it is likely to be several months later if asked to provide a statement. Stick to the facts and try not to speculate or give opinion, you are giving a factual true account of your involvement that’s all.

The coroner will decide who is required to attend after review of the statements presented to him. You may not get called to attend the inquest and your statement may be adequate.

However, if there are any further enquires, that have not been answered by your statement, you may be asked to attend and answer questions from the coroner.

Family and legal representatives will be invited to ask questions. Focus on the facts and if unable to recall, just be honest and say so. It may be that you are questioned by a barrister, and they use emotive language or encourage conjecture from you.

Continue with the facts only and try to avoid getting drawn into this. It is not your job to summarise or decide on events.

If you are called as an interested person, your organisation will direct you accordingly but as noted you may wish to draw upon your unions legal team to assist and advise you.

One of the most difficult parts of the inquest, is the knowledge that the deceased’s family are in attendance. Inquests are also in the public domain and press can be in attendance as well.

The press can attend and print what they hear in court. However, the coroner will give clear instruction to the press prior to the inquest. You may be approached at the end of the inquest by local media to give a statement.

Your trust / employer is likely to have prepared a statement around this and ask you to divert any enquiries to their own communications department.

What Will Happen On The Day

The coroner will outline the purpose of the inquest.

The process for you:

• You will be required to take an oath to tell the truth before you give your testimony

• You will have to introduce yourself, as will all other witnesses and interested persons

• You will outline role

• Your title

• Years of experience

• Any specialist backgrounds

• How you came to know the deceased

The coroner will read out the order of events and how the day will procced in terms of who and when each witness will take the stand. You will then have an indication of where you are placed.

Each interested party: legal representatives, barristers, family, the coroner will then be given the opportunity to examine and cross examine the witness statement / report that you have provided.

It is important to keep in mind, that as hard as you might be finding the whole experience, it is likely to be far more unbearable for the family that have lost their loved one.

Giving Evidence

You are there to assist the court. Family give evidence first; the pathologist then follows. Afterwards any health professionals involved will be required to take the stand.

Make sure you arrive in plenty of time and dress appropriately (as if you were going to an interview).

Make sure to have all phones turned off or silenced.

The coroner will ensure no unsuitable / inappropriate questions / challenges are directed at you. Ensure to avoid medical jargon and answer the question that has been asked. Speak clearly and slowly.

Remain courteous and always demonstrate professionalism. Avoid arrogance or over confidence, try not to overreact or retaliate if a challenge comes your way.

Make sure to take a copy of your statement so that you might refer to it when questioned.

After Giving Evidence Conclusions

You are free to go, or you can stay for the verdict and conclusion.

If the coroner offers recommendations in relation to his findings, you may wish to reflect on how this might impact, change, or influence your practice. It can be a stressful process and you may feel very emotionally drained at the end of it.

It may be worthwhile, trying to negotiate a couple of days off afterwards, so that you can reflect and recover. Your organisation / trust / employer may offer a debrief at the end, especially if a few professionals have been involved.

At the end of the inquest, the coroner will provide an outcome, detailing the cause of death, and at this point he will make it clear if there are any short comings or malpractice.

Hopefully, that will be the end for you.

Checklist

1. When writing you statement STICK TO THE FACTS! We are often so pressured and busy within our clinical settings, and often writing notes with a sense of urgency because the next task awaits. But remember they can be used in legal proceedings and therefore need to accurately reflect what we do. If it’s not there, it didn’t happen!

2. Make sure you are aware of your legal position and what role you play within the procedure- are you a witness or interested party?

3. Have you got or do you need legal representation?

4. Get a good night’s sleep prior to the inquest and arrive to the inquest in plenty of time.

5. Try to meet with your legal representative before and after the inquest to pre and de brief.

6. Take care of yourself and ensure you have time off after to reflect and de stress.