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Writing a coroner's report

Authors: Bhavani Balakrishnan 

Publication date:  13 May 2006


Writing a coroner's report for the first time can be a daunting experience, but remember that the coroner's job is to investigate the cause of death and not to accuse you.

  • Check in what capacity you have been asked to write the report, for example, either as an on-call doctor or as the patient's team doctor

  • Obtain and photocopy the patient's medical notes so you can read them thoroughly and formulate your report

  • Read through the notes of your team members

  • Start working on your report early

  • Address the coroner as “Sir” or “Madam”

  • Give a detailed chronological order of events leading to death

  • Avoid jargon. If it is unavoidable, explain the meaning in brackets

  • At the end of the report you could add that it is based on events as recorded in your notes and from memory

  • Avoid criticising the inefficiency of your colleagues or the system. Only do so if absolutely necessary

  • It is useful to get the report typed by your secretary and obtain a hard copy. You can then read through it several times and make any necessary changes before you produce the final draft

  • Show your report to your specialist registrar, consultant, or your defence union and get their opinions

  • Remember to read through colleagues' coroner's reports. This helps to prepare explanations of any inconsistencies

  • Finally, discuss your report with the trust's lawyers. They are the experts in the field. You need to be cautious if they ask you to make changes—it may not be in your best interest, but could be in the best interest of the trust. ■

Bhavani Balakrishnan specialist registrar in child and adolescent psychiatry South London and Maudsley NHS Trust  bavs45@yahoo.com

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