Going to coroner’s court

Authors: James Brooks 

Publication date:  12 Jan 2012

James Brooks says that appearing in a coroner’s court can be nerve wracking, but awareness of protocol reduces anxiety

With its connotations of death in suspicious circumstances, mention of the coroner might inspire a shudder down the back for many people. For medical students, junior doctors, and their supervisors, this unfortunate situation could happen at some point during their careers.

Widespread media coverage follows when coroners’ investigations unearth deficiencies or errors in medical care that led to the death of a patient. The case of the doctor Daniel Ubani, who unintentionally administered a lethal overdose of a painkiller to 70 year old David Gray, sticks in the memory nearly two years after the coroner’s verdict.[1]

As a senior pathologist, Sebastian Lucas, head of clinical histopathology at King’s College London Medical School, has given evidence at countless inquests over the years. Much of the fear and trepidation that surrounds coroner’s courts, he says, is “completely unnecessary.”

As with all the commentators in this article, Professor Lucas’s experience is with the coroners’ system in England and Wales. Every country has its own procedures for investigating violent deaths and deaths of unknown cause, with different titles for the relevant officials—for example, the “medical examiner” is responsible for some or all of these duties in many US states. Several points are concordant, however.

Firstly, uncovering the factors that led to someone’s death is a universally important undertaking. It is essential for all doctors to contribute to it when they are called on to do so. Secondly, in many jurisdictions coroners are involved after a death more often than might be imagined. In 2010, 230 595 deaths in England and Wales were reported to the coroner—47% of all deaths. A postmortem examination was ordered in 101 943 cases.[2]

Minority of a minority

Professor Lucas is keen to emphasise this little known statistic: 21% of all deaths in England and Wales receive a coronial autopsy. But of all the deaths reported to the coroner, he says, “only around 13% end up as inquests. And bear in mind that a lot of them will be deaths in the community; that’s to say people found dead outside [a healthcare setting], so there may not be any relevance to doctors at all. Even the GP may not have anything useful to say. Where junior doctors are in the hospital team and the patient has died in hospital and there’s been an autopsy and it goes to inquest—this is a minority of a minority, it’s not terribly common.”

The several circumstances where deaths must be reported to the coroner in the UK include when no doctor has attended the deceased during his or her last illness or when a person has not been seen by a doctor during the last two weeks of life. Deaths in police custody, as a result of industrial incidents, or during medical operations must also come to the coroner’s attention.[3]

In the UK, coroners are independent judicial office holders appointed by local authorities. They may be lawyers or doctors or—as in the case of Roy Palmer, coroner for the southern district of greater London—both.

Dr Palmer says that medical students and junior doctors should be aware that “all deaths that are violent, or unnatural, or are sudden, or of unknown cause must be reported to the coroner. And that should be done properly and promptly . . . The General Medical Council imposes on all doctors a duty to cooperate fully with coroners and to volunteer information—not just wait to be asked, but actually positively volunteer it—if it’s relevant.”

If there is any uncertainty about the cause of death after it has been reported, the coroner will arrange for an autopsy. In most cases, the autopsy will show death by natural causes, and the coroner will decide that no further investigation is required. The coroner will issue the relevant certificate and the death can be registered. Should doubts remain, an inquest will be called.

“A coroner’s inquest is a fact finding inquiry; it is not a trial, and the coroner should make that clear to everybody called,” says Dr Palmer. “The scope is limited to establishing who died, when, where, and how. The coroner is not allowed to appear to decide an issue of civil liability such as negligence, and he or she is not allowed to pin a crime on a named individual. The coroner’s court is not a court of blame; it’s a court of fact.”

Accordingly, coroners’ verdicts are often drawn from a prescribed list of succinct descriptions of the manner of death. And although lawyers may be present in court, notions of “prosecution” or “defence” are entirely misplaced. Instead, the coroner will decide whom to call as witnesses and will lead the questioning on the day of the hearing.

Doctors as witnesses

Doctors appearing as witnesses fall into one of three categories: ordinary witnesses (called to give evidence in a capacity unrelated to their work as doctors); professional witnesses (of whom the deceased would have been a patient); or expert witnesses (doctors with advanced knowledge of a specific field relevant to the case).

Doctors acting as professional witnesses might not need to attend court on the day of the hearing. The coroner will ask them to write a report detailing their involvement with the patient and might simply read this report out in court and not ask the doctor to appear.

For this to occur, though, the report must be thorough but concise and free of ambiguity. Dr Palmer recommends that if a doctor is requested to submit a report for the coroner “they write in the first person singular, active voice: ‘I, John Smith, on 4 June at 10 am went on the ward round and saw this and did that,’ etcetera. I don’t want ‘it was decided that the patient should undergo a procedure.’ There, I have no idea who made the decision or when and so on. And I’m always interested in opinions, but first and foremost I want facts.”

Doctors in some specialties are more likely to be called to give evidence at coroners’ inquests than others because of the nature of their work. Deaths of psychiatric patients are less frequent than in other specialties but, as Bill Calthorpe, specialist registrar in adult psychiatry at Queen Elizabeth Psychiatric Hospital in Birmingham and Steve Choong, a consultant psychiatrist in Worcestershire, note: “When death does occur it is more likely to result from some unnatural cause such as suicide.”[4] Most psychiatrists will face at least one coroner’s court appearance during their careers.

First appearance

Dr Choong says that a first appearance at a coroner’s court “can be nerve racking primarily because you don’t know what to expect . . . It was the same for me. How do you dress? How do you address the coroner—do you call the coroner sir or madam, doctor, or your honour? Who will question you? It was as basic as that.”

The answers to those questions are: dress smartly, all those interviewed here recommend that men wear a tie; the coroner is called sir or madam; the coroner asks questions first, usually followed by the family of the deceased and then any legal representatives.

Paul St John-Smith, a consultant psychiatrist in Hertfordshire and coauthor of the paper Coping with a Coroner’s Inquest: A Psychiatrist’s Guide,[5] says that “you would have to be a very strange person not to be anxious or worried or in some way upset about having to [attend an inquest]. This is one of the most important things in our society and in our life—the respect for law and for our fellow human beings. The loss of someone is always an important event that one takes with the greatest of seriousness and responsibility.”

Dr St John-Smith recommends that any doctor attending an inquest should prepare thoroughly and bring along information—studies or clinical guidelines—that can help justify their actions.

Inquests, not trials

Still, coroner’s inquests are not trials. Even so, Rupert Pardoe, a barrister from 23 Essex Street Chambers in London, concedes that “as a criminal lawyer it’s very easy to slip into the terminology of the criminal trial—cross examination and so on. But there isn’t any cross examination. You are questioning the witness.”

“If you go in all guns blazing as you might in a criminal trial,” he adds, “the coroner will pretty quickly stop you.”

Mr Pardoe’s experience at inquests has come primarily from representing police officers (doctors are also entitled to legal representation and will often be provided with it by their healthcare trust). He has, however, attended several inquests where healthcare professionals were called as witnesses. His key recommendation for doctors considering this subject is the maintenance of good clinical practice in their work, particularly with regard to note taking.

“It’s not until you start doing inquest work that you realise how important that is,” he says. “When you’re there in the cold light of an inquest looking at every nuance of it, the records become very important. And if the records are deficient it can be easy to come to the conclusion that so was the standard of care. That doesn’t necessarily follow, but one could buy into that.”

Although no one is on trial, coroners’ guidelines dictate that any inquest be “full, frank, and fearless” in uncovering the factors leading to a person’s death. As Dr Palmer says: “If there has been a mess made of a person’s treatment then some really quite tough questions will get asked. There is no way around that.”

Competing interests: None declared.

From the Student BMJ.


  1. Dyer C. Out of hours care scrutinised as inquest begins into deaths of two patients. BMJ  2010;340:c286.
  2. UK Ministry of Justice. Coroners statistics England and Wales 2010. [Link] .
  3. UK Ministry of Justice. A guide to coroners and inquests. [Link] .
  4. Calthorpe B, Choong S. The coroner’s court and the psychiatrist. Adv Psych Treatment  2004;10:146-52.
  5. John-Smith P, Michael A, Davie T. Coping with a coroner’s inquest: a psychiatrist’s guide. Adv Psych Treatment   2009;15:7-16.

James Brooks science editor, BioNews, and freelance journalist, London


Cite this as BMJ Careers ; doi: