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Coroner’s inquests: what you need to know if you are asked to give evidence

Inquests can be intimidating, but there are resources and support available that can help you

Inquests can be intimidating, but there are resources and support available that can help you

  • The coroners role is to establish who died and how, when and where they died not to make a finding that someone is guilty of something
  • Nurses asked to write a statement about a case should have the support of their employers legal team
  • How to prepare if you are called as a witness or asked to give a statement, and where to find helpful resources
Picture: iStock

In the course of your nursing career, you may be called on to give evidence at a coroners inquest.

This article sets out what you can expect at an inquest

...

Inquests can be intimidating, but there are resources and support available that can help you

  • The coroner’s role is to establish who died and how, when and where they died – not to make a finding that someone is guilty of something
  • Nurses asked to write a statement about a case should have the support of their employer’s legal team
  • How to prepare if you are called as a witness or asked to give a statement, and where to find helpful resources
Image showing a coroner's court sign
Picture: iStock

In the course of your nursing career, you may be called on to give evidence at a coroner’s inquest.

This article sets out what you can expect at an inquest and how to prepare to make the experience as smooth and stress-free as possible.

What is the purpose of a coroner’s inquest and what form does it take?

A coroner’s inquest is a public inquiry into the cause of a death in England, Wales or Northern Ireland. In Scotland this is known as a fatal accident inquiry, called by the procurator fiscal.

The coroner’s role is to determine who died, and how, when and where they died. A coroner is usually a lawyer but can be a doctor.

Nurses can be called to give evidence about the care given to a patient who dies in circumstances where the reason for death is unclear, unexpected, unnatural or violent, or the death took place in prison, police custody or another type of state detention, such as a mental health hospital.

A coroner cannot make a finding that someone is guilty of something or blame a person for something.

What happens when a death is reported to a coroner?

Different people can report a death to a coroner’s office, including the police, prison officers, the registrar of births and deaths, doctors or a hospital.

A coroner will first decide whether an investigation is needed. They carry out enquiries to see if they can determine the cause of death quickly. If they can – and the death was due to natural causes – in most cases the coroner has no further role.

If they feel an investigation is needed, they will seek to establish the identity of the person who has died, how, when and where they died, and any information they need to register the death.

If the cause of death is still not known or appears unnatural or violent, the coroner will investigate to find out the cause of death. This may include requesting a post-mortem examination.

When does an inquest take place?

If the cause of death is unknown or the death was violent or unnatural, the coroner is expected to open an inquest. Sometimes, the coroner may need to hold an inquest even if the death was natural and the cause is known. This will happen when the person died in state detention, for example, in prison.

The majority of cases reported to the coroner do not lead to inquests. In 2019, 210,900 deaths were reported to coroners in England and Wales and only 30,000 inquests were opened, government statistics show.

What will happen if a death is considered by a coroner?

RCN head of legal services Roz Hooper
RCN head of legal services Roz Hooper
Picture: John Houlihan

The court will initially request written statements from witnesses about what happened.

RCN head of legal services Roz Hooper says if a nurse is asked to write a report, they will usually have the support of their employer’s legal team and that should be the first place to seek assistance.

‘However, if they do not have their employer’s support, or if they are at all concerned that they might be subject to criticism for the care they provided, they should contact the RCN as soon as possible,’ Ms Hooper says.

‘In some cases, the RCN legal team provides representation at a hearing and the RCN statement checking service can assist with statements.’

The RCN advises that when giving evidence, nurses ‘must be honest and trustworthy and make sure that any evidence or documents you write, or sign, are not false or misleading. You should recognise and work within the limits of your competence’.

The college has a template form to guide nurses and says respondents should be clear about what they did, saw and heard.

‘Some nurses feel anxious because giving evidence in a formal setting is daunting, but we ask them to remember that the coroner is not there to assign blame’

Roz Hooper, RCN head of legal services

Nurses have a right to see clinical records to help them write a statement accurately. If they are denied access to these, they should state that in their report.

The RCN says use the first person (‘I’) when writing a report, relate the facts from the beginning and keep them in chronological order, giving precise dates and times.

Avoid jargon or official language and be as brief as possible, while covering all the essential points needed to address the request.

Nurses should not speculate, elaborate or exaggerate, or use emotional language and if they cannot remember something, they should say so.

What happens when a nurse is called as a witness?

The coroner may decide to hold an inquest, which is a fact-finding inquiry, in a court. Sometimes the inquest may be heard with a jury.

Even if a nurse has provided a statement, they may not need to attend the inquest if their evidence is unlikely to be controversial.

If called, the coroner may ask the witness to read through their statement or may take them through the statement in court.

The coroner will decide who meets the criteria of ‘interested persons’ and they are permitted to ask witnesses questions. These are most likely to be family members of the deceased, but can be other people involved, including those who may have caused or contributed to the deceased’s death.

Often interested persons will have appointed legal representatives, who will ask questions on their behalf.

The questions are not a cross-examination (as in other courts) and witnesses are not obliged to answer the questions if the answer could incriminate them.

How to be a well-prepared witness

A woman sitting a a desk preparing a written statement
Picture: iStock

NHS Resolution is an arm’s-length body of the Department of Health and Social Care that provides expertise on resolving health service concerns and disputes fairly.

It advises healthcare professionals who are called as inquest witnesses to:

  • Be aware of the importance of giving a full, straightforward factual account, not speculating or guessing
  • Ask for clarification if you do not understand the question
  • Redirect or decline questions that you are unable to answer (for example, questions that are outside of your professional expertise)
  • Familiarise yourself with medical records before court and any investigations or serious incident reports (including any action plans)
  • Add post it notes to important areas in the medical records so that you can find them when you are giving evidence
  • Liaise and seek support from your employer’s legal team and line management
  • Address your answers to the coroner
  • Speak slowly, sharing the story of what happened logically from beginning to end in plain English
  • Give the full, honest answer, however difficult this may feel
  • Understand the order in which questions are asked: coroner, family and, finally, the health organisation’s appointed lawyer

Source: NHS Resolution

What is the experience like for nurses?

Mark Weetman, health ward manager who gave evidence at an inquest as a nursing student
Mark Weetman: Use all the support
available to you before giving evidence

It is not uncommon for healthcare staff to be called to give evidence at an inquest, but that does not stop it being a stressful experience for those involved.

Ms Hooper says: ‘The coroner quite often needs the assistance of medical staff to understand what happened. Some nurses feel anxious because giving evidence in a formal setting is daunting, but we ask them to remember that the coroner is not there to assign blame.

‘Having said that, in a few cases a nurse’s care can be criticised and the coroner can make a referral to the Nursing and Midwifery Council (NMC).’

Essex mental health ward manager Mark Weetman gave evidence at an inquest as a nursing student, after working on a unit where a patient died during his first placement.

He encourages other nurses and students in a similar position to take all the support available before giving evidence.

‘I had help and support from the trust and my university when it came to writing my statement and preparing before I went,’ he says. ‘They went through what would be involved on the day. This helped me understand that it was not a procedure about blame, and without that I would have felt ten times more anxious than I did.’

Mr Weetman saw some of the other staff give evidence before he was called at the inquest, which took place in 2016. He was mainly asked for extra clarity on points in his written report.

‘There was nothing I couldn’t answer,’ he says. ‘But the part I found difficult was that the family were there. Up until that point I had talked about it a lot with the trust and the university for various investigations, but having to talk in detail about what happened that day in front of the patient’s relatives was hard and I found it emotional.’

Image from a court room, showing people holding documents
Nurses deemed ‘interested persons’ may have legal representation in court Picture: iStock

What can a coroner decide?

A coroner or jury can make a number of conclusions about the cause of death, including natural causes, accidental death or misadventure, lawful or unlawful, and road traffic accident. Another possible conclusion is ‘open’, if they feel there is insufficient evidence.

Alternatively, or sometimes in addition, the coroner or jury may make a brief ‘narrative’ conclusion that sets out the facts surrounding the death in more detail and explains the reasons for the decision. A narrative conclusion is likely to be given when the case is complicated, as it can offer a longer explanation of the reasons for the decision and what the important issues are.

Healthcare professionals should be aware that the coroner’s findings may be critical of what happened, but the coroner cannot blame individuals or organisations or find them responsible for the death. The coroner can refer cases to the NMC.

The coroner can also write a report to help prevent future deaths. They will send this report to the organisations involved in the death so that they can take action.

Will COVID-19 lead to more inquests?

With thousands of people dying as a result of COVID-19 in the UK, could this lead to a surge of inquests?

Most deaths related to the pandemic will not be referred but some will, according to the RCN.

RCN head of RCN legal services Roz Hooper says that COVID-19 has been deemed a natural cause of death, which means that it is not a reason to refer to a coroner.

‘However, if there are additional factors, such as the deceased person contracting the virus at work or a human failure contributing to the death, then COVID-19 deaths will be the subject of inquests,’ Ms Hooper says.

‘It is hard to know what the overall impact will be, but there is the potential for the numbers of inquests to rise as a result.’

Erin Dean is a health journalist


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