An inquest is a fact finding exercise - to find out who died and when, where, how and in what circumstances they died.

Importance of preparation

The aim of an inquest is not to apportion blame. However, the family of the deceased may feel aggrieved and may be hostile. They may have questions concerning the facts surrounding the death. In these circumstances, the healthcare provider may need legal representation to protect its interests and ensure that its employees are not exposed to questioning which may stray outside the remit of an inquest.

A healthcare provider needs to be mindful of the risk of a Rule 43 letter and/or a future civil claim.

Rule 43 letter

Where the evidence during an inquest indicates that a recurrence of a regrettable event might occur, the coroner may write a report or letter to the person or organisation who has the power to reduce the risk of recurrence.

A typical recommendation might include further training of staff, a request to put in place certain procedures or protocols, or a request for better record keeping and communication.

Risk of civil claim

The inquest process can be used by those representing the family as a mechanism for building a later civil claim.

It is therefore prudent for the healthcare provider to have legal representation to ensure the inquest process is used as intended.

Preparation by healthcare provider

In order to ensure the healthcare provider and its staff are in the best possible position prior to an inquest, good preparation is essential. Ideally, the following should be undertaken:

  • Coroner’s officer: early contact should be made with the coroner’s officer to establish the preferred approach of the coroner and whether he has any particular concerns. The healthcare provider may be able to assist the coroner in clarifying questions relating to the care that was provided and allay any concerns.
  • Documents: an early request should be sought for disclosure by the coroner of all witness evidence and any expert evidence obtained. Documents acquired during an inquest may be used in subsequent criminal or civil proceedings. It is important to be aware of the existence of any evidence which may impair reputation and/or lead to later complications.
  • Witnesses: it is the coroner who decides who is called to give evidence. Witnesses will be summoned by the coroner and clinicians may have little or no experience of a coroner’s court. An inquest is held in public and clinicians called will give evidence in the witness box. The formal nature of the process may, understandably, intimidate those clinicians and nurses called. Furthermore, any "interested person" (which will include the family or their representatives) may put questions to any witness. Clinicians therefore need to be briefed on the process of an inquest so they know what to expect.
  • Press statement: mindful of adverse publicity, the press department should be updated at the earliest opportunity of any forthcoming hearing with a view to preparing an appropriate press statement. Depending upon the care provided, it may be appropriate to include an apology.

Preparation by individual clinicians

Inquests are by their very nature a difficult and harrowing process for the family. They may also be difficult and emotional for those clinicians who treated the deceased.

It is therefore important to ensure staff are looked after and do not feel vulnerable in advance of, or whilst giving, evidence. The following should assist in preparing any clinician involved:

  • Investigate: a meeting should be held in advance of the inquest with each clinician called to give evidence to establish what care they provided and any details they may have of the facts surrounding the death.
  • Test: whilst questioning at an inquest should not take the form of a cross examination it may be of benefit, prior to an inquest, to test each treating clinician and ensure they have considered the different ways the facts surrounding the death can be viewed. It is far better to go through this process in advance in more comfortable surroundings than wait to be tested in the witness box.
  • Explain: clinicians need to be informed of the importance of answering any appropriate question put to them honestly - evidence is given under oath. They should review in detail any statement previously written by them and submitted to the coroner. The coroner may ask that the statement be explained and clarified in court. Clinicians should be reminded they are not obliged to answer questions about matters they feel are outside their area of expertise or which may incriminate themselves.
  • Medical records: clinicians should ensure that they are not only aware of the notes they have made in the medical records, but also that they are familiar with notes made by others. When giving evidence, the clinician will need to fully understand the whole story and this may assist him in clarifying his own notes.
  • Inconsistencies: by ensuring clinicians have considered the medical records in detail and have tested themselves on those notes and recollection of events, any inconsistencies should come to light. The clinician can then explore the reason for any such inconsistency in their own mind in advance of the inquest and offer an explanation when in the witness box.

Benefit of a full and thorough investigation

The ideal inquest is a full and thorough investigation of the events surrounding the deceased’s death. Such an inquest will be of benefit to both the family and healthcare provider.

A failure to adequately prepare may result in the healthcare provider appearing evasive or even obstructive. Documents may not be located and points raised may not be clarified. This will not assist the coroner and may also frustrate the family and lead to a lack of trust which could increase the chance of a civil claim being brought.

If there is an area of concern with regard to the care provided, careful preparation will allow the healthcare provider an opportunity in advance of the inquest to put in place mechanisms to avoid a recurrence. Furthermore, the healthcare provider may be able to demonstrate to the coroner that improvements have been made. Doing so may avoid recommendations under Rule 43 and possibly go some way to appeasing the family.