What to expect when you visit the Coroner

I’ve had the pleasure recently of attending a Coroner’s Inquest as a professional witness. Overall, it wasn’t a bad experience and the outcome was as I had expected. In this blog post, I’ve tried to summaries the typical events and what you can expect if you are called as a witness.

Please recognise that I base this on a limited number of real cases. I have tried to anonymise my account to prevent attribution to any patient. I also declare I am not an experienced expert in this, having only attended two so far. If you have your own experience, please leave a comment at the bottom of this post.

Who is the Coroner?

There is one Chief Coroner for England and Wales. At the time of writing, it is His Honour Judge Mark Lucraft QC. Under him, there are many Senior Coroners who are responsible for a distinct district. They are supported by Assistant or Area Coroners.

A Coroner must be of legal background (solicitor or barrister) for at least five years. It used to be possible to be a medical doctor, but this is no longer the case.

What does the Coroner have to do?

Who, where, when and how?

That’s the remit of the Coroner for most cases. Who, where and when are generally easy to define. How is the majority of the case. The Coroner must examine the submitted evidence, and may ask questions of the witnesses, prior to concluding. Their conclusion can be either a short form or narrative conclusion (verdict is no longer the term used).

Available short form conclusions include:

  1. Accident
  2. Misadventure
  3. Alcohol related
  4. Drug related
  5. Industrial disease
  6. Lawful killing
  7. Unlawful killing
  8. Natural causes
  9. Open
  10. Road traffic collision
  11. Stillbirth
  12. Suicide

An alternative, narrative conclusion can be given where the death does not fit neatly into a box. The Chief Coroner has provided guidance that includes only using this if absolutely necessary and keeping it concise and without attributing blame.

The burden of proof required for most short form and narrative conclusions is based on the balance of probabilities (that is, more likely than not or > 50% likely). The alternative criminal burden of proof is beyond reasonable doubt, which I believe is required for lawful / unlawful killing conclusions.

If a death occurred in custody, or there are elements of the case that relate to the European Convention on Human Rights, a Coroner may require a jury to be present to draw a conclusion. This will be approximately 10 people from the public summoned by the Coroner.

What does an Inquest Hearing involve?

The process of a hearing is formal. The attendees will usually be met by a Coroner’s Officer. Once gathered, the attendees will be asked to stand when the Coroner enters the room. They are smartly dressed but do not wear court robes or wigs. Both hearings I have attended have been in a room resembling a large office meeting room. They are not intimidating.

The Coroner will open the hearing and explain their remit. Interested Parties will be introduced (more on that later). Each witness will be called and questioned. Sometimes a statement will be read out in their absence.

Everything will be recorded for the audio record. Notes can be taken.

What does a witness have to do?

A witness can be a professional witness, expert witness or other witness. For example, a medical doctor that cared for a patient will be a professional witness, an expert in cardiac physiology or pathology will be called as an expert witness, and finally anyone else that was involved in an incident may be called as a non professional witness.

Witnesses usually write a formal statement in advance. The Coroner may accept this without contest, so that the witness does not need to attend the inquest. If there are further questions, the a witness will be summoned to the inquest hearing.

Most hearings are public, so what’s said by a witness is recorded for the court and may become public knowledge through the press!

When taking the witness stand (a chair at a table in my experience), a witness will be asked to make an oath. This can be a religious oath or a non-religious solemn promise. It is written for you on card in large print! It’s probably less effective than a Harry Potter truth spell, but the point is you’ve been warned: if you tell a porkie-pie after that oath, you’re going to get in to trouble!

You may be asked to read your statement. You may just be asked focused questions by a Coroner. Following the Coroner, any Interested Parties can ask questions. They must all remember that this is a fact-finding inquiry and not a criminal trial.

A witness should answer after considered thought with a concise, polite and professional answer. Remember that the family are in front of you and the public can find out what you’ve said. If you don’t know, say so. If you are making a guess at something, state that you are uncertain. Avoid pointing blame at another individual.

If there is a silent pause after a question and answer, a witness should be patient. A witness does not need to say more than the answer. The Coroner will probably be writing notes and may need a moment to catch up. Do not be tempted to fill the silence with more opinion!

Finally, try to bring a friend. Your hospital Trust can support you by sending a member of the Risk and Legal Services Department. If you are a trainee, I highly suggest you bring your Consultant along!

5 things that might surprise you

    1. There’s no party, just interested people

      In a criminal or civil trial, there are parties: those for and those against, or prosecution and defence. At a Coroner’s Inquest, there are only Interested Parties. These can be anyone with a significant interest in the case, but are usually family members, healthcare establishments, businesses or police institutions. They can represent themselves but more commonly they are represented by solicitors or barristers. They have the opportunity to ask questions to the witnesses and to submit guidance to the Coroner prior to the Coroner making their conclusion. In my experience, this involves the Interested Party’s solicitor politely telling the Coroner how to do their job and recommending a simple, blameless, short form conclusion.

    2. The family come second only to the law

      I have been amazed at how compassionate Coroners are towards the family and those involved in a death. They are firm but very polite. Although Coroner’s have a duty to the law, I feel in the cases I have seen their second priority has been the comfort of the family and the support of them reaching closure over the death.
      I have also seen a Coroner very quickly close family down when they tried to speak up and ask questions out of turn! Firm but fair.

    3. You get paid to attend

      Coroners are employed by local councils. Ask the Coroner’s Officer for an expenses form. You can usually claim for travel and accommodation expenses. There is also payment for time away from home or work. Although it’s not supposed to be profitable, it certainly helps and shouldn’t be overlooked.

    4. The family is often grateful, not hostile

      At both Inquest hearings I have attended, both families have thanked me for my provision of care. Perhaps this isn’t always the case and the cases in the press probably select those with hostility as more interesting to report. Do not be surprised if the family approach you to say thank you. Be polite and professional.

    5. Attending an Inquest hearing will make you a better healthcare professional

      There is huge benefit in attending. Try to attend an inquest as an observer at least once so that when you are called as a witness, it will be less intimidating.

2 comments to “What to expect when you visit the Coroner”

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  1. Dave Boulter says: 9th March 2018 at 6:57 pm

    Why show a photograph purporting to be deceased person? The deceased’s body is not on display at an inquest. Those non-professional witnesses totally unfamiliar with the process might well think it is from that image.

  2. Duncan Chambler

    Thanks for your comment Dave. I take your point, and it’s something I hadn’t considered when posting with this feature image (this photo comes up in Adobe Stock when you type “Coroner”, so I went with it). I’ve changed it to something that better resembles the true atmosphere of a Coroner’s Inquest hearing.

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