Inquests: Top tips and advice for the medical witness

Interviewed at University of Plymouth, December 2019.

Timestamp summary

0.12–1.59 mins What is a Coroner’s Court and the purpose of an inquest?

2.00–4.21 mins What sort of deaths are referred to the Coroner’s Court?

4.22-5.06 mins Meeting with the family after a bereavement?

5.07–5.26 mins How to prepare for an inquest?

5.27–7.27 mins How to give evidence at an inquest?

Intro My name is Ian Arrow and I'm the Senior Coroner for Plymouth, Torbay and South Devon.

0.12–1.01 mins It's important for you to understand that when you come to a Coroner's Court, you're coming to a court of record and in that court of record, the Coroner is to determine answers to four questions, which are, who is the person who has died, how has the person died, where and when did the death come about?

Now it's not for the Coroner to find any fault, liability or blame. There's no person or organization on trial.  The Coroner can do it [answering the 4 questions] by receiving evidence in person from a witness who gives evidence before the court or the Coroner can receive to documentary evidence. That's under Rule 23 of the Coroner's Rules and the Coroner or the Coroner's Officer will read that evidence into the hearing.

1.02–1.36 mins When there is a coroner's inquest, as well as answering the four questions, it may be helpful for you to know that one of the key purposes of a Coroner's Court hearing is to ensure the Coroner allays the family's fears and concerns. Whilst to them it may appear an unexpected and unusual death, there can often be a perfectly reasonable explanation and part of the Coroner's duty is to ensure that the family understand that reasonable explanation.

1.37–1.59 mins Now occasionally, when a coroner hears evidence, it may produce information which if acted on could prevent future deaths. So, the coroner has power to make a report to a person or organization that has power to reduce or prevent future deaths.

2.00–3.10 mins A lot of the cases that come to my court follow from an injury and more often than not, that is an injury where someone has fallen and they've invariably injured either their head or their hip, which has ultimately resulted in their death. Sadly, we do have a number of falls in the hospital and accordingly it is possible that a clinical member of staff may be asked to come to court to give an explanation of what has led to that particular fall happening. I'm sure the hospital will have various procedures and policies in place to reduce those, but my understanding is that often there will be a Root Cause Analysis or a SIRI [1] report whereby there's an independent internal investigation to ascertain how that fall has come about. Sadly, it’s often because the patient is unattended, but sometimes that's inevitable anyway.

So, in simple terms, in a simple case, a doctor could be asked to come and give their account of their involvement in the care of that particular patient. That's a simple case.

3.11–4.21 mins A more contentious case might be where something goes wrong during an operation. There are various high-risk operations and the coroner is obviously very aware that there is potential mortality, depending on how serious or complex the operation is. So, the Coroner will be alert to the fact that the family may have particular concerns. They are going to want to know why, unfortunately, it is their loved one who was the unfortunate one who proved to be the mortality in this case. Now, in certain circumstances, that family may have recruited a lawyer, that lawyer possibly to seek further information with a view to pursuing a negligence claim. Now the doctor appearing in court should not be unduly concerned about that because the Coroner is under a duty, whilst under a duty to help the family, is also under a duty to ensure that only relevant questions are asked of the witness. It is not the purpose of a coroner's inquest to provide clear evidence for a civil claim.

4.22–5.06 mins A lot of difficulties that arise can often be resolved by a quiet, honest and frank discussion with the bereaved family close to the point of death. Of course, it's a matter for each Hospital Trust, but I do believe there might be an advantage in recruiting bereavement nurses who might work with the Medical Examiners [2] to ensure that the families have a proper understanding of how someone came to die. An early explanation prevents fears and concerns developing, as they invariably do, if people don't get a proper story to begin with.

5.07–5.26 mins Well, I think it's well worth going to have a look at the court before you arrive. There would be an opportunity to go and see an inquest that is heard before the one you are to attend, or you could just go and see the empty court. It would allay any fears you might have. It will give you an opportunity to meet the coroner's officer who is dealing with the case.

5.27 mins I think it's important that the witness is themselves. It's important that they keep things simple and plain. Please work on the basis that most families will have little medical knowledge themselves, so use plain ordinary language, particularly in your statement. You will probably be asked for a statement in advance of coming to court. Keep it brief, keep it neutral. Please understand that when you're coming to court to give evidence, you are basically telling the story of how this person came to die. In effect, the coroner is listening in to the story that you are giving to the family. Assume that you have an excellent bedside manner. You will have no doubt honed it over the years, but make sure the family goes away understanding what has happened. When you do come to give your evidence, then rely on the statement that you have prepared. Do ensure your evidence is simple, chronological, factual, keep the story simple. I like to think that I'm explaining the story to my mother and once you have given your evidence and the coroner has thanked you, there's nothing wrong at all with your offering your condolences to the family. In my experience that is very well received.

If the family go away understanding in simple terms what has happened, you have eminently discharged your duties.

Timestamp summary

0.00–0.26 mins Introduction

0.27–0.59 mins How do you first hear of an inquest

1.00–4.17 mins How to prepare a witness statement

4.18–6.04 mins How to prepare for an inquest hearing

6.05–6.52 mins How to give evidence at an inquest hearing

6.53–8.58 mins Is there a risk of a clinical negligence claim

Introduction

0.00–0.26 mins

I'm Peter Whitfield. I'm a consultant neurosurgeon at University Hospitals Plymouth and as a neurosurgeon, I look after a lot of patients with serious head injuries and brain haemorrhages and high-risk operations and as a result I've appeared in the coroner's court on a number of occasions over a long period of time.

0.27–0.59 mins

When I'm asked to attend an inquest, usually I'm expecting that to occur because I've already given a witness statement in relation to the care of a patient that's been under the care of myself or my team. So, I get a written request, normally from the legal department in the hospital. I then prepare a witness statement and usually it's many weeks, two or three months later that I actually get asked to attend court.

1.00–4.17 mins

When I get the request to provide a statement, I feel it's important to do the job properly and thoroughly and therefore make sure I have all the records available and the scans available. I go through the notes quite carefully preparing a statement. I try to make the statement fairly concise, telling the story of what happened to the patient, and using information particularly in my specialty related to scans and the timing of events, so that the coroner can appreciate the story of events as they’ve happened.

When I'm asked to be a witness in the coroner's court, the main people who might be able to advise on that process are really the hospital legal department, and certainly if the deceased patient’s family are being represented by a barrister, the hospital will be aware of that and they will provide [you with] legal support. In my experience that's [representation by a barrister] actually really uncommon.

When you're preparing a statement, the legal department will give you a template for the statement and that will have about eight or nine paragraph headings. So, usually the statement starts off with your full name and what your occupation is and how long you've been doing it. Then you should re-tell the story of what happened in a chronological order. I think it's important in that statement to try and use clear english to explain medical terms so that the Coroner isn't baffled by medicine. Some of them are medics but most of them are lawyers without a medical degree.

Be very clear in your statement. I think it's important that you stay within your area of your contact with the patient. If you're a more senior doctor, as a consultant, you may have to give them an overview of care provided by your team, including your juniors. I think it is reasonable to explain where there's a range of opinion on doing an investigation or how important that investigation is and explaining your opinion and what you believe the thinking to be. It's really important to realize that any statements that you make, your signature is at the bottom of them, so they are Statements of Truth.

In that statement, I always put a short section, one or two sentences offering my condolences to the family, because I'm sure the family will get to see the statement if they wish to.

And I think to be careful, re-read it. Don't think it's job done, press send. Read it through carefully and make sure you're happy with all the content. If there's any areas you're not clear on, I think it would be worthwhile stating that in your statement.

For a junior doctor preparing a statement, it would be wise, and certainly my juniors have shown me statements they’ve prepared. So, it’s wise to show your statement to your consultant or a more senior doctor to see if they feel that that is an appropriate statement.

4.18–6.04 mins

When I'm preparing for a hearing at the coroner's court, I review my previously written statement quite carefully to remind myself of the case. I get hold of the medical notes. I had in one of my earlier appearances, assumed the notes would be in court and they weren't. So, make sure you've got access to the medical notes; and it may be that your hospital legal department will be taking the notes to court, particularly if more than one witness from the hospital is providing evidence. I look at scans and in fact I have printed out pictures of scans to help explain things in court as well.

If you're called to the coroner's court and this is your first time, so, you've never seen a coroner's court, I think it's well worth speaking to the legal department in the hospital. They will know the local set up of how the court looks and works. Definitely read through your witness statement and reference notes and scans so that you're well prepared when you go to court. When you get to court, if you've not been before, have a look around and usually the coroner's officer will let you have a look into the courtroom and will explain who will be sitting where. And, take all that in, try and keep calm; it's not a court where the coroner's trying to find anyone guilty of doing anything wrong. The coroner's trying to find out how the patient died. Act professionally, dress professionally and be clear. Talk about things that you know to be true and try and avoid speculation and stick to the facts.

6.05–6.52 mins

I think it's really important when you're presenting evidence in the court to talk in clear English. I always look at both the coroner and the family members to try and get non-verbal feedback from both of them. When you're talking about medical matters, try and put them into plain English speak and try and be sure that people are understanding what you're talking about.

I think be open to questions. So, if questions challenge what you're saying, don't be rigid in your opinion. Be prepared to change your opinions in the light of the circumstances. You are only one piece of the jigsaw and it's not until you're in court that you will have seen the other pieces of the jigsaw.

6.53–8.58 mins

When you’re called to the coroner's court and you're attending as a witness, there's always a concern that did something go wrong and might this lead to a clinical negligence claim. If the patient's family are being represented with a legal representative, which might be a barrister, I think there's a high chance that the family have grave concerns about the quality of care and that they may well be using evidence that's presented in the coroner's court to try and help inform their side of the case, and that might lead to clinical negligence. I can't personally think of a case where that has actually happened, where I've been in the coroner's court where a clinical negligence case has followed, but I think it's a very legitimate concern that doctors may have. I think that's why it's so important to be very thorough in delivering your evidence and sticking to the facts, being truthful, and also being accepting that there may be a range of opinions on how an action has been taken.

As a doctor, we are all members of indemnity organizations, Medical Defence Union etc, and I think it is quite wise to seek advice from them, particularly if you've got any concerns about the care that you've provided. There's no harm at all in contacting the Medical Defence societies and they will almost certainly advise you to write your report and almost certainly offer to read it through.

I think when doctors go to the coroner's court, they can feel like they're on trial themselves. They shouldn't feel like that, the coroner is not looking to apportion blame on a given doctor. The coroner may be looking for systems to try and improve care in the future and the coroner maybe issuing a report to your hospital chief executive on how systems of care can be changed in the future.[1]

[1] This is called a Prevention of Future Deaths Report

Timestamp summary

0.16–2.22 mins Why does a family ask a solicitor to represent them at an inquest

2.23–3.31 mins What sort of questions will the family’s solicitor ask a medical witness at an inquest

3.32–4.28 mins How should a medical witness prepare for a hearing

4.29–5.42 mins What to put in a statement and how to present it at an inquest

5.42–7.42 mins What is the difference between an inquest and a patient’s claim for compensation

7.43–8.58 mins How should a medical witness give evidence at an inquest

Introduction 

My name is Mike Bird and I’m a solicitor. I am a partner at Enable Law, and I represent families at inquests.

0.16–2.22 mins

There are several reasons why a family might want to involve a solicitor at an inquest. Sometimes a family will decide that in order to participate fully in the inquest process, they feel that they’re unable to ask questions themselves because they might feel that they’re too close to what’s happened, obviously close to the person who’s died, and they want to have somebody independent brought in who’s more emotionally detached to ask questions on their behalf.

The other common circumstances where the death has occurred in a situation where it’s possible that there will be a claim, a legal claim of some sort arising from the death, and so the family will take legal advice quite early, and if they do, then the lawyer will usually suggest that a lawyer represents them when it comes to the inquest so that they can ask the right questions and obtain any information that might be relevant to a potential claim from the inquest process.

If we take a hospital death, for example, a family may not know very much about what has happened and they may know a great deal less than the hospital team who’s been treating the person prior to their death. So, there’s often quite an unequal level of information available to those two different entities, the hospital on the one hand, and the family on the other.

Now, the family may have formed an impression that something has gone wrong. They may have developed a suspicion that something was done that shouldn’t have been done or there was a missed opportunity to do something which might have changed the course of events, and that suspicion could be well-founded or it could be not so well-founded. So, it may well be something which is not right to look into, but that doesn’t stop the suspicion from arising. One of the purposes of an inquest, which is written in statute, is to allay suspicions. So, if somebody does have those reasonable questions, then the inquest is a vehicle for unravelling those and trying to find out whether the suspicion was well-founded or not.

2.23–3.31 mins

When it comes to deciding what questions to ask of a medical witness in a hospital death, it’s important to remember that the inquest is a fact-finding investigation. It’s about establishing what happened and it’s about answering the four questions – who’s died, where, when and how? It’s not about apportioning blame. It’s not about pointing a finger at anybody. No-one is on trial, not the person who’s died and not any of the people who have provided care in a hospital setting to the person who’s died.

So, when it comes to working out what questions to ask on behalf of a family, I’m only able to ask questions which are within the scope, within the confines of the investigation. I am not allowed to ask questions which might relate to what we’d call negligence. About the standard of care that was provided, some questions could be asked, but not to an extent where anyone would be pointing a finger and saying you were negligent as a medical professional.

3.32–4.28 mins

An inquest is not a trial. No-one is on trial, but you as a medical witness, when you walk into the witness box and you swear your oath to tell the truth, the whole truth and nothing but the truth, and you’re asked a series of questions about what you did maybe nine or 12 months ago, you may very well feel that you are on trial. Now, that’s not something that anyone in the inquest arena wants, but it is something that you, as a medical witness, need to be prepared for. So, if you are called to give evidence at an inquest and have never been before, I would say first of all, go and watch an inquest and see what happens. Talk to more senior colleagues who have been to inquests. Talk to the Trust, to your employer, and if the Trust is being legally represented, you will probably spend some time with the Trust’s legal representatives. Take any support that you can.

4.29–5.42 mins

When you write a report it’s as if you are giving your evidence in court. So, you must tell in the report the truth, the whole truth and nothing but the truth, before you put your name to it. Before you then get into court, you should review what you have written and make sure you know exactly what you have said because you can create an impression if you give your evidence in an unconfident way or muddle up some details which you might think are not important but which the family might, you may find that somebody criticizes you for that and it undermines the quality of what you’re saying. So, you should know your stuff and you should think about where the questions might come from, remembering of course, that they may not be the questions that you would ask yourself, but they would be questions that might be coming from a family who are still in grief, who may not understand the medical or biological processes involved, or from a lawyer for that matter, who may not understand the medicine. So, you need to be prepared for those unexpected questions too.

5.42–7.42 mins

It’s important to remember that a compensation claim and an inquest are two very different things. There is sometimes some overlap, but sometimes not. There are two concepts in a compensation claim. First, was there a duty of care and was that duty of care breached by substandard care being provided, and secondly, did that substandard care contribute or cause the death. The inquest is really only concerned about the cause and effect, the causation element of that issue and not about the standard of care because an inquest is not a place for blame. No-one is on trial at an inquest. It’s a fact-finding investigation. An inquest can uncover mistakes that have been made, but it then doesn’t take the next step of saying a mistake occurred and you were to blame for it. The coroner’s rules prevent the coroner from making that sort of finding.

It may well be that the answers that are given in evidence at an inquest, in fact tell me, as a lawyer advising a family about a compensation claim, that there is no claim, because it may be that the evidence that’s come out about causation, about how the person died, is such that I can establish that I would not be able to prove that (a) any negligence occurred or (b) that if it did, it’s made any material contribution to the sequence of events leading to death. So, it’s just as likely, after an inquest, that I will advise a family that there is no claim to pursue, as I might advise a family that having been to the inquest, there is a claim to pursue, which is another reason why it’s very important for all witnesses and all the evidence at an inquest to be given in as full a way as possible because it can be a mechanism, a secondary mechanism of course, but it can be a mechanism of also dealing with a compensation claim by meaning that the compensation claim stops.

7.43–8.58 mins

I’d expect the witness to give their evidence professionally. They’re going to be asked questions about what they did and why, and I would expect a professional medical person to be able to explain why they took a certain course of action or to answer a question about what they did and justify what they’ve done. That’s not to say that in asking the question I’m accusing the professional of doing something wrong, although it may feel that way from the professional’s point of view, that’s not my job. My job is to ask the question and listen to the answer.

I can imagine that for a doctor who’s never been involved in the inquest process, to be called to give evidence at an inquest, it’s going to be a daunting and potentially difficult experience. They’ll certainly going to be worried about it. Perhaps partly because it’s an environment they won’t be used to, but I’d expect any doctor or any professional healthcare witness to display the same sort of resilience in an inquest setting, as they would in a pressured situation at the hospital.

Timestamp summary

0.18–1.42 mins Who are the Coroners Court Support Service and what do they do

1.43–3.49 mins What do families think and feel about the inquest process and hearings

3.50–5.29 mins What rights do families have within the inquest process

5.30–6.17 mins What do families expect from the inquest process and what is their role within it

6.18–9.44 mins How should medical witnesses give evidence and interact with the family

9.45–11.07 mins Meeting with the family prior to inquest

Introduction

I’m Beverly Radcliffe. I’m the director of the coroner's court support service and we are a charity whose trained volunteers support people when they attend inquests at the coroner's courts.

0.18–1.42 mins

So, the people that we support at inquests are families, but they're also witnesses and anybody else that needs our support. And support can mean many different things to different people depending on what their needs are on the day. So, we can give them emotional support around the inquest and bereaved families are often emotionally charged in that environment, and we can also offer practical information, so, that's around the remit of an inquest - what the process will be, what will happen on the day; and I think a lot of people who attend an inquest don't really know about an inquest, about what to expect on the day, and what their rights are within that inquest process.

I think families before the inquest can receive support from the coroner’s office but that support is very limited and tends to be of a factual nature. We are able to support lots of people in lots of coroner’s courts but we are only in about half of the coroner’s courts within England and Wales and that’s purely down to funding. Out of choice we would be a national service and so people, it doesn’t matter where they attend the coroner’s court for the inquest, we would be there to support them. We do have a national helpline and can support them over the telephone but we only have a limited number of resources around the country at the actual coroner’s court.

1.43–3.49 mins

I think when people attend, particularly bereaved families, they don't really know what to expect when they attend an inquest. They may have seen things on the television, but that might be things like ‘Silent Witness’, which doesn't bear any resemblance to what actually happens at an inquest at the coroner's court in England and Wales. So, they have very mixed expectations about what's going to happen on the day. If they have had contact with our organization before they attend the inquest, they will know what the remit and the process will be because we can explain that to them, but often if they arrive without any expectations at all or have no prior knowledge about what to expect, they may think of it as a criminal court because they hear the word court, coroner's court, and think of all the things that relate to a criminal court. So, their understanding might be that it would be quite intimidating, quite daunting, maybe quite challenging, adversarial, that sort of thing, all the things that conjure up the word ‘court’ when they attend, and a coroner's court isn't like a criminal court.

I think when bereaved families attend the inquest, they may be feeling lots of different things. Often, they will be very emotionally charged because they are grieving. They are trying to grieve the death of a loved one and they are trying to do that at the same time as make sense of what's happening, why there was a need for an inquest, what is an inquest and sometimes they find it difficult to assimilate that information, not because they wouldn't normally be able to take that information in, but I think sometimes when people are thrown into such an alien environment and they are grieving at the same time, information just does not go in in the same way  and so I think people really struggle with understanding what's happening.

3.50–5.29 mins

Some members of the family will have certain rights when they attend an inquest at the coroner's court. So, the next-of-kin have the right to disclosure, but we would always say to the family, what's disclosure, because the family may not understand what disclosure is, and that's about certain reports and statements that the coroner is going to rely upon to use within the coroner's court and at the inquest. So, the next-of-kin can ask for that disclosure and we would suggest that when they receive it, to have somebody with them to act as support because it can be quite emotionally difficult to read the information surrounding somebody's death, and to have somebody there to support them, things like the post-mortem report, that they could take to their GP and ask the GP to read through it with them so that the GP can explain any medical terms or any medical jargon that's within the post-mortem report. 

Also, that report can be quite distressing to read. I think sometimes the post-mortem report goes into great detail about parts of the body that have been examined and as a family member, that's a person that is being talked about and being recorded and reported on and they are reading things like the weight of the heart or the consistency of the liver, and I think that can be incredibly distressing for family members to read that very clinical medical term around the person who they loved.

5.30–6.17 mins

I think most families expect to get answers from an inquest and that's the reason why the coroner will ask certain witnesses to come to give evidence because the next-of-kin has a legal right within that inquest process and one of those rights is that they can ask witnesses questions. The questions should relate to the remit and the procedures of an inquest, but they are able to ask questions. So, they can ask those questions that they've had around, what happened to the person when they died, but sometimes they have questions around why. Why did it happen. That won't necessarily get answered because it's not about why, it's about how the person died. They will get answers to the questions that they have around what happened.

6.18–9.44 mins

I think when a doctor attends an inquest it's really important for them to have a really good understanding of where bereaved families are at when they attend, emotionally, because when somebody dies in normal natural circumstances, that's a terrible thing, it's a shock and even when it's expected, it's a shock to the system and that shock will probably last quite a long time. Put yourself in the shoes of a bereaved family member. That person will have put their grief on hold for many months until the inquest and even beyond the inquest and so they are still within that grieving process, but in a skewed sort of way. Sometimes it really complicates or halts the grieving process and so people will feel very emotionally charged. When you ask them to attend an inquest and they are hearing details again about how somebody's died, that can put them right back to as though the person died yesterday. So, their emotions are very, very high.

I think if I were going to give some top tips to doctors or other medical professionals about how they could interact with the family or be with the family when the inquest happens, is that they would again be human. Put yourself into the shoes of the family person. What do you think it's like for them attending the inquest? It's very difficult for the family. Try and explain things in normal everyday language terms, break down medical jargon, break down medical terms. Explain things in everyday ways if you can, rather than explaining them in your professional capacity. Try and speak to them as though you're speaking to a friend who's got no medical experience at all. 

And then speak to the family, directly speak to the family, give them eye contact; be that human-being, that compassionate person and reach out to them in a way that you may not have done so in the past because of your medical background, and maybe even approach them after the inquest and say that you're sorry for their loss, because I think sometimes that's all somebody wants, is to hear somebody else say that they're sorry that somebody has died. You're not admitting guilt. You're not saying I'm to blame, you're far from saying that, but what you are saying is that you are a compassionate person and that you are sad for somebody else going through such a difficult time.

When somebody is shuffling lots of papers in the witness box or saying I'm not sure about that or I can't remember, then I think that really does make the family think that that person doesn't really know anything about what happened or that the person, the loved one, was forgotten because they don't even remember the case and referring to them as a case, as opposed to a person, again, has an impact on the family. Whereas, if you talk about Fred who died or Mabel who died or whoever, then it can make them think, make the family think, that you are dealing with the only person that they cared about as a person, as a human-being.

9.45–11.07 mins

If a death has been referred to the coroner and there will be an inquest, then I think the trust and the doctors that were involved should offer the family a meeting, even before the inquest date has been discussed, to talk to them about what happened. Sometimes that will answer all the questions that the family might have, even before it even gets near to the inquest, and that might be soon after the death, but I think it should also happen or be offered at different times before the inquest because if it happens soon after the death, the family may still be grieving. 

They may still feel find it difficult to assimilate some of the information or the information may bring up even more questions. So, offering more than one meeting, I think, will really, really help and ease some of the tensions that sometimes happens once it gets to the inquest, and those questions haven't already been answered or those meetings haven't been offered. I think it's really, really important and I've heard family say, you know, we asked for a meeting, but they didn't give us a meeting or we wanted to speak to them beforehand or we had lots of questions beforehand that they just ignored or they just didn't respond to, and I think that would really alleviate a lot of the tensions beforehand.