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Inquests – understanding a GP practice’s role

29 January 2024

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Coroners frequently call on GPs to attend or provide information for an inquest into a patient’s death on behalf of the practice. Dr Heidi Mounsey explains how inquests work and why it is important for practice managers to be aware of the process

GPs often seek out our advice in relation to inquests. While the GP of the patient at the centre of the inquest is usually the one to attend an inquest or provide a written statement, it’s common for the coroner to request detailed information to gain a fuller picture, and the practice manager may need to assist.

Here are some basic facts about what inquests are and what a surgery’s involvement may be.

What is an inquest?

An inquest is a fact-finding exercise and is an inquisitorial rather than an adversarial process. The coroner does not aim to establish blame, culpability or liability but rather to answer four questions. These are:

• Who died?
• Where did they die?
• When did they die?
• How did they die (or sometimes “in what circumstances” the deceased came by their death)?

The GPs in your practice are required to assist the coroner in an inquest into a patient’s death by offering all relevant information. They are permitted to remain silent only if commenting may lead to criminal proceedings being taken against them. 

GPs have a number of professional obligations with respect to producing a statement for the coroner (or in other circumstances such as for a serious incident investigation), and these are set out in the GMC’s Good Medical Practice at paragraph 71, which states:

‘You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must make sure that any documents you write, or sign are not false or misleading.

a. You must take reasonable steps to check the information is correct.

b. You must not deliberately leave out relevant information.

In addition, Good Medical Practice highlights the requirement for a GP to inform the GMC without delay if they are criticised by an official inquiry; this would include criticism from a coroner in relation to an inquest.

In providing a written statement, or giving oral evidence at an inquest hearing, a GPs role is to provide factual information to assist the coroner in concluding the process and answering the above questions.

The coroner will usually collect statements from individuals who have been involved in the care of the patient, often including a close relative of the deceased, and those clinicians and agencies who were involved in the care of the deceased prior to their death. 

If a GP in the practice is requested to provide a written statement, Medical Protection has some guidance on report writing that can help.

What is the role of a GP asked to attend an inquest?

In the event a GP from your practice is requested to attend an inquest, they may be called as a factual witness or as an interested person (IP).

An IP is either a government body responsible for the care of a patient (for example, an NHS trust or a prison), or any individual whom the coroner believes is pivotal to the case or has sufficient interest in the inquest, such as the practice or an individual GP. A patient’s family would normally be an IP, for example. 

A factual witness attends to give evidence and can be questioned by any of the IPs or their representatives. A factual witness does not have a right to see all the other documents relevant to the inquest, cannot question other witnesses and does not have a right to legal representation. 

An IP has the right to full disclosure of all the documents relating to the inquest and also has the right to legal representation. An IP (or their legal representative) may ask questions of any of the witnesses giving evidence at the inquest.

Consequently, if a GP at the practice is requested to attend an inquest it is helpful to know from the outset on which basis they have been asked to attend. 

What happens during the inquest?

During an inquest itself, the coroner will question the witnesses followed by questions from any IPs, including the family of the patient or their legal representative. The coroner may either ask the GP to read their statement in court or may take them through it, asking relevant questions.

As mentioned, an inquest is inquisitorial rather than adversarial. However, many healthcare professionals understandably find it stressful being questioned in these circumstances.

When giving evidence GPs will need to be familiar with their written statement and the medical records and have these to hand. If attending to give evidence in person, they should attend the court in good time.

If providing evidence remotely, it is recommended to undertake a test run with the court in advance and have a quiet private room to give evidence from, so as to not be disturbed. Unless there is permission from the court, GPs must be alone when giving evidence. 

At the end of the inquest the coroner will reach a conclusion. This may be of a short form, for example, the death was due to natural causes, suicide or accidental death. Alternatively, the coroner may provide a more detailed narrative conclusion, which contains more information as to how the patient came about their death.

What risks should the practice be aware of?

There are potential risks to a GP involved in an inquest even if that doctor is there to represent the practice as a whole. If the coroner is concerned that the standard of care provided to the patient contributed to their death, they could add a neglect or poor care comment to the conclusion. 

Less frequently, the coroner may also produce a Regulation 28 Report (Prevention of Future Deaths) if they believe that this is necessary. If a GP is criticised during a coroner’s conclusion, they must refer themselves to the GMC (as noted above) and to NHS England under regulation 9 of the Performer’s List.

It is also important to note that failure to comply with a request to attend as a witness at a coroner’s inquest can result in the order of a fine for contempt of court and a complaint to the GMC.

Therefore, if there are any potential areas in the care that could be subject to criticism we advise that practices meet as soon as possible to undertake a robust significant event analysis and put in place any actions or changes to practice in order to reduce the risk of future occurrences.  

There is support available. If a GP is requested to provide a statement to the coroner, it is advisable to contact Medical Protection as soon as possible so we can provide an objective review of their statement and consider any possible risks and their mitigation at an early stage, which reduces the risk of criticism by the coroner at the inquest itself. 

Dr Heidi Mounsey is medicolegal consultant at the Medical Protection Society