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Inquests and Medical Negligence: What to do and what to expect

02 Aug 2021

If you have been contacted by the Coroner’s office and have been advised that an inquest is to take place in respect of a family member or loved one’s death, you will understandably have a number of questions about the process. At Hay & Kilner, our specialist medical negligence team can help you with the inquest process.

Why is an inquest needed?

There are certain circumstances when a Coroner must hold an inquest for example, where a doctor is unable to give a cause of death, where the death is violent or unnatural or the death occurred whilst the patient was in the custody of the state such as a prison, police cell or psychiatric hospital.

What is the purpose of the Inquest?

The purpose of the inquest is to enable the Coroner to finalise the death certificate. In order to do so the main purpose of the inquest process is for the Coroner to establish who the deceased person was, when they died, where they died and how they came by their death. A Coroner’s investigation is very different to a civil liability investigation and the Coroner is not looking to establish blame or liability on the parties involved, but simply to establish the facts.  If the patient died in the custody of the state the Coroner will also investigate in what circumstances the patient died.

Prior to the Inquest Hearing

The Coroner will, in normal circumstances, conduct some initial investigations and approach the relevant parties i.e. those involved in the care of the patient and their loved ones.  It may be necessary for the Coroner to request a Post Mortem examination to be performed in order to assist in establishing the medical cause of death.  The Coroner may also direct that certain witness statements are provided on behalf of clinicians involved in the care of the patient.

The Coroner may also decide that it would be beneficial to hold a Pre-Inquest Review hearing.  The purpose of the Pre-Inquest Review Hearing is to ensure that the issues for investigation (also known as scope) are determined and to ensure that all necessary documentation and evidence has been obtained prior to the inquest hearing.  The Pre-Inquest Review stage is a helpful opportunity to ensure that all parties have the necessary documents they require or to make submissions to the Coroner that further documentation would be helpful in assisting the Coroner in their investigations.  Practical issues such as obtaining availability for witnesses can also be discussed at Pre-Inquest Review.

The Inquest

The inquest itself will then be held in a Coroner’s Court and most witnesses will be invited to give evidence in person or, in certain circumstances, by video link. In cases where the patient was in the custody of the state it will likely be necessary for the Coroner to hold the inquest with a jury present (also known as an Article 2 inquest).

As the inquest is an inquisitorial process rather than a trial, the Coroner leads the inquest itself and will invite witnesses to give their evidence and then ask any questions that they may have of that witness.  It is then open to the family of the deceased to ask any additional questions they may have and other interested parties may also ask additional questions of witnesses.

Inquests and medical negligence

Inquest Conclusions

A Coroner must provide a conclusion as to the patient’s death. Possible short form conclusions include:

  • Accident or misadventure.
  • Alcohol or drug related death.
  • Industrial disease.
  • Lawful killing.
  • Unlawful killing.
  • Natural causes.
  • Open conclusion.
  • Road traffic collision.
  • Still birth.
  • Suicide

If the circumstances of the deceased’s death do not lend themselves to a short form conclusion the Coroner may instead provide a short narrative conclusion detailing the facts however, this may not use words or phrase which apportion civil or criminal liability upon the parties involved. In a jury inquest, the jury would usually decide the conclusion with some limited direction from the Coroner and the jury may use judgmental wording inferring criticism of the care provided.

Concerns following the Inquest

If a Coroner feels that there is a likelihood of future deaths occurring in the same way that the patient came to their death the Coroner may order a Prevention of Future Deaths Report also known as a Regulation 28 Report. In doing so, the Coroner will make a formal report to the parties involved outlining the concerns that have been raised during the inquest, whether that be regarding specific medical care or Trust policies and procedures. The party will then be required to review those concerns and provide a formal report outlining steps that have been taken to ensure that the situation does not happen again.

Legal representation and Medical Negligence

You may already have concerns about the care a loved one has received in hospital or from their general practitioner prior to their death and we understand that embarking upon the inquest process at this difficult time can be overwhelming. At Hay & Kilner, our specialist medical negligence team have significant expertise in representing families throughout the inquest process and a subsequent medical negligence claim.

If you are concerned that medical negligence may have played a part in a family member or loved one’s death and an inquest has been opened, please do not hesitate to contact us for a free no obligation discussion as to whether we would be able to assist you throughout the process.