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Providing effective evidence for the coroner
  1. B George,
  2. K Nicholls,
  3. S Pompeus,
  4. V Vasu
  1. East Kent Hospitals University NHS Foundation Trust, William Harvey Hospital, Ashford, Kent, UK
  1. Correspondence to Dr V Vasu, East Kent Hospitals NHS Trust, William Harvey Hospital, Ashford, Kent TN24 0LZ, UK; vimal.vasu{at}

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In England and Wales in 2013 approximately 45% of all registered deaths were reported to the coroner with 13.1% of these resulting in an inquest.1 Therefore, at some stage during their medical career, clinicians may be called upon to provide evidence at a coroner's inquest. This can often be a challenging and worrying experience not least because of the often protracted time frame between knowing that one has to attend an inquest and the inquest date itself. In addition, because the inquest is a recognised legal court, clinicians may have concerns about whether or not there will be an inference of clinical negligence. The aim of this article is to decipher the process of attending a coroner's inquest for clinicians by providing guidance in the form of a combined legal and medical perspective. In the article we will describe the judicial role of the coroner, the salient legislation that underpins the role of the coroner and the inquest process itself. We will also provide generic guidance on preparing a witness statement for the coroner, describe the day of the inquest itself and provide suggestions as to how to provide effective evidence to the coroner.

The judicial role of the coroner

Coroners are independent judicial office holders appointed directly by the local authority. Their work is overseen by the chief coroner who provides national leadership for coroners in England and Wales.2 Scotland has different legislation and the procurator fiscal undertakes this role. Historically, coroners held either Legal or Medical qualification or both. However, since the implementation of the 2009 Coroner and Justice Act,3 newly appointed coroners can only be lawyers. Their primary judicial duty is to investigate upon any death in their area, as outlined in box 1.

Box 1

Reasons that deaths are referred to the coroner for further investigation

  1. If the …

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  • Contributors VV conceived the original idea for the manuscript. BG and KN wrote the draft versions of the manuscript and produced the Figures. VV and SP clarified clinical and legal points raised within the manuscript. All authors contributed to the intellectual development of the final manuscript as submitted.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.