Preparing a witness statement for a coronial inquest
A request to provide a witness statement can be stressful and intimidating experience for a new consultant. We hope that this guide can provide you with the background knowledge and insight to help you manage your unease and provide a high quality report.
This guide is intended to complement the consultant conversations podcast on ‘dealing with the coroner’.
I have been asked to provided a witness statement – does this mean I have done something wrong?
In a word no. An inquiry is directed solely to ascertain; who the deceased was; how, when and where the deceased came by his or her death; and the particulars (if any) required by the Births Deaths and Registrations Act 1953 to be registered concerning the death. The inquest is not to attribute blame.
The Coroner is expected to open an inquest where there is reasonable suspicion that the deceased has died a violent or unnatural death, where the cause of death is unknown or if the deceased died while in custody or state detention as defined by section 1(2) of the Coroners and Justice Act 2009.
Unnatural causes include: industrial disease relating to death, if a medical intervention may have contributed to death or if an accident (including road traffic accident) contributed to their death. It is important to note that this un-natural element may have occurred several years before their death (for example hypoxic brain injury occurring 2 years prior to death from pneumonia). The Coroner may also hold an inquest if the death was due to natural causes but it is considered by the Coroner to be in the public interest to hold one.
In view of all of this, a request for a statement clearly does not only not equate with you ‘having done wrong’
What exactly is an inquest? Can I discuss patient details?
Inquests are legal inquiries into the cause and circumstances of a death, and are limited, fact-finding inquiries; a coroner will consider both oral and written evidence during the course of an inquest.
Inquests are public hearings and can be held with or without juries. As they are public events, the information is no longer confidential – so yes, you can take your notes with you. Additionally the public and the press are free to attend.
An inquest will open to record a death, ensure the deceased is identified and for a body to be released for burial or cremation.
Providing a witness statement or attending a summons in person are statutory requirements. Failure to comply with a summons can be met with a custodial sentence.
Do I need to inform the GMC that I have been asked to provide a witness statement or attend an inquest?
Not at this point. There is GMC guidance on this issue but in short there is an expectation to engage and to be open and honest. You must make clear what is factual evidence and what is opinion based on judgement and experience. If a particular question falls outside of your knowledge you should explain this and decline to comment.
You are required to inform the GMC if you are specifically criticised by the coroner for your role in the patient’s care in the course of an inquest. It would also be wise to inform a personal indemnity society at this point if you had not already done so.
Ok, so how do I write a witness statement?
As with so many aspects of consultant life; a great starting point is to speak to an experienced colleague. Additionally many trusts will have a coroner liaison team who can provide you with a clear idea of what information is required and crucially, a template on how to structure the statement.
It is also worth double checking the case and confirming that you were a) actually involved in the patient’s care and b) are the most appropriate clinician to provide the statement (i.e. one, isolated and uneventful ward round in a lengthy admission may suggest that there is a more appropriate colleague to provide a statement)
Inquests can occur several months after your involvement in the patient care, or even several months after their death. It is important therefore that you stick to the evidence in the medical notes and make it clear when you are drawing on your recollections rather than notes. It is very important to stick to the facts and not to speculate.
As mentioned above, the inquest is a public event and the coroner is unlikely to have a medical background. You must therefore avoid jargon, keep the report factual, but simple and explain any complex concepts in understandable terms.
Providing a detailed account and overview as the most consistently involved clinician (for example, the parent consultant during a prolonged admission) will minimize the need for you to be called to the inquest in person.
Providing a witness statement can be time consuming. Ensure that you allocate sufficient time in your diary to focus on this task and do so in a timely fashion.
Now I’ve been summoned to attend an inquest in person – what now?
As we discussed above, there are several reasons that you may have been asked to attend in person and this does not equate to bed practice or personal error. It is worth taking the time to speak with an experienced colleague and you organisation’s liaison team to help you prepare for what this experience will be like.
Make sure that you clear your diary of other commitments for the day (or days) that you need to attend the inquest, including on calls. Also take the time to plan something pleasant to do afterwards.
You will be expected to read out your statement under oath (reading into the inquest record). After this the coroner will ask you some clarification questions and examine your statement by asking you questions. Any interested person (such as the family of the deceased) or legal representatives acting on their behalf can then ask you questions so long as they are relevant to the inquest and not seeking to apportion blame.
As discussed earlier, avoid jargon and remember that this is not a medically trained audience.
It is important to bear in mind that evidence given can be used in civil court where the remit may be to attribute blame. Remember to be open, honest and not to speculate – if you don’t know the answer to a question, it is reasonable to say this.
Do I need to speak to a solicitor?
It would be wise to consider reading through your statement with the trust solicitor to ensure that you are well prepared and that there are no legal concerns that you had not previously appreciated. The trust solicitor represents the trust. Your witness statement is you own individual legal statement as a trust employee. In most cases it is unlikely that there is any conflict in these positions, but the trust solicitor does not provide legal advice to you as an individual person. In addition, it is therefore worth involving your own personal medical indemnity service.
What is the difference between England & Wales and Scotland?
In Scotland the Procurator fiscal’s office provide an inquisitorial process to establish cause of death via a fatal accident inquiry.
This may be initiated: if the death was sudden, suspicious or unexplained, or occurred in circumstances giving rise to serious public concern AND in the public interest, for example when lessons may be learned from the death that may prevent future deaths occurring.