LMC Coroner’s Event: ‘How to prepare for an inquest’ – 8 November 2019

What follows is a report on the event held for GPs on 8 November 2019 by the LMC working with the coroner’s office, a very broad overview of the main areas covered and useful information for GPs and colleagues to be aware of.

Areas covered:

There was an introduction to the session from the Deputy Coroner, Dr Elizabeth Didcock and Michael Wright, Chief Executive of Nottinghamshire LMC. Dr Didcock took the audience of 40-50 GPs through a set of slides outlining the role of the coroner.

The intention of Dr Didcock was to ensure that GPs present were made aware of the contents of the new guidance that came into force in October 2019. She stated that there is an expectation that the new guidance will lead to less referrals to the coroner and more decision-making by GPs on whether referrals are necessary.
Stats and information, and some information stood out as interesting to share such as:

  • In Nottinghamshire during 2017/18 there were approximately 6,700 referrals to the coroner out of c.12,000 deaths in the year, a referral rate of 56% – there is a low post-mortem rate.
  • 96% of coroner referrals come from GPs.
  • Aim is always to hold an inquest within six months of the death of a person.
  • Generally speaking, referrals within 48 hours of death are acceptable.

Hints and tips:
It was clear from the event that some hints and tips for GPs to bear in mind would be helpful, some are captured below:

  • Make referrals electronically, reduces mistakes and provides GPs with an audit trail they may wish to use in the future
  • Ask for assistance from your medical defence organisation if called forward by the coroner, also consider if the LMC can also support
  • If you are called as a witness but want to understand more around the surroundings of any case, you may email the coroner’s office to become an ‘interested person’ which would then grant you access to the bundle of relevant papers
  • You are always welcome to observe an inquest hearing to better understand how it works, particularly useful is requested to attend having not been there before
  • Look upon probability, lawyers are used to working in black and white, doctors often work within the grey. If not confident to certify, refer to the coroner
  • Referral may be needed if the care leading to a death may be argued as causing the death, even if not for unnatural causes
  • No requirement to inform NHS England of being called forward as a witness
  • Inform NHS England only if named as an interested party or if explicitly criticised in a coroner’s report in which case you’d be urged to consider self-referring to the GMC (the GMC publish specific guidance about this)
  • Used to always have to refer when a death occurred within 12 months of a surgical procedure, now only necessary where the GP considers that the procedure may have led to the death


This was a helpful event and it enabled GPs to ask questions of the coroner’s office that would better inform them in the future. The general themes to emerge from the evening were that more is expected of GPs to make their own decisions about whether to refer to the coroner now that there is more flexibility allowed. Also, GPs called forward to be witnesses or to as persons with an interest are invited to observe an inquest as a member of the public to help to prepare themselves. Email contact to attend a hearing coroners.office@nottinghamcity.gov.uk

Forthcoming inquests are listed on their website https://www.nottinghamcity.gov.uk/coroners. Ultimately, the question for all GPs to ask is ‘do you know why this person died?’ Are you able to certify death with confidence?’ If not, referral may well be the best route to take. It is an option for anybody involved in an inquest to obtain copies of transcriptions/recordings from the hearing and in the event of post-inquest queries, GPs are encouraged to contact the coroner’s office directly.

Before leaving, all were taken on a guided tour of the upper reaches of the Council House in Nottingham and were shown the council chamber and committee room where inquests are held and the event was held in the tea room which helped to demystify this element of the coroners inquests. Because of the interactive nature of the session, there was more time spent on the new guidance and answering questions from the floor and it was suggested that a follow up session could be convened to concentrate more on preparing for an inquest. This was touched on regularly during the session hence the hints and tips but there is adequate content to set up a separate session to complement this one.