Referring deaths to the coroner

Just like signing death certificates, as a junior doctor you will be called upon, on occasion, to discuss a patient's death with the coroner. It is therefore helpful to know at the outset which deaths the coroner will need to be made aware of.

You are likely to be asked to sign a Medical Certificate of Cause of Death (MCCD) early in your role as a junior doctor and it is important to know when this is, and is not, appropriate. If you have any doubts or concerns about the cause of death, you should discuss the death with a senior colleague and/or the coroner.

In order to sign the MCCD, which allows the patient's death to be registered, the doctor must know what illness caused the death, have treated the patient during that illness and must have seen them within the 14 days before they died – or seen the body after death. Where no doctor is available to fulfil this role, the death must be reported to the coroner.

Which deaths should be reported?

There are also a number of other situations in England and Wales where a death must always be brought to the coroner's attention. These include:

• All deaths of children and young people under 18 years of age. This applies even where the death is due to natural causes, to ensure that there are no safeguarding concerns.
• Deaths that are associated with a person's occupation. This, for example, may include death from asbestosis.
• Deaths that occur within 24 hours of admission to hospital.
• Deaths that may be associated with medical treatment that the patient received, including surgery or if they have had an anaesthetic.
• Deaths that may be associated with an accident the patient was involved in, even where this accident happened a long time ago.
• Deaths where there is a possibility that the patient took their own life.
• Deaths that may be associated with medications that the patient took, or other drugs, whether these were prescribed, recreational or illicit.
• Deaths associated with certain illnesses, such as hepatitis or tuberculosis.
• All deaths of people who were in custody or detained under the Mental Health Act. These should be reported even where the death was due to natural causes. It includes people living in care homes where they have been subject to Deprivation of Liberty safeguarding.

If a patient's death falls within any of these categories it should be reported to the coroner, in addition to any other death where you feel you are unable to identify the cause or have concerns. If, having spoken to a senior colleague, you or they are not sure whether the death should be referred to the coroner, it is better to contact your local coroner's office to discuss the death and seek their advice.

Any discussion that you have should be documented carefully in the patient's medical record.

Next steps

Once a death has been reported to the coroner, they will decide what action is needed. If the coroner is satisfied that the death was due to natural causes, it is unlikely that anything further will be needed; however, the coroner may feel that a further investigation into the death is warranted and this may include the need for a post mortem examination.

The most likely reasons for this arise where the cause of death was unnatural, such as being due to trauma (for example, a fall, accident or assault, or where it was related to surgery or medical treatment), or associated with the patient's employment. A post-mortem is also likely to be needed where the patient died in custody or the cause of death cannot be established.

Depending on the outcome of the post mortem examination, the coroner may open an inquest to investigate the death further. An inquest is a public judicial inquiry and aims to satisfy four questions:

• Who the deceased was
• When they died
• Where they died
• The medical cause of their death (how they died).

As well as being asked to provide a report for the coroner in relation to the care the patient received, you may also be asked to attend a hearing to give oral evidence.

It is most likely that the trust you were working for at the time of the patient's death will ask you to provide the report for the coroner and, if the coroner requires, attend a hearing. The contact at the trust will generally be from the legal services department or patient liaison department.

Preparing a report for the coroner and attending an inquest hearing

You may be asked to provide a report for the coroner where you have been involved in the patient's care. This may, for example, be related to a patient who has attended the emergency department or a patient who has been seen in the Medical or Surgical Admissions Unit and then been admitted to a ward.

It could also be for a patient who has undergone surgery or one that has been an in-patient for some time. You may have had a significant amount of involvement in the patient's care or you may only have attended to them briefly, for example, when you were on call.

It is for the coroner to decide who is required to provide a report, and they will contact the GP practice or trust to request these. It is important that you do not delay preparing your report; a deadline will often have been set by the coroner. If you think you will have difficulty completing your report by the deadline – for example, if you have planned annual leave or you have been working nights – you should let the coroner or the trust know as soon as possible.

Any delay in preparing a report, or not preparing one at all, can result in criticism from the coroner or your employer, and is in breach of GMC guidance.

Your report should be a factual account of your involvement in the patient's care. It is important that you have the opportunity to review the patient's clinical records in order to prepare your report, rather than simply rely on your recollection of events, and your report should be consistent with the records.

The report should be detailed and include all relevant information and you should make sure it is not false or misleading. If you need to mention care provided by another clinician, state their name and make it clear who did what, rather than creating the impression that you provided all of the care you have mentioned in your statement.

You can contact the MDU for support; we can review your draft and assist you in preparing your report prior to it being submitted.

Attending a hearing

Depending on the degree of your involvement and the relevance of your written evidence, the coroner may require your attendance at a hearing. An appearance at any court is understandably stressful, so the more prepared you are the better.

If you are working in a trust, it is likely that the legal services department or equivalent will arrange a meeting with all members of staff who have been asked to give oral evidence.

The MDU strongly recommends you attend these meetings, even if you have moved on to a different trust in the intervening period. These meetings give you the opportunity to ask questions about the process and discuss your evidence in conjunction with your colleagues. It's also an opportunity for the trust to advise you if the family of the deceased have raised any concerns about the patient's care or if any conflict is likely to arise between your evidence and that of any of your colleagues.

You can also contact the MDU for advice and support, even where there is no suggestion that you are likely to be criticised.

Generally, where a doctor works in an NHS trust, that trust will provide legal representation if it is required. It is usually better for all of the staff to be represented as a group, rather than individuals having their own legal representation, as this may appear overly defensive.

Where there is conflict between one doctor and the rest of their colleagues, or with the trust, it may, however, be necessary for that doctor to have their own solicitor. This highlights the importance of doctors being members of a medical defence organisation, like the MDU.

When giving evidence in any forum, it is important to be honest and trustworthy and, as in the written report, not deliberately leave out any relevant information.

Your responses to questions should be factual and you should avoid giving an opinion, disparaging colleagues or trying to answer questions that are beyond your expertise or experience.  

The GMC produces guidance for doctors who are required to give evidence as a professional witness.

While the purpose of an inquest is not to apportion blame with regards to the circumstances of the deceased's death, it is possible in some circumstances for a doctor to be criticised regarding their involvement in the patient's care. This may not only relate to the clinical care they provided and decisions they made, but also to their documentation or communication with the patient or their family. Again, this highlights the importance of making full documentation of any interactions with patients and their loved ones.

Where a doctor has been criticised directly by the coroner, it may be necessary for them to inform the GMC of this; the GMC will then decide whether or not this warrants further investigation. Again, this highlights the importance of doctors of all grades and specialties having their own indemnity, so that their personal interests are best protected.