Coroners Court Flashcards
Who is the coroner
An independent officer of the Crown who will be a solicitor or doctor appointed by the local council
What do coroners do
They investigate deaths which are
Unnatural or unexplained
Cause of death is unknown
In state detention
It is an enquiry to establish the facts
What types of deaths are reported to the coroner
The deceased was not seen by doctor during their final illness
No death certificate is available
The death certificate cannot be signed by the doctor delaring death within 14 days
Death occurred during surgery or before emerging from anaesthetic
Death occurred from industrial disease or poisoning
Death was sudden, unexplained, violent, or due to neglect, suspicious or occurred in police custody or prison
What is the purpose of coroner investigations
To establish who died, when they died and how they died.
It is the primary mode of investigation
Inquests
Who is involved in an inquest
The coroner, general witnesses, police witnesses, interested parties (solicitors, family), media, family members, expert witness (give comment from professional opinions)
Why are witnesses called
Called by the coroner to give evidence to establish the facts
Questioned by the coroner and properly interested people (usually through solicitors or lawyers) this can include family of the deceased
Who are properly interested persons
Anyone with a valid interest in the deceased and the cause of death and their legal representatives
Why can the media be present
This is an open court and can be reported freely
Why do family members attend
Bereaved relatives derive comfort from the process of inquest
Why are expert witnesses called upon
They’re an individual of considerable expertise who reviews the case and offers their opinion
They are paid by the corner to provide a service
Do coroners courts assign blame and issue charges
No, the inquest is a fact finding exercise.
If evidence emerges that a crime had been committed the coroner must adjourn the inquest until after criminal proceedings are completed.
Can witnesses bring legal representation at a coroners court
Yes, as a witness you are a properly interested party and therefore welcome to bring legal representation
Does being summoned mean you have done something wrong
No the coroner just need your information in order to make his decision
What must you do at a coroners court
You will be expected to account for your actions, decisions and judgements under oath
What happens in the event of an incident (including investigation documentation and justification)
Investigation:
Any death involving a coroner will be investigated. Police, corners officers and healthcare organisations will also be involved
You will have to make a statement - seek legal advice
Documentation
You have the right to take copies and refer to notes and records without prejudice
Justification
The coroner will expect you to be able to justify your decisions. This will be examined by the legal teams
How do you prepare for an inquest upon initial summons
Upon initial summons:
Re read your notes and a statement
if youre unsure go back over the patient records
Alert your representation if you have them - some counsel will arrange a pre in quest briefing to discuss strategy
How do you prepare for the day of the inquest
Be early
Dress smartly
Expect to see relatives of the deceased
Bring your notes with you - you may refer to them on the stand
Be prepared to be questioned by the relatives
You do not have to say anything that may incriminate you
How do inquests conclude
The coroner issues conclusions not verdicts
They may also issue a narrative decision where the details of the case are outlined and decisions are explained in detail
What conclusions could an inquest draw
Natural causes
Drug dependent
Attempted or self induced abortion
Accident or misadventure
Disaster subject to public inquiry
Self neglect
Suicide
Unlawful killing (murder, manslaughter, dangerous driving)
Lawful killing (war, death penalty)
Industrial disease (asbestos, radiation)
Open (there is no evidence to support another decision)
What is a rule 43 report
A formal letter from the coroner to interested parties in order to prevent future deaths
These letters must be responded to in writing
They’re copied to the Lord Chief Justice and are summarise twice a year
If you are served with a rule 43 letter you must act upon it immediately
When can civil litigation proceedings (law suits) begin
Civil litigation can only occur after the inquest has concluded
Make your indemnity insurer aware of your involvement in proceedings and seek legal advice
What is the bolam/bolitho test
The standard against which one is judged is that of one’s own peers - not that of the wisest and most prudent.
You can only be judged against what the accepted average practice of what other pharmacists will do
What type of records can be used in a coroners inquest
Anything that makes reference to the care of the patient called as evidence
The approach to record keeping the courts of law adopt tends to be that if it is not recorded it has not been done
Make sure your records are clear accurate and easily reviewable in years to come
What are the GPHC standards surrounding the coroners court
Work in partnership with others, behave in a professional manner, speak up when you have concerns or when things go wrong and demonstrate leadership
