Coroners Court

Question 1

Who is the coroner

Answer 1

An independent officer of the Crown who will be a solicitor or doctor appointed by the local council

Question 2

What do coroners do

Answer 2

They investigate deaths which are
Unnatural or unexplained
Cause of death is unknown
In state detention

It is an enquiry to establish the facts

Question 3

What types of deaths are reported to the coroner

Answer 3

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

Question 4

What is the purpose of coroner investigations

Answer 4

To establish who died, when they died and how they died.

Question 5

It is the primary mode of investigation

Answer 5

Inquests

Question 6

Who is involved in an inquest

Answer 6

The coroner, general witnesses, police witnesses, interested parties (solicitors, family), media, family members, expert witness (give comment from professional opinions)

Question 7

Why are witnesses called

Answer 7

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

Question 8

Who are properly interested persons

Answer 8

Anyone with a valid interest in the deceased and the cause of death and their legal representatives

Question 9

Why can the media be present

Answer 9

This is an open court and can be reported freely

Question 10

Why do family members attend

Answer 10

Bereaved relatives derive comfort from the process of inquest

Question 11

Why are expert witnesses called upon

Answer 11

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

Question 12

Do coroners courts assign blame and issue charges

Answer 12

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.

Question 13

Can witnesses bring legal representation at a coroners court

Answer 13

Yes, as a witness you are a properly interested party and therefore welcome to bring legal representation

Question 14

Does being summoned mean you have done something wrong

Answer 14

No the coroner just need your information in order to make his decision

Question 15

What must you do at a coroners court

Answer 15

You will be expected to account for your actions, decisions and judgements under oath

Question 16

What happens in the event of an incident (including investigation documentation and justification)

Answer 16

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

Question 17

How do you prepare for an inquest upon initial summons

Answer 17

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

Question 18

How do you prepare for the day of the inquest

Answer 18

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

Question 19

How do inquests conclude

Answer 19

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

Question 20

What conclusions could an inquest draw

Answer 20

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)

Question 21

What is a rule 43 report

Answer 21

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

Question 22

When can civil litigation proceedings (law suits) begin

Answer 22

Civil litigation can only occur after the inquest has concluded

Make your indemnity insurer aware of your involvement in proceedings and seek legal advice

Question 23

What is the bolam/bolitho test

Answer 23

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

Question 24

What type of records can be used in a coroners inquest

Answer 24

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

Question 25

What are the GPHC standards surrounding the coroners court

Answer 25

Work in partnership with others, behave in a professional manner, speak up when you have concerns or when things go wrong and demonstrate leadership