THE death of a patient in difficult circumstances can be traumatic enough for all concerned. But what should a doctor or dentist do on receipt of a letter from the coroner’s officer asking for a statement about the death? The short answer is to telephone MDDUS and ask for advice.
Having said that, the advice will be more immediately helpful if some preliminary steps have already been taken.
A coroner’s inquest is the procedure used in England, Wales and Northern Ireland (fatal accident inquiry in Scotland) to investigate a sudden death for which the cause is unknown, violent or unnatural, or which has occurred in prison. The inquest is not a trial but a limited inquiry, with or without a jury, to establish the facts surrounding the death.
It is not the coroner’s function to determine any question of civil or criminal liability, or to attribute blame for the death. Nor is it his function to explore issues of potential medical negligence but that’s not to say it doesn’t hold risks for doctors.
Drafting a statement
The main thing that the clinician can do while the events are as clear in the mind as possible is to begin the process of drafting a statement for the coroner. This will act as the basis for the final document submitted to the coroner after discussion with MDDUS.
Remember that an inquest is an investigation into the death of a person. It aims to answer four fundamental questions and, increasingly, focuses on a fifth related question. The five questions are:
● Who was the deceased?
● When did the deceased die?
● Where did the deceased die?
● How did the deceased die?
● In what circumstances did the deceased die?
The doctor’s or dentist’s statement will give the coroner help mainly with the last two of these. Bear in mind that the coroner may well read out the report so it is best if it is joined-up prose with medical jargon eliminated or expanded. Because the family will be present at the inquest, some clinicians will start the report with a sentence of condolence, particularly if there has been a close connection with the deceased.
Coroners find it helpful if the report starts with a couple of sentences setting out a miniature CV. This allows the coroner to decide how much weight to put on the statement. If, for instance, the coroner is investigating a death that may be related to drugs of addiction, the statement from a GP with a declared interest and expertise in substance misuse is likely to be given more weight than one from a GP with other interests.
The clinician then needs to go on to the facts of his or her involvement with the deceased in the period leading up to the death. Sometimes there may be relevant information from many years ago, especially where occupational disease may have contributed to the death.
Unless the coroner has asked the clinician specifically to provide an expert report, the statement should confine itself to factual evidence. It is often difficult to know where facts end and opinion begins and this is one of the areas where MDDUS advice can be very helpful. Straightforward facts include the direct recollection of the clinician as well as those events that can be reconstructed from the notes and the custom and practice of the clinician. The statement should also include the opinions of the clinician formed at the time the patient was seen but not in retrospect, as well as the contemporaneous views of others involved in the deceased’s care. Below is an annotated paragraph of a fictional GP’s statement:
Mrs A came to see me for the first time as an urgent patient on 29/02/2009. I remember she looked well but seemed anxious with a rapid breathing pattern [direct recollection]. Her blood pressure is recorded as CCC/DD [fact from notes]. When taking a BP, I will always take note of the pulse; I have not recorded this so I can be sure that it was normal [custom and practice]. I knew that Mrs A’s usual GP felt she was prone to non-organic illnesses [contemporaneous view of another clinician]. I diagnosed that she was having an anxiety attack and did not feel that any further investigation was needed [contemporaneous personal opinion]. I now know that she had early ketoacidosis [retrospective opinion and so of no help to the coroner in understanding how the deceased came to die].
At the end of the statement, the clinician can help the coroner by giving contact details for anyone else who might be able to assist (for instance, the “usual GP” in the paragraph above). Many doctors and dentists then close with a statement of truth. The whole statement should be typed and numbering of paragraphs is helpful to the coroner as well as to any lawyers or advisers.
Once the draft statement is complete, it should be sent to MDDUS. An adviser will look over it and, if necessary, discuss it with a solicitor. The adviser cannot help with documenting the facts but can be very helpful in making these clearer and more accessible. The adviser will also look out for medical jargon and for pieces of information that need to be expanded. An example of this might be where the deceased may have been hoarding medication with a view to an overdose. In such an instance it would be helpful to the coroner to have a detailed list of dates, drugs and quantities prescribed over the past few months.
Summons to appear before the coroner
Inevitably, there are times when the coroner will ask a clinician to appear in court to amplify or explain any statement already submitted. This can happen even when the facts in the statement are not disputed in any way. Sometimes the family will be keen to have an opportunity to ask questions of a clinician involved in the death of one of their relatives. The coroner may summon a clinician who seems only very peripherally involved in the events leading up to the death if it will assist the court in understanding the processes that failed to prevent the death.
Clinicians are often concerned that such summons might mean that they are to be criticised or faced with hostile questioning in an inquest. This is an area where support from MDDUS is very important and there are a number of ways of forecasting whether or not a clinician is to be criticised. In some cases, the coroner or the coroner’s officer will directly inform the clinician that some hostility is to be expected. If you are called to give evidence, it is a good idea to phone the coroner’s officer and ask if criticism is likely. The other key question to ask before the inquest is whether or not the family is legally represented. Families who bring along lawyers are usually out for a show-down of some kind so this is a key question.
Look for Part 2 of this article in the next (Summer) issue of Summons in which we will offer guidance on appearing at inquests and potential outcomes.
Mr Des Watson is a medico-legal adviser based in the London office of MDDUS