Coroner’s inquests: an overview

Jonathan Purday, Medical Director, QEQM Hospital Margate, East Kent Hospitals UFT

Death registration seeks to record clear information about how people die;
On 9 September 2024 the statutory medical examiners scheme and the related rationalisation and reform of the death certification system were introduced, having remained largely unchanged for over 50 years.
Introduction of a robust system in England and Wales whereby all deaths will be subject to mandatory scrutiny by a medical examiner where a death is natural, if not subject to an investigation by a coroner where section 1 of the 2009 Act is engaged.
Medical Examiners (employed by Trusts but independent in this role) scrutinise all deaths occurring within their Trusts in order to:
Agree proposed cause of death and accuracy of MCCD;
Discuss cause of death with family and explore any concerns;
Act as a medical advice resource for local Coroner;
Inform selection of cases for further review via clinical governance processes.
Determine when to refer to the Coroner.

Referrals to the Coroner

Cause of death appears unknown
Death during operation or while under anesthetic
Death occurred at work or due to industrial disease
Death was sudden or unexpected
Death caused by violence (self or others) or neglect
Death arising in suspicious circumstances
Death occurred in prison, police custody or other state detention
No doctor attended during last illness or doctor is not available within a reasonable time to sign a MCCD

Scope of Coroners’ Investigations

Coroners are tasked with answering 4 questions:

Coroners also have a duty to consider whether to write a “Prevention of Future Deaths Report” (more on this later).

Fact finding (inquisitorial) not an adversarial process. It is not a court of blame. No criminal or civil liability can be determined.

Finally, I will give several examples of inquests that I have been involved with as a medical director or interested party.

References

The medical examiner system and its relevance to anaesthesia and critical care. Levy, D. M.de Beer, C. D. The medical examiner system and its relevance to... : BJA Education