A Coroner’s inquest is a legal inquiry into the cause and circumstances of a death. In Scotland this is known as a Fatal Accident Inquiry called by the Procurator Fiscal.

You may be asked by the Coroner’s Court/Procurator Fiscal to explain what care was given to a service user where their death is unexpected or the reason for their death is unclear.

If you are a witness or an interested person and you are not being supported by your employer, please contact us for advice.

A Coroner is usually a doctor or a lawyer - sometimes both - and leads the investigation of all sudden, accidental or suspicious deaths. For more information please see the Coroners’ Court Support Service.

An inquest decides the cause of death only and does not apportion blame.

At the end of an inquest, the Coroner will reach a conclusion about the death which will answer the following four questions:

• who the deceased was
• when the person died 
• where the person died, and 
• how the person came by their death. 

Common short-form conclusions include: 

• natural causes
• accident or misadventure 
• suicide 
• unlawful killing (or lawful killing) 
• alcohol 
• drug-related 
• industrial disease
• road traffic collision. 

Some inquest conclusions can be left open, which means there was insufficient evidence as to how the death occurred. A ‘narrative’ conclusion can also be provided which is a brief, factual description of how the death happened. 

Remember, a Coroner will not apportion blame or name an individual in any conclusion to an inquest. 

Witnesses

A witness is an individual whose factual account is helpful to the Coroner. The individual will be asked to write a statement in most cases, setting out their version of events to help the Coroner understand their involvement in the care of the deceased.

In some cases, the Coroner may decide that their evidence, while helpful, is uncontroversial and/or too far removed from the circumstances of the death. In these cases the witness statements will be read out (known as Rule 23 witnesses) and the witness need not attend in person. However, if the Coroner requires their attendance at the inquest, they must attend to give live evidence. Failure to do so will result in a court summons, and a referral to the individual's regulatory body is likely. Witnesses should not assume that they are being called to give evidence because they have done something wrong or the Coroner wishes to criticise them.

There are many reasons why witnesses are asked to attend in person. For example, the Coroner may require the witness to attend because:

• they had a key role in the deceased's care
• they were one of the last individuals to treat the deceased, and/or
• it may help give the family some closure to hear from those who knew the deceased well/were involved in their loved one's last moments.

If there is a jury, live witness evidence is much easier to follow. 

Witnesses do not need and are not entitled to legal representation. They can take someone with them for support but they cannot speak on their behalf. Witnesses are not entitled to see the evidence the Coroner has collated (such as the post-mortem report, witness statements from other witnesses, Trust reports, police reports etc). They can request to have a copy of their statement in front of them when giving evidence. 

Witnesses will be asked questions first by the Coroner, then by the family and their representative and then finally by any other interested persons. Once finished, they are released and free to either leave the hearing or return to their seat to listen to the remainder of the hearing. 

Witnesses need only attend on the day that they are giving evidence. 

Interested person(s)

An interested person can be an individual or an organisation. The deceased's family are automatically granted interested person status. However, the Coroner can also appoint interested persons on two other grounds:

1. Where there is ‘sufficient interest’ (a catch-all discretion). Sometimes employers such as Trusts or care homes are appointed as interested persons because of their sufficient interest – i.e. where there is no suggestion that anyone did anything wrong but as the deceased was cared for by these institutions, they will wish to have the opportunity to be more actively involved in proceedings. 
2. Where an individual may, by any act or omission, have caused or contributed to the death of a deceased. This can capture a range of actions such as accidentally administering an overdose to a patient or failing to commence CPR in a timely manner. 

The RCN can request interested person status on either of the above two grounds. However, it is not done lightly.

As an interested party, the individual has a right to be legally represented. They have a right to receive copies of the Coroner’s disclosure which could include the post-mortem report, witness statements, investigative reports etc. They have the right for their legal representative to ask questions of any other witness and to make submissions to the Coroner on points of law. 

Interested persons are also likely to be witnesses so they too will need to give evidence and will be subject to questions from the Coroner, the family and any other interested person.

The Coroner may change the status of a witness to a properly interested person. Often this simply means that the Coroner considers that this person may be able to assist further.

The RCN’s expectation is that interested persons attend on each day of an inquest to provide instructions to their legal representative.

If you are a witness or an interested person and you are not being supported by your employer, please contact us for advice.

In Scotland, the Procurator Fiscal goes through the evidence at the Inquiry. It is held in front of a Sheriff, who then issues a determination once all the evidence is heard. The determination will include findings on the cause of death, any reasonable precautions by which the death might have been avoided and other relevant matters. For more information please see the Crown Office and Procurator Fiscal Service.

The Sheriff can make findings that an individual ought to have taken precautions which might have avoided the death in question.

Usually, the police will gather evidence on behalf of the Procurator Fiscal in readiness for the Inquiry. If you are approached by the police to provide evidence as a witness, please see our guide for witnesses to help you prepare.

If there is a risk of you being prosecuted in connection with a death or found to have some responsibility for the death, it is important that you contact us for further advice.

As part of the investigation, the court will request written statements and the Coroner/Procurator Fiscal will then decide who to call as a witness. You may not need to attend the inquest/inquiry if your evidence is unlikely to be controversial.

If you are called as a witness, please read our guidance on attending an inquest to give evidence (login required). 

If you have been summonsed (or cited in Scotland) and do not attend you may receive a penalty, a fine or even a prison sentence. Referral to a regulatory body like the Nursing and Midwifery Council (NMC) is also likely. A witness summons should not be ignored.

If there is a risk of you being prosecuted in connection with a death or you are found to have some responsibility for the death, it is important that you contact us for further advice.

For more information on what to expect when attending a Coroner's Court please go to the Coroners’ Court Support Service.

Statements

If you are asked to provide a statement for an inquest/inquiry, you should check your employer’s policy. Your employer will usually support you. You may be required to talk to management, or your employer’s solicitor, before speaking to the Coroner’s Office. The policy should outline whether your employer will arrange representation for you. 

If you are a witness or an interested person and you are not being supported by your employer, please contact us for advice or complete our online form. You must have been in the correct category of membership at the time of the incident for RCN to check your statement.

If there is a risk of you being prosecuted in connection with a death, or you may have contributed in some way to the death, contact us for advice prior to submitting or signing any statement.

Read more about statements here. 

RCN representation

The RCN's policy is that we would expect the employer to represent a member at an inquest/inquiry.

In certain exceptional circumstances, the RCN may provide support. However, this will be determined on a case-by-case basis if:

• there is a clear conflict of interest between a member and any other staff involved in the patient's care (such as doctors) and it would be difficult for the employer to represent all staff and the interests of the employer, or
• the employer is refusing to represent, and the RCN cannot persuade the employer otherwise.

Your employer may arrange legal representation to protect their interests. They may not be able to also represent you if there is a potential conflict between your interests and those of your employer.

You must have been in the correct category of membership at the time of the incident for RCN to support. Please contact us if you wish to discuss this further or complete our online form.