Understanding the Coroner and Coroner's Court 

If you've ever received a letter from the Coroner's Office, you will be familiar with the sinking feeling I felt several months ago. Many nurses and midwives describe the same reaction: a mix of worry, defensiveness, and a sudden urge to reread every set of notes I’d ever written. 

The coroner's system in England isn't there to catch us out. It exists to seek clarity, answer important questions, and ultimately support the bereaved who need to understand what happened when their loved one died. 

So, what does the Coroner do? 

Coroners are independent judicial officers appointed by the local council. Their role is to investigate deaths that are unexpected, unexplained, or where concerns have been raised. They are not looking to attribute blame; they are looking for facts. If a death meets the criteria for referral, the coroner decides whether a post-mortem and/or an inquest is needed. An inquest is a fact-finding process to establish who died, where, when, and how they came by their death. The coroner may also identify something which could be a risk to others and issue a "Prevention of Future Deaths" report. 

The Coroner's Court – what's it really like? 

Despite the word “court,” the atmosphere is usually quiet, more respectful, and far less dramatic than you might imagine. There's no adversarial cross-examination by lawyers like in TV dramas. It's usually a calm room where the coroner guides the proceedings and ensures that everyone keeps to the legal requirements. The inquest I attended had a jury present. This initially felt intimidating—but it helped me to remember that they are everyday people, not medical experts. Their role was to listen and help determine the factual circumstances of the death. 

The bit we all worry about: giving evidence 

Being honest—few things make any healthcare professional's heart beat faster than being told they need to write a statement or give evidence. Those worries are completely normal, I remember feeling 

• “What if I can't remember?”
• “What if they think I've done something wrong?”
• “What if I get upset?” 

Here's the reassuring truth: you're not expected to recall every detail from memory. I'd prepared my statement using patient notes and the coroner directed me to the relevant parts. The coroner understood the pressures of clinical work and knows none of us can store every patient encounter in our heads. I was there as a professional witness, not a defendant. 

Speaking in lay terms 

One of the most helpful things I was advised to do—both in my report for the coroner and speaking to the family—was to use clear, simple language. The bereaved family may be hearing clinical details about what led to their loved one’s death for the very first time. Medical shorthand, abbreviations and technical terms can feel alienating or confusing. Swapping “hepatic failure” for “their liver stopped working properly” is not dumbing down—it's supporting understanding at an incredibly vulnerable moment. 

Holding space for grief 

The family's presence was the hardest part for me. Their grief was still overwhelming. They could ask questions directly and at times they reacted emotionally to my evidence. It was helpful to consider their reaction was not because of me, It was helpful to consider their reaction was not because of me, it was because they had lost someone they loved and missed. A calm, clear explanation could offer something they desperately needed: answers. When families are treated with empathy and respect, it often helps them begin to make peace with the circumstances of the death. 

You're not alone 

If you're called to give evidence, speak to your organisation's legal or governance team—they are there to guide you. You can also reach out to colleagues who have attended an inquest before; their practical insight may be reassuring. The University of Plymouth has a great resource for medical witnesses attending coroner’s court.

Most importantly, remember that attending coroner's court isn't a punishment. It's part of the openness and transparency that sit at the heart of nursing. Your experience matters, your professionalism matters, and your compassion matters. I walked out feeling that I’d done something valuable – helping a bereaved family to understand the facts of what had happened to their loved one.