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31 Mar 2021

Coroner’s Inquests – Being prepared

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Attending a Coroner’s Inquest may feel like a daunting prospect for nurses, but it is sometimes a necessary part of the nursing role, in order that the death of a patient or resident can be fully explored and cause of death determined.

Further to this, it is an opportunity for reflection and learning; for the Coroner to make recommendations and the nurse to think about how their practice in the future could be adapted.

What is a Coroner’s Inquest?

A Coroner’s inquest is a public enquiry into the cause of death of a person and is often required when a death is sudden or unexpected. The Coroner will usually be a doctor or a lawyer, sometimes they can be both. They will be in charge of the investigation into the death and will decide which witnesses are necessary to contribute to the enquiry. The purpose of the inquest is to establish the facts around the death – it is not about apportioning blame.


As a nurse, being fully prepared to give evidence is essential to reducing anxiety related to being called as a witness. You may be called to give detailed information about the nursing care that you gave to a patient or resident and therefore it is vital that your actions are fresh in your mind.

You may, as a witness, be asked to provide a written account of your involvement. The Coroner may then call you to the stand as a witness,  and may wish to talk through your written statement of events. As inquests can sometimes occur some time after the death of a person, it is important that you refresh your memory by familiarising yourself with your written statement  and the nursing records that you, and your colleagues made at the time that care was given. It is also important to understand the care and treatment given by your colleagues, including the medical team, in order that you fully understand the care package and the holistic picture.

Always ensure that you inform your employer that you have been called as a witness to a Coroner’s inquest. They will support you to ensure that you have the relevant information to be able to submit an accurate account of your involvement with the patient. They may also wish to provide you with legal counsel, depending upon company or organisational policy.

What to expect

The prospect of being called as a witness can cause many nurses to feel very anxious. Try to remember that the process is a fact-finding exercise and that, unlike other court room experiences, is there to discover the circumstances around a person’s death, rather than to apportion blame.

The Coroner’s inquest is often attended by the family and this can add to the anxiety that witnesses can feel. Sometimes a statement written by the family may be presented at the inquest and this can be filled with emotion and feelings. It is important that nurses take this on board while, at the same time, ensure that the evidence that they give is based on facts, rather than emotion.

The Coroner will ask each witness to give their account of their involvement in the person’s care or treatment and it is important to give an accurate account of your actions. The family or Coroner may wish to ask you questions about the care that you gave and you should try to answer as comprehensively as possible. Your answers should always be honest and you should not omit relevant information; remember that the purpose of the inquest is to ascertain the full circumstances around the death. The Coroner may ask you to elaborate on your understanding of certain conditions, particularly if a condition is considered to be a contributing factor to a person’s death. You should be prepared to demonstrate your knowledge of any conditions that the person experienced and be able to justify your clinical judgement and decision making.


Following the inquest, it may be beneficial to reflect on the Coroner’s outcome, with a view to analysing your own practice. Consider whether you could have done anything differently that could have influenced a different outcome. This is an essential part of personal and professional development and you should take every opportunity to discuss this with your employer.

Lesson learnt

At the end of the inquest the Coroner may make recommendations to try to ensure that any avoidable contributing factors can be applied to the care of other patients. It is important to remember that this isn’t about apportioning blame, it is about protection for others. You may feel as though your practice, or that of your team is questioned; if this is the case then it is important that you discuss this at the earliest opportunity with your employer. Ensuring that the recommendations of the Coroner are implemented are a key part of any enquiry.


As a nurse, you should be prepared to account for both your actions and omissions. This can take place in different circumstances, one of which can be the Coroner’s Inquest.  In order to do this effectively, you should be honest and detailed in your account. As a witness, you may well be expected to discuss your actions and to account for the decisions that you have made. Speak calmly and be sensitive to the fact that family members are likely to be present. Be empathetic while giving your account based on facts, not emotion.

Being called as a witness at a coroner’s inquest is not ever going to be something a nurse looks forward to, but it can be a new experience that allows clarity and understanding to be offered to family members and can also offer further opportunities for professional learning.

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