This court is alien to many healthcare staff, whose only obligation is to speak the truth and assist the coroner to reach a verdict

The coroner is an independent office holder with responsibility under the law for the medico-legal investigation of certain deaths. There are 48 coroner districts in Ireland, each with a coroner and deputy coroner. Coroners act on behalf of the State and are independent in their role.

The legislation establishing the role, jurisdiction and duties of coroners consists of the Coroner’s Act 1962, the Coroner’s (Amendment) Act 2005 and the Civil Law (Miscellaneous Provisions) Act 2011. Coroners investigate sudden, unexplained, unnatural or violent deaths. This may require a post-mortem examination, sometimes followed by an inquest. The coroner’s inquiry will establish whether death was due to natural or unnatural causes. If it is found that death was due to unnatural causes, the law mandates that an Inquest must be held.

An Inquest is a public inquiry into the circumstances surrounding a death. The public policy underlining the coroner’s duty is that an Inquest is necessary to protect not only the interests of the deceased but also the public interest. The key feature of a coroner’s Inquest is that it is a purely inquisitorial procedure. The principal function of the coroner is to establish the identity of the deceased person and the cause of their death. The Inquest provides an opportunity to establish the facts surrounding the death and place those facts on the public record. A jury is empanelled at an Inquest in certain circumstances, which are laid down by law.

A verdict will be returned in relation to the means by which death occurred. There are a number of verdicts open to the coroner or the jury: death by natural causes; accidental death; death by misadventure; death by suicide; unlawful killing; an open verdict; and a narrative verdict.

The verdict of an Inquest cannot impose civil or criminal liability on any person. There are a number of occasions on which a death must be reported to the coroner. These include deaths that occur at home, in a hospital or in custody, sudden infant deaths, certain stillbirths, the death of a child in care and where a body is to be removed abroad. For a full list of reportable deaths, see www.coronerdublincity.ie

If in doubt, a person may telephone him directly for advice. The fact that a death is reported to the coroner does not mean that a post-mortem will be required.

Healthcare professionals (HCP) are increasingly being requested to assist the coroner in the investigation of deaths reported in hospital. This involves providing a witness statement, and possibly attending the inquest, if the coroner deems it necessary to hold one. It is important for the HCP to realise that their primary function is to assist the coroner in establishing the facts surrounding the death of the person. The HCP is not on trial. On receipt of all the requested witness statements, the coroner will decide who may best assist him at the Inquest. The HCP should present at the Coroner’s Court at the requested time. They will be required to give evidence on oath or affirmation.

The HCP will be asked to read their prepared statement and sign it into evidence. Once the statement is read, the coroner will usually ask the witness some questions. Following this, ‘interested parties’ (the family), or solicitors acting on their behalf, may ask the witness questions. The witness must answer any question allowed by the coroner. However, by law, the coroner is entitled to stop any solicitor asking a question that would in any way suggest incompetence, negligence or criminal liability on the part of the witness.

Any questions asked must address only the facts and circumstances surrounding the death of the deceased. Once all the witnesses have entered their statements into evidence, the coroner will usually retire for a period to consider the verdict, which they will then deliver. An Inquest might not be completed in a single day.

The Coroner’s Court is an alien environment for healthcare professionals. The better prepared HCPs are, the less intimidating the experience will be. Support is available and should be sought from the line manager and clinical risk manager. The hospital staff will be supported by the State Claims Agency and their nominated solicitors. HCPs should avail of their expertise and clarify any issues of uncertainty.

The HCP should be familiar with the medical records and their own statement. They should confirm in advance which aspects of the case they are addressing so that they do not cross over into another witnesses’ evidence. In pre-court consultations, likely questions will be anticipated and prepared for. As an Inquest is held in public and deals with matters of public interest, the media are often present and may try to talk to any HCPs present. The public relations company for the hospital will usually handle any media presence.

The role of the HCP as a witness is to assist the coroner to reach a verdict. The HCP is there to communicate information they have to others, who do not. The HCP is the expert in their area and their only obligation is to tell the truth.

Susan P Kelly is a registered general nurse and midwife with a diploma in healthcare risk management and quality

The Dublin District Coroner’s Office and the VHGRMF publication ‘Updated Guidance Notes Attending an Inquest’ was used in preparing this article

Midwifery Matters - The Coroner’s Court