Doctors, Inquests & Prevention of Future Deaths

Doctors and Inquests - Prevention of Future DeathsCoroners Inquests and Prevention of Future Deaths – Guidance for Doctors

The prevention of future deaths is a mandatory obligation imposed on coroners. Where a death has occurred, a coroner will look at who died, when they died, where they died and how they died.

An inquest verdict should not name and shame people, or hold people criminally or civilly liable. Nevertheless, a coroner is obligated, when the above findings have been made, to determine whether sufficient steps have been taken by those who have contributed to or caused the death of an individual, or those who have local control of an organisation, to prevent the risk of recurrence. This has a particular resonance for doctors who are called to give evidence as a witness or interested party.

Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, sets out the statutory provisions (duty) for coroners to draft such reports. They can be sent to a person, organisation, local authority or government department or agency where the coroner believes that they are in a position to take steps to prevent future deaths.

A doctor who receives a report from a coroner must respond within 56 days, and a doctor’s response should deal properly with the area of concerns. If a doctor fails to respond, the GMC is likely to be informed. A doctor is obliged under the code of conduct Good Medical Practice (GMP) to assist inquiries. Paragraph 73 of GMP states: “You must cooperate with formal inquiries and complaints procedures and must offer all relevant information while following the guidance in Confidentiality.” A failure, therefore, to respond to the coroner could constitute serious professional misconduct.

Statutory Law

Role of a Coroner

S.5 of the Coroners and Justice Act 2009 (“the 2009 Act”) sets out the purposes of an inquest:

(1) The purpose of an investigation under this Part into a person’s death is to ascertain—

(a) who the deceased was;

(b) how, when and where the deceased came by his or her death;

(c) the particulars (if any) required by the 1953 Act to be registered concerning the death.

(2) Where necessary in order to avoid a breach of any Convention rights (within the meaning of the Human Rights Act 1998 (c. 42)), the purpose mentioned in subsection (1)(b) is to be read as including the purpose of ascertaining in what circumstances the deceased came by his or her death.

(3) Neither the senior coroner conducting an investigation under this Part into a person’s death nor the jury (if there is one) may express any opinion on any matter other than— (a) the questions mentioned in subsection (1)(a) and (b) (read with subsection (2) where applicable); (b) the particulars mentioned in subsection (1)(c)…

Prevention of Future Deaths

Section 7 of Schedule 5 of the  2009 Act and Regulations 28 and 29 of the Coroner’s  Investigation Regulations 2013 enables a coroner to publish reports. They are published in a public document, which the press has access to. The legislation is as follows:

(1)  Where—

(a)  a senior coroner has been conducting an investigation under this Part into a person’s death,

(b)  anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and

(c)  in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action.

(2)  A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it.

(3)  A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner.


Case Law

The duty of a coroner in relation to making reports was considered in: Gorani, R (On the Application Of) v Sanghera [2022] EWHC 1593 (QB) . At paras 92 to 97 held that the coroner was not obliged to hear submissions on whether a future risk report should be made in the inquest proceedings (at least in the case under consideration). (22 June 2022)

The Steps a Doctor Needs to Take to Minimise the Risk of Future Deaths

There will usually be a number of learning points arising from the death of a patient or a person in a doctor’s care. It is important that a doctor facing inquest proceedings can demonstrate to the coroner that they have made changes to their practice to prevent the risk of repetition of events that they may have been a part of, where there is evidence of their having caused or contributed to the death of a patient, even peripherally.

Many employers will provide relevant training to deal with learning points. But many doctors do not have such support from employers, or they otherwise work independently, so necessitating their taking their own steps of remediation.

A doctor should compile evidence of any further training, assessment, appraisal, or their development of a new policy. The coroner may well ask the doctor about the steps that they have taken to remedy any personal deficiencies, or lack of knowledge of skill.

A doctor should therefore give careful consideration to this aspect of the coronial process.

Published Reports

Read the latest published Prevention of Future Death Reports

Further Articles 

Inquest Law for Doctors

Guidance on Completing Death Certificates

The Office for National Statistics has produced a document called Guidance for doctors completing Medical Certificates of Cause of Death in England and Waleswhich explains what a doctor should and should not include in a death certificate.

Legal Advice and Assistance for Doctors, in relation to Inquests and the Prevention of Future Deaths

If you are a doctor facing inquest proceedings and you would like advice on remediation and submissions relating to a coroner’s duty to inquire into and write reports on the prevention of future deaths arising from a risk that similar circumstances could occur unless appropriate steps of learning have been adopted, call Doctors Defence Service on 0800 10 88 739