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In the article, Marie Hutton, Clinical Risk Legal Advisor and solicitor, describes what is involved in an inquest and provides advice on how to prepare for one if called as a witness.

What is an inquest?

An inquest is an inquiry into the circumstances surrounding a sudden, unexplained, or violent death heard in public by a coroner, sitting with or without a jury. An inquest, which is a difficult and challenging process for families, is required by law when death is (or may be) due to unnatural causes. The purpose of the inquest is to:

  • establish the facts surrounding the death
  • place those facts on the public record
  • make findings concerning the identification of the deceased, the date and place of death and the cause of death.

Questions of civil or criminal liability cannot be considered or investigated at an inquest. At the completion of an inquest, a verdict will be returned in relation to how death occurred. The range of verdicts open to a coroner or jury include accidental death, misadventure, suicide, open verdict, natural causes and in certain circumstances, unlawful killing. Recommendations designed to prevent a similar death occurring may be made by the coroner or jury.

The State Claims Agency (SCA) provides legal representation at Coroner’s inquests, under the Clinical Indemnity Scheme, to consultants, non-consultant hospital doctors and nurse practitioners employed by the HSE or a HSE-funded health and social care service.

Preparing a statement

If you have been involved in the care of a patient whose death is the subject of an inquest, you may be asked to prepare and provide a statement. The request may come from the Coroner, An Garda Síochána, a solicitor or the person who manages legal matters on behalf of the health and social care service involved.

If you are asked to prepare a statement you should:

  • Obtain a copy of the medical records from the hospital / organisation involved
  • State your name, address, qualifications, experience, and your employment status in the hospital at the time you were involved in the care of the patient
  • Carefully read the records and set out, in chronological order, your involvement in the patient’s care and treatment, referring to your entries in the records where relevant
  • Should you identify any inaccuracies or inconsistencies in the medical records, explain them in your statement - never alter the records
  • Refer to any guidelines or protocols you relied on to treat the patient and explain any deviations from these
  • Sign and date your statement, send it to the relevant person in your organisation, and keep a copy for yourself

Your statement will be forwarded to the assigned Clinical Claims Manager within the SCA, who will review and forward it to the legal firm representing you/your hospital at the inquest. Frequently, the Clinical Claims Manager and nominated solicitor will arrange to meet you in advance of the inquest to go through your statement and answer any questions you may have.

The Coroner reviews all statements and decides who to call to attend the inquest. Frequently, the Coroner will advise that your statement is sufficient, on its own, and your attendance at the inquest may not be necessary.

On the day of the inquest

  • It is usual to meet the hospital’s legal team on the day of the inquest
  • You will be asked to take an oath or state an affirmation
  • It is usual for you to be asked to read your own statement
  • You may be asked questions by the Coroner, members of the hospital’s legal team or the legal team representing the patient’s family
  • Address the Coroner and answer the questions within your own expertise and knowledge
  • If you don’t understand the question or know the answer, say so
  • Stick to the facts and don’t offer opinions

Our Clinical Claims Unit is on hand to assist you or provide you with advice in relation to any matters concerning inquests.

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