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The role of the district nurse in a coroner’s inquest

The role of the district nurse in a coroner’s inquest

Due to the nature of their work, the death of a patient will not be an uncommon event for district nurses. In England and Wales, 484,367 deaths were registered in 2011.1 The coroner was informed of 222,371 deaths and inquests were opened on 30,981 deaths.2

Therefore, in the course of their practice, district nurses will undoubtedly be involved in the care of patients whose deaths are required to be reported to the coroner in order for the cause of death to be ascertained. In some cases, they can be summoned as witnesses at a coroner’s inquest to give evidence about the circumstances surrounding the death of a patient.

The coroner’s inquest is probably the most likely court that nurses will be required to attend. It can be a stressful experience and it is important that they are aware of the procedure so that they are able to make significant contributions to an inquest.

Duty of the coroner
The role of the modern day coroner is set out in Section 8 of the Coroners Act 1988, and their duty is to inquire into the cause and circumstances of a death reported to them.

They will seek to establish the identity of the deceased, the circumstances surrounding the death and the cause of death. Coroners are lawyers or qualified medical practitioners, although in future only those who possess a legal qualification will be eligible to be appointed as a coroner.

The newly appointed chief coroner, His Honour Judge Peter Thornton QC, is responsible for overseeing the proper functioning of the coronial system, especially in relation to timely and effective inquest and support for the bereaved (Coroners and Justice Act 2009 Part 1).

Reporting a death to the coroner
Less than half of all deaths registered in England and Wales are reported to the coroner.3 The circumstances where a death must be reported to the coroner for investigation includes where:

- The deceased was not attended by a doctor during the last illness, or the doctor treating the deceased has not seen the person after death or within 14 days before death.

- The death was violent or unnatural.
- The death occurred under suspicious circumstances.
- The cause of death is not known or is uncertain.
 - The death occurs while the person was having an operation or did not recover from an anaesthetic.

- The death occurred at work or was due to industrial disease or poisoning.
- The death occurred while in state detention such as prison, police custody or detention under the Mental Health Act 1983.

When a death is reported, the coroner will try to establish that the death was due to natural causes. Otherwise, a post mortem examination may be ordered, and where the result is inconclusive or the death was unnatural, the coroner has the right to hold an inquest.

Circumstances requiring an inquest
Under certain circumstances, the coroner must hold an inquest into a death such as where there is reasonable cause to suspect that the person has died a violent death, such as murder, or an unnatural death.1 A death would be considered ‘unnatural’ if it was due to a cause other than a common illness. For example, the Court of Appeal held that the death of a woman could be held as unnatural after her blood pressure was left unmonitored after a caesarean section.4 

The coroner must also hold an inquest where there is suspicion of self-neglect or neglect by others. Neglect by others is a gross failure to fulfil one’s responsibilities to provide care for someone who is in a dependent position.5 An inquest must also be held where the death is both sudden and the cause is unknown, or where the person has died in prison or in such place or circumstances that may require an inquest under any other Act.

Coroner’s inquest
A coroner’s inquest is an inquisitorial trial with the purpose of establishing the identity of the deceased and the circumstances surrounding the person’s death. The coroner cannot apportion blame or liability on anyone for the death.

Inquests are held in public except in cases of national security. Generally the coroner sits alone, but they are legally required to sit with a jury in some cases, such as where the death has occurred in prison or where the death was caused by poisoning or certain diseases.3

Interview by a coroner’s officer
A district nurse involved in the care of the deceased whose death requires an inquest can be called as a witness by the coroner. As a prospective witness, they would be interviewed by a coroner’s officer - who is a police officer - and asked to provide a statement relating to their involvement in the care of the deceased. This will be submitted to the coroner who can then make a decision about whether or not to call the district nurse as a witness.

When asked to provide a statement, it is very important that district nurses follow the policies of the Trust or Health Board. During the interview, all questions should be answered truthfully and clearly; it is important to refer to relevant clinical or other records detailing the care the patient received prior to their death. Questions which are unclear should not be answered.

Always focus on the care provided and avoid expressing an opinion on care that was not given. Where the evidence in the statement is unlikely to be controversial, the coroner can dispense with the need for the nurse to attend the inquest.

It is therefore important to provide a well written statement. Each paragraph should be numbered; the whole statement checked thoroughly and each page should only be signed and dated after it is established that it is a true representation of the evidence given at the interview. A copy should be retained for future reference.

Witness at an inquest
A witness will be called through a request or formal summon and will give evidence under oath or affirmation. Generally this is confined to reading the statement prepared at the interview, or a recount of the event leading to the person’s death. Where the circumstances of the death are more contentious, the coroner and other interested persons, such as a family member, are entitled to ask the witness questions to test the reliability of the evidence. Therefore a district nurse acting as a witness must be prepared to face challenging questions.6

Giving evidence at an inquest
When attending an inquest as a witness, district nurses must ensure that they get to the court in good time and dress appropriately. In court, the way in which evidence is given affect the weight of credibility attached to it.6 It is important to take a copy of the statement prepared at interview with the coroner’s officer to court and it should be referred to whenever necessary. This is important where there are doubts about answers to particular questions.

The deceased health records can also be consulted with the permission of the coroner. Always turn to the coroner when answering questions and the coroner should be addressed as Sir or Madam. It is very important to listen carefully, take time to respond, consider an answer carefully and answer questions clearly and truthfully.

Always ask for clarification of questions which are not clear. When you do not know an answer to a question or cannot remember an event, say so. The golden rule is to never make up an answer.

Where technical or medical terminologies are used, these should be explained clearly and concisely. Personal opinion should not be expressed, and a question beyond a district nurse’s scope of practice should not be answered. Since an inquest is inquisitorial, any question must be relevant and sensible and must not be accusatory. Therefore, a witness is not obliged to answer any incriminating questions.7 Where a witness has been asked such a question, the coroner will inform the witness that he or she may refuse to answer.

Record keeping
A record detailing the care the deceased has received is important in the inquest process. The coroner may decide that certain records or documents should be produced to assist them in their inquiries. Properly interested persons, such as a relative, can receive and inspect relevant documents, subject to confidentiality of information.

Records are also important when writing a statement for the coroner and when giving oral evidence at an inquest. Therefore it is important that district nurses, during the course of their practice, keep records which are sufficiently detailed to show that they have discharged their duty of care.

A good record should contain relevant and factual information and should include an evidence-based care plan, regular progress reports and other relevant information. Contemporaneous recording is also important as it adds to the reliability of the information.  

Coroner’s verdict
In most cases, a coroner will return a verdict as to how the deceased came to their death. The verdict does not consider whether a person is guilty or otherwise and cannot attribute civil or criminal liability. The coroner can report to an authority, such as an NHS Trust, an action required to prevent a recurrence of further deaths.8

Due to the nature of their work, district nurses may be called as witnesses to an inquest. Attending court and being questioned can be a distressing experience. It is therefore important that they are aware of the process of an inquest. This will enable them to be better prepared to discharge their role as a witness effectively.

1.    Office of National Statistics. Births and Deaths in England and Wales 2011. 2012. Available at:
2.    Ministry of Justice. Coroners Statistics 2011 - England and Wales. London: TSO; 2012. Available at:
3.    Ministry of Justice. Guide to Coroners and Inquests and Charter for coroner services. London: TSO: 2012. Available at:
4.    R v HM Coroner for inner London ex parte Touche [2001] EWCA Civ 383.
5.    R v Coroner for North Humberside and Scunthorpe ex parte Jamieson [1995] QB1.
6.    Griffith R, Tengnah C. Principles of Good Evidence Giving. British Journal of Community Nursing 2010;15(11).
7.    Coroners Rules 1984 (SI 1984/552).
8.    Coroners (Amendment) Rules 2008 (SI 2008/1652).

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