Background
Dr E is a GP at The Heath Centre (“the Practice”), a GP practice responsible for providing primary medical care to patients in a commuter town outside of London.
The deceased, Mr Y, was an elderly patient who suffered a number of physical conditions including hypertension, type 2 diabetes mellitus, chronic liver disease, and bilateral hydronephrosis, as well as dementia. As such, Mr Y was a vulnerable adult who was dependent for all aspects of his care on carers who attended his home three times per day. Mr Y’s medical conditions were managed by his GPs at the Practice, including Dr E. A number of other agencies were also involved in Mr Y’s care, including the district nursing team, which does not fall under the remit of the Practice.
Several days prior to his death on 22 March 2025, Mr Y developed bronchopneumonia, which led to acute pericarditis, and a kidney infection. He did not display any obvious signs of being unwell and his illness was not detected or treated. On 28 March 2025, Mr Y suffered a cardiac arrest and died at home.
An Inquest into Mr Y’s death was listed to take place on 30 November 2025 at the Commuter Town Coroner’s Court. At the Coroner’s request, Dr E prepared a witness statement and sent this to the Coroner before notifying the Medical Defense Society of the Inquest proceedings.
Prior to the Inquest hearing, Dr E was contacted by the Coroner’s Officer and asked to attend the Inquest hearing to give evidence in person, and to provide a further statement dealing with the following issues:
1. Across 2024 and 2025, the Practice was invited to four Multi-Disciplinary Team (“MDT”) meetings regarding Mr Y, but did not attend. Dr E’s statement does not address these meetings. Nor does it address whether the Practice’s non-attendance was because of an oversight or some other reason. Why was it that the Practice did not attend the MDT meetings? What system is in place to ensure MDT meetings are attended? Is there monitoring of attendance and, if so, what form does this take?
2. Dr E’s statement does not address what, if any, care was provided to Mr Y in the period prior to 27 March 2025. Please could Dr E set this out in detail.
3. Please can Dr E provide details of whether any reviews of Mr Y’s hypertension were carried out and, if so, when? Does the Practice have any systems in place for reviewing and monitoring vulnerable patients with hypertension? If so, what are they?
Unsure why he had been asked additional questions by the Coroner, and concerned about giving evidence at the Inquest hearing, Dr E contacted the Medical Defense Society for assistance with his response to the Coroner’s three questions.
Assisting Dr E
As soon as we were instructed to assist Dr E, we contacted him straight away and arranged a face to face meeting to suit his availability. We also obtained a copy of all of the relevant documents, including the patient records, and reviewed these in detail to ensure we fully understood all aspects of the case.
When we met with Dr E, we put his mind at ease and explained to him that the purpose of any Inquest was inquisitorial rather than adversarial, and a Coroner may not determine any question of civil or criminal liability. The role of the Coroner is to determine who the deceased was, where they died, when they died and how they came by their death. We also observed that, in this case, the Coroner had likely asked the questions because the statement that Dr E had provided was not sufficiently detailed and key areas of the care provided to Mr Y still needed to be addressed.
Dr E told us that all appropriate systems and processes were already in place at the Practice, and that he had simply rushed his statement and had not realised that this information would be needed. Dr E also confirmed that the reason the MDT meetings had been missed was due to an administrative error, whereby a new member of reception staff had accepted the meeting invitations, but had not shared them with the Senior Leadership Team. A new administrative process had been introduced to ensure this sort of error could not recur.
We assisted Dr E with a detailed supplemental statement to the Coroner, setting out his responses to the Coroner’s questions, supported by evidence confirming the full extent of the care provided to Mr Y. The statement also made it clear that all appropriate systems for reviewing, monitoring and managing vulnerable patients were already in place, and all mandatory training for all staff had been completed and was regularly reviewed. The statement also provided an explanation regarding the missed MDT meetings, backed up with
evidence of the new system that had been introduced.
Outcome
Dr E received confirmation from the Coroner’s Officer that following provision of the supplemental statement, Dr E was no longer required to attend the Inquest to give evidence in person and instead, his statement would be read into the record. The Inquest later
concluded with no criticism of the care provided by Dr E, or any other GPs at the Practice.
Learning points
It is not uncommon for a healthcare professional to be required to prepare a statement for the Coroner at some point during their career. Although this can be a daunting prospect, providing a clear and comprehensive statement to the Coroner is important and should not be overlooked – it is not something to be undertaken lightly or in haste. Preparing a detailed statement is not only the best way to assist the Inquest proceedings, it also increases the chance of you not having to attend an Inquest to give evidence in person.
– Although the Coroner may not determine any question of civil or criminal liability, they can issue a Prevention of Future Deaths Report. Under the Coroners and Justice Act 2009, Coroners are obliged to report about deaths with a view to preventing future deaths. These reports, known as PFDs, are published by the Chief Coroner and become a matter of public record, with obvious reputational consequences for all concerned. PFDs also impose a legal obligation to respond to the Coroner within 56 days providing either (a) details of all action taken, or proposed to be taken, and a timetable for action, or (b) a cogent explanation as to why no action is proposed. If
you are asked to attend an Inquest, please contact the Medical Defense Society as soon as possible, the advice provided is likely to include whether a PFD could be an issue in your case.
– Inquests can sometimes be used as information-gathering exercises by families considering clinical negligence litigation, so it is important to seek advice and support at an early stage.
– Contact the Medical Defense Society as soon as you receive any correspondence from the Coroner regarding an Inquest.
A real life example expertly written up for Medical Defense Society by Anne Marie Rugeris, Partner – Keystone Law, drawing on her extensive medico-legal experience.
