Inquests: information for midwives and birth workers
Attending an inquest is one of the most difficult experiences for a midwife or birth worker. It means re-living distressing and sad memories, it creates high levels of anxiety, and it brings bereaved families and the health professionals who cared for them together in one room. Everyone involved is emotional and worried as to how things will go and what they will say when asked.
However, coroners are very skilled at managing the charged atmosphere in their courts and helping everyone to stay as calm and as objective as possible. They understand the difficulties and issues and deal with them daily. Coroners’ courts are generally quiet, calm, albeit sad places.
People will cry. Families will look at those who gave them care. Difficult questions will be asked. However it is also a chance to set the record straight, to describe what truly happened and to provide answers. It can also be a cathartic experience for all involved.
Midwives Haven has a number of midwives available who have appeared at an inquest and who will talk to you by phone if you would find that helpful.
What follows is written by midwives to help other midwives and birth workers prepare for an Inquest. Suggestions to improve the page are welcome and can be sent to email@example.com
You should have support from your colleagues, your Trust, and your union, but sometimes this is inadequate or absent for some reason. Please contact Midwives Haven if you wish (firstname.lastname@example.org) as we can provide a contact for ongoing support.
If you are employed, your employer should provide you with representation at an inquest. You should also liaise closely and seek advice from your union. If you are not being supported by your employer, or if you are unsure whether you are a witness, it is extremely important that you contact your union as soon as possible.
There is also a national charity whose focus is the support of anyone appearing at or attending an inquest, The Coroner’s Support Service (https://coronerscourtssupportservice.org.uk/).
“The Coroners’ Courts Support Service (CCSS) is an independent voluntary organisation whose trained volunteers offer emotional support and practical help to bereaved families, witnesses and others attending an Inquest at a Coroner’s Court…… The vision of the CCSS is to have volunteers available at every Court in England and Wales. It is our hope that no one should attend an Inquest without the practical and emotional support our volunteers can provide…… When you arrive at court our volunteers will be there to greet you. They will explain what is going to happen, show you the building and the facilities. They will answer any questions where appropriate.”
The CSS Helpline is 0300 111 2141.
CWhat is an Inquest?
Coroners inquire into violent and unnatural deaths, sudden deaths of unknown cause, and deaths that have occurred in prison as well as certain other categories specified in the Coroners Act 1988. The coroner’s inquiries may result in the holding of an inquest.
An inquest is a fact-finding inquiry to establish:
• who has died, and
• how, when and where the death occurred.
The role of all witnesses at an inquest is to assist the coroner in finding out what happened.
As a witness, you will not always be called to give oral evidence – sometimes a statement will suffice. If you are asked to provide a statement, the RCN and RCM both have guidance on statement-writing on their websites.
The coroner can send a summons to request your attendance as a witness at the inquest. If you receive a summons, you must act on any instructions provided as soon as possible. If you are unable to attend the inquest on the date and time stated, you should contact the Coroner’s Office immediately. Failure to attend a coroner’s inquest if summonsed could result in you facing criminal charges.
We have heard some midwives say they believe they do not need to respond to coroners once they have left the profession or retired etc. This is not the case as it is not a professional obligation but a legal obligation to respond to a coroner and engage with the inquest process.
There are often Pre-Inquest Meetings or reviews which the Trust lawyers may attend or you may be asked to attend too. This is for the Coroner to get a “helicopter” view of the issues, determine which witnesses will be required to attend, what statements and other papers are needed, and what order the Inquest will follow. This meeting or meetings may be several months before the actual inquest.
DInformation and Resources
NHS Resolution (https://resolution.nhs.uk/)
The NHS Resolution website has a number of useful resources, firstly a downloadable leaflet for health professionals attending an inquest (Inquests: A guide for health providers Supporting staff to prepare for an inquest):
and secondly 3 films:
1. Conversation with a Coroner – https://resolution.nhs.uk/resources/a-conversation-with-a-coroner/
2. How to prepare for an inquest – https://resolution.nhs.uk/resources/how-to-prepare-for-an-inquest/
3. Giving evidence at an inquest – a well prepared witness – https://resolution.nhs.uk/resources/giving-evidence-at-inquest-a-well-prepared-witness/
EThe Coroner’s Court: Some Practicalities
A coroners court is a law court and is set out like other courts with a raised bench for the coroner to sit. Coroners do not wear robes and wigs. There is a witness stand where those summoned (including the family) give evidence. The family sit in the front row and the witnesses and observers sit further back in a designated area. In some courts there may be space allocated for a jury (if one is required). although a jury is not required in the majority of inquests.
What to wear?
Wear something formal but comfortable, particularly on the day you are giving evidence. Jewellery and any makeup should align with a professional dress-code. You only want people to listen to you, not to get distracted by what you are wearing. If you have colourful hair, consider toning it down. You need the Coroner to take you seriously so do not give any suggestion of casualness or disrespect.
The Trust may have appointed a support person for you but you are able to take your own support person (or more). This can be a friend, relative, colleague, union rep, PMA or anyone else you are comfortable with. However some courtrooms are very small so space may be limited
How long will an inquest last?
This can vary but usually the summons indicates the exact number of days the inquest is listed for; this can be one session (morning or afternoon), or a number of sessions over several days. You are expected to attend the court until you have given evidence and been formally released by the court. Once you are released you may continue to observe the remaining hearing or leave if you prefer. You are able to attend any reaming hearing dates if you wish but you are no longer obligated to attend.
How will I know when I will be called to the stand?
In the days leading up to the hearing the coroner will provide a ‘running order’ of witnesses to be called and they may provide estimates of the timings. These are subject to change.
How long will I need to give evidence for?
Some of the witnesses may give evidence for a longer period than expected whereas others may give evidence for a shorter than expected period. It will depend on how long it takes for the coroner to ask the questions and get the answers they require, and if any new issues are raised during evidence giving.
Sometimes evidence may be un finished at the end of a session. In this case the witness will still be under oath overnight and therefore will not be able to discuss the case with others, particular other witnesses. At this time an uninvolved support person becomes a useful distraction. At the start of the next session the witness will return to the stand to continue giving their evidence.
NHS Resolution has some very useful FAQs, the most relevant are reproduced here with many additions by midwives from their own experiences of inquests:
1. What do I call the coroner?
Sir or Ma’am.
2. Who will ask me questions?
The coroner, interested persons (e.g. family members) or their legal representative and your legal representative, if you have one. If you are employed, this will be your employer’s legal representative who will have been speaking with you and probably meeting with you before the inquest.
3. What do I say if I can’t remember something?
You are not expected to remember every detail. Do not guess or speculate. If the answer is in your statement or records, you can look at the document in order to answer.
There will be a bundle of all the documents on the stand when you give your evidence and you can look at these and will also be directed to them by the Coroner. If you cannot remember the answer to a question, and your statement or the records don’t contain the answer, you must tell the coroner that you cannot remember. There is no penalty if you can’t remember.
If there are documents you want to refer to or quote from but which may not be in the provided bundle, then make sure you have a copy of these with you and make them available to the Coroner if requested.
4. What do I say if it might upset a colleague?
If you are asked a question when giving evidence and you know the answer, then however embarrassing for a colleague, your answer must be fully honest. Do not filter your evidence. But you should not speculate, and do not second guess what might have been in your colleague’s mind. You are there as a factual witness, to say the things you saw, did, said or heard.
If people subsequently resent the fact that you have been truthful, then they have misunderstood the purpose of an Inquest.
5. Should I offer an opinion?
You may be asked to express a professional opinion. Sometimes the coroner needs to know whether an event is likely to have contributed to the death occurring at the time that it did. If you have, or are asked to offer, an opinion, and it is within your expertise/speciality to do so, then you can do so. If you do not know enough about the situation to give a professional opinion, you should say that.
6. What if my memory differs from the records or the evidence from someone else?
People often remember a situation differently, sometimes because it was a long time ago, or because it was a common event in a busy shift. In advance, do consider all of the written records and accounts from other people, to assess whether you might be remembering it incorrectly. Be ready to explain your recollection. You might be asked whether the records made at the time are more reliable than your memory or a statement written later. But if you are confident in your recollection, then say so.
7. Is it ok if I speak to the family? Should I speak to the family before or after the inquest?
Each situation and relationship is different. You can speak to the family before or after an inquest, if they want to speak to you. You can offer condolences or say sorry (saying sorry is not an admission of legal liability). If staff from the trust can express sympathy, then usually this is appreciated by families. But there is no obligation to do so on the day of the inquest, which can be a very stressful time for families and they may not feel like speaking to one or all of the staff. Trusts should not wait until the day of the inquest to express sympathy or offer apologies.
8. What is the coroner likely to be most concerned about?
The coroner is looking for evidence to establish who died, where and when they died, and how they came by their death, and will write down what you say. Your evidence is given ‘on oath’ or after an affirmation (promise to tell the truth). The coroner needs the evidence to be fully honest and accurate. Inconsistency between your evidence in court, your written statement or the records, is likely to be explored. This is why we recommend that you refresh your memory with the document, before going into the witness box to give your evidence. You should have the records and statement available in front of you in the witness box and you can refer to these when you want or need.
9. What if I accept that my record keeping at the time of the care was inaccurate or incomplete?
If your entry in the medical records is incomplete or inaccurate, be ready to explain why and apologise if appropriate.
10. Do I need to refer to relevant policies or guidelines and what if I have not followed guidelines?
If guidance or a policy was not followed, you are likely to be asked why this was and you should be ready to explain why.
11. What if there was inaccurate communication between staff?
Many inquests identify inaccurate communication between healthcare professionals (within or outside your organisation) and with the patient or family. The coroner is likely to explore these: be ready to explain any gaps in communication and lessons learnt (including any improvements made in how professionals communicate with each other to reduce errors occurring).
12. I am junior, is the extent of my training relevant?
Be ready to explain any relevant training you have had. If you feel you had not had training to deal with the situation, inform your line manager. If you are in a management position, be ready to explain what training was given, and whether this has changed or improved.
The Coroner may question you about this and the professional regulator (I.e. the NMC) may be approached to clarify what training is required as a pre-requisite for registration.
Be prepared to explain any barriers to education and training that may have been operating e.g. staffing shortages, cancellations, IT issues, sickness, lack of effective PDR processes etc..
13. Might there be personal or professional repercussions for me?
Information given to a court must be fully honest and accurate. There are criminal offences for intentionally withholding relevant information, or giving dishonest or misleading evidence to a coroner. Healthcare staff must also follow their professional regulatory requirements. Ask for advice from your legal department.
14. I am concerned that my actions were below my usual high standards.
The coroner will investigate and record what happened, and also what should have happened by reference to the standard expected of a reasonable clinician, or guidance and policy. You should also consider your professional regulatory requirements. Ask for advice from your legal department.
Any training and skills deficit should be addressed as soon as possible after the incident and this will help the Coroner (and the family) to see how issues have already been identified and actioned. Your PMA and manager should help you with this. However, if you do not have the help that you think you need, then do consider how you can meet your training needs yourself. ARM may be able to help as many members have skills and be willing to share those skills with you and help build your portfolio before the inquest. Please email email@example.com if you are seeking help with developing skill and knowledge around a specific area.
15. Is what is said in court recorded?
Yes, every hearing is audio recorded and, as it is a public court room, anyone can apply for a copy of the audio record.
16. What happens at the end of an inquest?
After the evidence, the coroner will ask the interested persons whether they have any submissions about the law and the possible conclusions. The coroner will consider all of the evidence, and ‘sum up’ (briefly describe) the significant parts which are relevant for their decision, before stating their ‘findings’.
The coroner will state their findings (decisions) on each issue which is required to be recorded by the law which includes who died, where and when they died, and how they came by their death (in addition to identification details and the medical cause of death). In some cases, the coroner may state that the person died on X date at Y location as a result of natural causes. Or they might include one of the following ‘short form’ conclusions
• Accident or misadventure
• Alcohol/drug related
• Industrial disease
• Lawful/unlawful killing
• Natural causes
• Road traffic collision
The short-form conclusions provide useful national data and statistics.
A coroner can also include a narrative conclusion; this describes events which are relevant to how the person died. A narrative verdict is where an actual cause of death cannot be determined but the Coroner will list some likely contributory factors for example, neglect, miscommunication, inadequate training, poor working culture and so on. There may be “a preventing future death order” (see 18 below). Or the Coroner may conclude with an “article 2 verdict” which is one of Negligence. Whilst a family may press for this, it is entirely the Corner’s decision.
Ask your legal department what the likely outcome is going to be and the implications.
Remember – whatever the outcome may be, remember your part is simply to tell the truth and make sure all relevant facts known to you are put before the Coroner.
17. If the family are not happy with the care we provided, will there be a claim for damages for clinical negligence following the inquest?
A family can make a claim of clinical negligence either before or after the inquest. The inquest is a separate process, and the coroner does not decide whether there has been negligence, although the findings of the coroner might help inform an approach to a claim.
18. What is a report to Prevent Future Deaths (PFD)?
A coroner must send a PFD report (also known as a Regulation 28 report) to the trust chief executive if they have heard evidence of a risk of death occurring in the future and believe there is something the trust can do about it. The PFD report and the trust’s written response is usually public (published on a website) and is copied to the Chief Coroner, the family, and Care Quality Commission (CQC). PFD reports are intended to reduce the risk of deaths occurring in the future. If a trust has already identified a problem, and ‘fixed’ or improved it, a coroner would not usually send a PFD report to that trust, although a PFD report might be sent to a national body to raise awareness of the problem.
19. Press interest.
At a public court hearing, anyone can attend, and journalists can generally print what they hear in court. Photographs are not allowed within the court building. A reporter from local media or television may approach you at the end of the inquest, although this is relatively unusual. Your trust might ask you to refer any media enquiries to your legal representative, or the Trust Communications Team.
There is potential for photographs to be taken in public areas e.g. outside the court without you being aware. There is also potential for these to be lifted from social media or the internet so you may want to ensure your privacy settings on social media platforms are set to prevent this as much as possible.