How to Write a Coroner Statement with Confidence (MIC)

Writing a statement for the coroner

Many healthcare professionals will be required to prepare a statement for the Coroner at some point during their career. A high-quality statement is not only invaluable to the Coroner’s investigation, but a well-drafted and comprehensive statement can also help avert the need for your in-person attendance at the Inquest.

The Chief Coroner’s guidance to Coroners on their legislative powers specifically “encourages Coroners to admit written evidence wherever possible, as in other courts, particularly where the evidence is unlikely to be disputed”, and notes that “without in any way jeopardising the process of justice, reading statements can save money and court time, and avoid the inconvenience of witnesses being brought to court unnecessarily”.

A step-by-step guide for healthcare practitioners

1. Before you start writing your statement, ensure you have access to the patient’s full medical records and take time to review them carefully. Drafting a chronology (which you can attach to your witness statement) may be helpful. Do not agree to provide a statement without access to the patient’s records, regardless of any time pressure.
2. Type your statement neatly on your hospital or practice letterhead. Use numbered paragraphs. Carefully check your spelling, grammar and punctuation prior to signing. These are simple things which go towards giving the Coroner and other parties an impression of professionalism and care.
3. Write your statement in the first person (“I….”). Start off your statement by setting out your full name and workplace address, your qualifications, background, experience and professional position. If you were in a different position at the time of your involvement with the patient, make that clear.
4. State why you are making your statement and what you have considered before doing so (e.g. “I am making this statement at the request of HM Coroner who is investigating the death of Mr A. Prior to making this statement, I have reviewed Mr A’s full medical records held by [NHS Trust/private hospital/GP practice] and [e.g. the PSIRF report dated xxxx”]).
5. Explain how you came to be involved with the patient. Were they an NHS or private patient? Specify who referred the patient to you or asked you to undertake a specific task, why they did so and the relevant date.
6. Proceed to set out a detailed, chronological, and scrupulously honest account of your involvement in the patient’s care. Start from the beginning and work right through to the patient’s date of death. In some cases, it may be sufficient to briefly summarise a protracted medical history which pre[1]dates your involvement, for example “Mr B had a long history of paranoid schizophrenia, having been diagnosed in 2005. The records indicate that, between 2005 and 2020, Mr B was treated with Clozapine, an anti-psychotic medication. His condition was stable throughout this period. I first saw Mr B on 10 January 2020, following the retirement of his previous treating consultant, Dr C”.
7. At each stage of your involvement, explain your findings, diagnosis, treatment options, the risks and benefits discussed with the patient and the agreed plan. Give a complete picture by including details of the patient’s comments to you and decisions or wishes in response to your advice.
8. Refer to key entries in the medical records as you tell the story (e.g. “As the records show, I saw Mr D at [name of ward/hospital] on [date/time]. My entry from this consultation notes….”).
9. Make clear what you saw, did or heard yourself versus what you may have learned from third parties or the patient’s records.
10. Stick to the facts. Avoid including speculation or comments on the actions of others. The Coroner will request statements from everyone relevant and others can speak to their own involvement. To assist the Coroner in identifying potentially relevant witnesses, name anyone else who was with you during your involvement with the patient and state their professional status.
11. Appreciate that many people other than healthcare professionals are likely to read your statement (for example, the Coroner him/herself, the family of the deceased patient, insurers, and solicitors). Explain all medical terminology and acronyms in simple terms. For example, if referring to high dysphagia, you could explain “Dysphagia means difficulty swallowing. High dysphagia means experiencing this sensation in the throat through to the top of the breastbone rather than lower down in the gullet”. If referring to shortness of breath, write that term and not ‘SOB’.
12. You may wish to include an expression of sympathy to the patient’s family in your statement. It is your statement, and this is a matter of personal choice. Expressing sympathy does not constitute an admission of liability in relation to any claim that may be brought on behalf of the deceased’s estate.
13. If there is an obvious learning point from the patient’s death, it is a good idea to address this within the statement so that the Coroner is reassured that no ongoing risk exists. Explain what new process or learning has been introduced in response to the issue. In this kind of scenario, it’s particularly important to have input from your insurer and hospital/place of work before submitting your statement to the Coroner.
14. Conclude your statement with a Statement of Truth. This should read “I believe that the facts stated in this statement are true to the best of my knowledge and belief” followed by your signature and the date.
15. Make sure to retain a copy of your signed statement so that you can revisit it to refresh your memory should you ultimately be called to give evidence at any Inquest hearing.

Require assistance?

Being asked to prepare a statement following the death of a patient can feel very daunting. Please do not hesitate to speak to us should you require any assistance.

The information contained in this document does not, and is not intended, to constitute legal advice. As every situation depends on its own facts and circumstances, specific professional advice should be sought and relied upon.

Furthermore, please refer to your policy terms and conditions, and in particular, your obligations to notify to your insurer.