This chapter will briefly describe the outcomes of a coroner’s inquest: the findings available to the coroner, and the types of concerns that they can express. It will also explain Regulation 28 (Prevention of Future Death) reports.

Many nurses will be asked to give evidence at a coroner’s inquest during their nursing career. Being asked to give evidence can feel incredibly daunting and generate complex feelings. It’s important to remember that the coroner is looking for your help with the inquiry. The coroner can also seek an expert opinion by a nursing professional on the care of the person who has died. This chapter provides advice on how best to fulfil your duty.

People reasonably expect their healthcare professionals to avoid causing harm. In the UK, there are various clinical and governance checks and balances to ensure that the individual is safe and treated with appropriate evidence-based care, and safeguards by the state to explore and investigate when these appear to have been breached. These include internal organisational disciplinary proceedings, public complaints processes, ombudsman investigations, civil claims for compensation, and criminal prosecutions, among others. In England and Wales, the coroner’s inquest is one such check and balance.

The Patient Safety Incident Response Framework is a new NHS-mandated approach to incident reporting. This chapter provides a brief overview with the aim of allowing readers to have an initial baseline knowledge of a framework with which they will have to work in the coming years.

The coroner decides which witnesses to call and their designation. This chapter gives practical advice for the professional who is called as a witness of fact.

An inquest is an inquisitorial process, and this has an impact on the roles of the advocates and the jury, if there is one. This chapter explains their roles, and also when a professional may require separate legal representation, with some further tips on giving evidence from the perspective of an advocate.

The role of the coroner is to investigate violent, unnatural or unexplained deaths, as set out in the Coroners and Justice Act of 2009. The coroner is a creature of statute; the oldest judicial office confirmed in 1194, but in existence before that time, to assist the Crown with the valuable and inevitable business of death. This chapter outlines the duties and responsibilities of a coroner.

The death of a patient by suicide (or homicide) can have a considerable, and lasting, emotional impact on mental health professionals, most commonly manifested as guilt, blame, shock, anger, sadness, anxiety and grief. There are often notable impacts on professional practice, including self-doubt and being more cautious and defensive in the management of risk. This chapter explores suicide and unlawful killing in the context of inquests.

The purpose of a pre-inquest review hearing is explored in this chapter.

Medical practitioners have a statutory duty to notify the coroner, where the doctor suspects a ‘notifiable cause’ of death and where one considers a death ‘suspicious’, the police must also be informed immediately. This chapter explores the duties of the medical examiner and the duty of the coroner to investigate.

Coroners have a wide discretion in the calling of witnesses, including expert witnesses. This chapter looks briefly at the role of experts in the coroner’s court, admissibility of expert evidence and some factors that experts consider when writing a report.

This chapter gives an understanding of the court setting and proceedings, and practical tips on to prepare for the day and give evidence effectively.