Good preparation is key to giving evidence in the Coroners Court, Catherine Brown explains how to contribute meaningfully to this critical part of the justice system.
The Coroner's Court system in England and Wales is a crucial part of the judicial system that many people don’t understand, indeed many may never have heard of.
But, for some, particularly those who work in health or social care and in custodial settings, rumours about bad experiences in the Coroner’s Court abound. It is then often built up into a ‘scary’ experience that potential witnesses hope never to have to undergo.
Although the process may seem daunting, having some understanding of the system, and preparing adequately, can make a significant difference.
The role of the Coroner’s Court
The primary role of the Coroner's Court is to determine the identity of the deceased, and how, when, and where they died. Coroners, now mostly lawyers by profession, are tasked with investigating deaths that are believed to be violent or unnatural, where the cause of death is unknown or where the death has occurred in custody.
A Coroner’s inquest is a fact-finding investigation. It is important to recognise that it is not a trial. It does not seek to assign blame or determine criminal liability but rather focuses solely on establishing the facts surrounding a death.
However, a criminal trial or a civil claim for damages may follow the inquest, and questions might be put to witnesses from interested persons such as the family of the deceased or another organisation which brings its own challenges.
This is why preparation and understanding is so important for professionals who might be called to give evidence.
Report to Prevent Future Deaths
One of the most impactful powers of a coroner is the ability to issue a Report to Prevent Future Deaths (also known as a Regulation 28 report). After an inquest, if the coroner has identified areas where improvements could be made to prevent future deaths, they can issue this report to relevant organisations or authorities.
These reports are intended to highlight risks or deficiencies uncovered during the investigation and prompt changes in policy, procedures, or practices.
The organisations receiving these reports are required to respond, outlining the actions they will take to address the concerns raised and they would generally prefer to avoid this and the bad publicity that comes with it.
However, this power serves a crucial public function by helping to prevent similar tragedies from occurring in the future. It underscores the broader societal value of the Coroner's Court, seeking to transform individual tragedies into catalysts for systemic improvements.
So, while the Coroner’s Court can be an overwhelming experience, it can be helpful for potential witnesses to reframe it as an invaluable service that plays a critical role in public safety and justice. The findings of an inquest can lead to important recommendations for preventing future deaths, whether through changes in law, healthcare practices, or industrial safety standards.
Remembering that the Coroner’s Court is not just about determining the cause of death but also about preventing future tragedies can help individuals and families see the process in a different light. It can make the experience much less distressing if you can see your part in it as forming a meaningful contribution to society.
The value of good records
Preparation is vital when dealing with the Coroner’s Court, and one of the most crucial aspects of preparation is maintaining good records.
Of course, for many, this responsibility pre-dates any knowledge that a particular case, or record, might undergo scrutiny at the Coroner’s Court so this is an area that all professionals should be aware of and seek to continually develop.
Many witness who have given evidence in a Coroner’s Court will state that having good quality records made the experience much easier for them. I have also met many witnesses who have confided that they learned about deficiencies in their record keeping as part of the inquest process which was ultimately useful but very uncomfortable at the time. You want to fall into the former category of witnesses if at all possible.
The significance of preparation and support
In addition to keeping good records, it is important to prepare mentally and emotionally for the Coroner's Court. It is useful for leaders to offer support to their team members before, during and after an inquest. The after is often forgotten and not only does that leave the team member in limbo, it also means that the organisation often misses out on valuable learning.
Preparation of good quality evidence can also improve the witness’s experience. A witness’s statement or report forms the basis of their evidence and you should be certain that you have included everything relevant and nothing irrelevant before you put your signature to that document.
Try to see your role as helping the coroner, who has very valuable work to do, rather than seeking to support your organisation or your colleagues. It is important to be honest and neutral, especially if something has gone wrong.
It can also be helpful to familiarise oneself with the procedures of the court. Understanding what to expect during an inquest can reduce anxiety and help individuals feel more in control and we cover exactly that on our one day Coroner’s Court course so that you won’t be taken by surprise.
It is useful to know, for example, that most questions will come from the coroner but that representatives of other interested persons, including the family or their representatives can put questions to each witness.
Sometimes lawyers or more senior managers assume that staff know more than is really the case, so don't hesitate to ask questions or seek clarification if needed.
Conclusion
Navigating the Coroner's Court system can be challenging, but with preparation, understanding, and the right perspective, it can also be a process that contributes to public safety.
By maintaining good records, preparing thoroughly, and reframing the experience as an opportunity for learning and prevention, individuals can approach the Coroner’s Court with a sense of purpose.
It is undoubtedly an area where knowledge is power.
Catherine Brown is a trainer at Bond Solon