Giving evidence in the Coroners Court is a process feared by many health and social care professionals. But it doesn’t have to be. Catherine Brown explains how training and preparation is essential in enhancing a witness’ experience in court.
1. Background
A nurse was recently called to give evidence at the Coventry Coroner’s Court relating to the death of 23-year-old man at a mental health facility back in August 2021.
At the inquest, the jury was told that the patient was left unchecked for three hours on the afternoon of his death. When asked why checks were not carried out on this man, the nurse told the court that she “made a mistake” - not realising that she was responsible for carrying out observations every 15 minutes.
Many health and social care professionals will either have or know of someone who has been asked to give evidence in inquests just like this one and the experience is rarely positive. In fact, it is often built up to be daunting and scary process that professionals hope they never have to undergo.
But it doesn’t have to be this way.
Read on to find out about the role of the Coroner’s Court and how comprehensive training and solid preparation can make a significant difference to the experience of a witness.
2. What is 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 are so important for professionals who might be called to give evidence.
3. Why is the Coroner’s Court such an integral part of the judicial system?
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 organisations are required to respond, outlining the actions they will take to address the concerns raised.
However, this power also serves as 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.
4. What can witnesses do to enhance their experience of giving evidence in the Coroner’s Court?
Maintain good records.
This is one of the most crucial aspects of preparation. 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. On the flip side, I have met witnesses whose deficiencies in their record keeping made the experience quite uncomfortable at the time.
Of course, for many, this responsibility pre-dates any knowledge that a particular case, or record, might undergo scrutiny at the Coroner’s Court. This is therefore an area that all professionals should be aware of and seek to continually develop throughout their career.
Seek mental and emotional 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, but it also means that the organisation often misses out on valuable learning.
Provide good quality evidence
Preparation of good quality evidence can also improve the witness’s experience. A witness’s statement or report forms the basis of their evidence. Therefore, they should be certain that they have included everything relevant and nothing irrelevant before they sign the document.
Witnesses should try to see their role as helping the coroner, who has very valuable work to do, rather than seeking to support their organisation or their colleagues. It is important to be honest and neutral, especially if something has gone wrong.
Learn about the court process
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.
A comprehensive and efficient way to do this is to enrol on Bond Solon’s one-day Coroner’s Court Training course where delegates will explore the role and responsibilities of all parties involved in an inquest, including their own. They will also take part in a mock Coroner’s Court, including gaining the experience of being questioned on a realistic case study.
The next available course date is 2 May 2025. If you would like more information about this course or would like to enquire about booking on the course for yourself or a colleague, please contact info@bondsolon.com or call 020 7549 2549.