Expert Witness Journal Dec 24 - Journal - Page 84
Understanding the
Coroner's Court System
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
EXPERT WITNESS JOURNAL
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
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