From Inquest to Oversight

Facing an inquest can be a naturally anxiety-provoking experience. The prospect of providing testimony and navigating the intricate legal process often gives rise to heightened stress and emotional strain. Employees may grapple with uncertainties and queries surrounding their involvement, the proceedings, and the potential implications on their professional standing. 

One of the most common questions put to legal counsel is, ‘can the coroner refer us to our professional regulator?’, whether it be GMC, NMC or HCPC.

The answer, in short, is yes, they can and they sometimes do where something has arisen in the course of an inquest so concerning, in the mind of the coroner, that it warrants a referral. However, it is important to emphasise that referrals to regulatory bodies are very rare. 

The Rare Occurrence of Regulatory Referrals

The GMC has confirmed that between 1 January 2021 – 31 December 2023 they received only 12 referrals relating to 13 identifiable doctors where the referring body was a coroner’s office (4 in 2021, 6 in 2022 and 2 in 2023). This is an incredibly small number. The most recent coroner’s statistics show that, in 2022, there were 35,600 inquest conclusions recorded.  

Strategies for Professional Accountability: Navigating Inquests and Regulatory Processes

Approaching an inquest with professionalism and accountability is paramount for individuals involved. When testifying as a witness, honesty and transparency are key. If a mistake has been made, openly acknowledging and taking responsibility for it demonstrates integrity and a commitment to learning from the experience. Reflecting on the mistake and expressing a sincere intent to prevent similar occurrences in the future can contribute positively to the proceedings. A witness who displays accountability is less likely to raise concerns prompting a referral to their regulatory body.

Moreover, proactive measures can be taken to reduce the likelihood of a referral. This includes thorough preparation for the inquest, ensuring a comprehensive understanding of the events in question. Clear, concise, and factual communication during testimony is crucial. Collaborating with legal counsel and providing evidence that illustrates a commitment to ongoing professional development and adherence to industry standards can also enhance one’s credibility. Ultimately, a cooperative and respectful demeanour throughout the inquest fosters a constructive atmosphere, potentially minimizing the need for regulatory referrals as the coroner perceives a genuine commitment to accountability and improvement.

Following an incident, organisations typically conduct internal investigations to assess the care provided and identify any potential issues. It is crucial for individuals involved to actively engage with this investigative process, carefully considering its findings in advance of any impending inquest. This proactive approach allows relevant parties to be aware of potential care issues that may impact them during the inquiry. Armed with this information, individuals can seek guidance from legal counsel and consult with senior colleagues to assess the gravity of the situation. Additionally, individuals may be advised on whether a self-referral to their regulatory body before the inquest is necessary, demonstrating a commitment to transparency and accountability. By taking these pre-emptive steps, individuals position themselves to address concerns effectively, potentially minimising the likelihood of regulatory referrals and fostering a culture of continuous improvement within the organisation.

In conclusion, while being referred to a regulatory body may understandably evoke some anxiety, it is essential to recognise that such a referral does not automatically translate into imminent disciplinary action. An inquest and a regulatory body serve distinct purposes, with the former primarily focused on establishing the facts surrounding an incident, and the latter concentrating on professional conduct and standards. Individuals should approach regulatory referrals as opportunities for thorough examination and fair assessment rather than as immediate causes for undue concern. Engaging with the regulatory process transparently, seeking legal counsel, and actively participating in the proceedings can contribute to a more comprehensive understanding of the situation. Ultimately, regulatory bodies aim to ensure accountability and maintain the integrity of professional standards, and individuals can navigate these processes effectively with appropriate support and a commitment to professional growth.

This article was authored by Holly Streeter.