The cost of delay: how late disclosure derails inquests

Clinical vs coronial commitments

Balancing clinical commitments with the duty to comply with coronial directions can be challenging, but it is an essential part of professional responsibility. Clinicians often work under intense pressure with limited time, yet coronial deadlines exist to ensure that inquests progress fairly and efficiently. The key is recognising that coronial work is not an “extra” task, but a statutory obligation linked to patient safety, learning, and public accountability.

When clinicians flag difficulties early, organisations can provide support or adjust workloads so that statements are completed to a high standard without compromising patient care. Achieving this balance protects both the integrity of the inquest and the wellbeing of clinical staff, while ensuring that the evidence provided is accurate, considered, and useful to the coroner’s investigation.

The consequences unfold

Late disclosure doesn’t just slow things down, it can change the entire direction of an inquest. When important documents or information appear at the last minute, everyone involved is forced to react rather than prepare.

For the family, late disclosure can feel like a shock. They come to the inquest expecting answers, only to find out that new evidence has suddenly surfaced. This can make them feel as though things have been hidden from them or that the process is not being handled openly. It also makes it more difficult for them to understand the evidence or obtain sufficient advice in time. This can damage their trust in the process and make it harder for them to take part in a meaningful way.

For legal representatives and other interested persons, late disclosure disrupts preparation. Questions may need to be reconsidered and client instructions may need to be sought urgently. Such imbalance can weaken the ability to properly test the evidence.

For the coroner, late disclosure can derail the timetable. If the material is missing, the coroner may have no choice but to adjourn the hearing. This causes delay, increases costs, and prolongs the distress for the family. It can also affect witness availability and the quality of their recollection.

Interested Persons (IPs)

A significant risk arising from late disclosure is that it can unexpectedly change the status of a witness. Fresh material may reveal that a witness was more deeply involved in the circumstances surrounding the death than had previously been appreciated.

For example:

• It may show that the witness made key decisions or had responsibilities that were not known earlier.

• The new evidence might suggest that their actions or omissions need to be examined more closely.

• The material may raise questions about their conduct

When this happens, the coroner may decide that the witness should be afforded IP status.

Becoming an IP may mean that:

• They need legal representation.

• They gain rights to disclosure, to ask questions, and to make submissions.

• Their own conduct may come under scrutiny.

• The scope of the inquest may need to be widened to reflect their involvement.

This shift can cause further delay because the newly‑designated IP must be given time to prepare, review the evidence, and take advice.

Conclusion

Late disclosure can place both clinicians and the wider organisation in a difficult position, but there are practical steps that can help minimise risk and maintain confidence in the inquest process. Individuals should seek early support from their governance or legal teams as soon as they become aware of any outstanding records, missing statements, or potential delays. If disclosure is likely to be late, raising this proactively with the organisation, and providing a clear explanation of the reason, allows appropriate steps to be taken with the coroner and helps avoid any suggestion of obfuscation or non cooperation.

Ensuring that personal records are kept up to date, responding promptly to internal requests for information, and asking for advice where needed can also significantly reduce the risk of late or incomplete disclosure.

Clear communication and early escalation are key. Coroners recognise that delays are sometimes unavoidable, particularly in complex cases or when clinicians were not aware of relevant material until later in the process. What they expect, and what ultimately protects both the clinician and the organisation, is transparency, prompt action, and a willingness to engage constructively.

This article as co-authored by Paralegal, Lucy Parker