The realities of inquest disclosure for healthcare organisations

Coroner’s rely on full and timely disclosure to understand how a death occurred and whether any learning is required to prevent future harm. For healthcare organisations especially those operating across multiple sites and systems, meeting these expectations can be demanding.

The legal duty is clear, but the practical reality is shaped by organisation size, and the different systems in which information is stored and governed. This article explores why coroners require extensive disclosure, what the law expects and how large organisations can navigate these responsibilities with openness and care.

Why coroners require wide disclosure?

The Coronial process is inquisitorial. Its purpose is to establish the facts surrounding a death, not to apportion blame. To do this fairly, coroners must see the full picture: clinical records, incident reports, internal review(s), correspondence and any other information that may shed light on what happened. Without comprehensive disclosure, coroners cannot make reliable, evidenced based, findings, families cannot have confidence in the process and opportunities for any learning may be missed. Disclosure is not simply a legal formality, it is central to the Coronial process.

Legal expectations

The duty of disclosure is set out in the Coroners and Justice Act 2009 and the Coroners (Inquests) Rules 2013. Organisations must provide all relevant material promptly, transparently and in a form that supports the coroner’s investigation. The obligation continues throughout the process, for example, if new information emerges, it must be shared promptly. Coroner’s can also issue formal notices or directions where deadlines are missed or where information appears incomplete. The legal framework is designed to ensure that coroners can carry out their role effectively and that families receive a full and honest account of events.

Public and judicial scrutiny

Recent media reporting, including allegations that an organisation misled an inquest, shows how quickly disclosure concerns can attract public attention. In these circumstances, the distinction between deliberate withholding and organisational complexity is often lost. What remains visible is the impact this has on families, the frustration for coroners in further delays and the subsequent public confidence in the process. These cases highlight the importance of clarity, consistency and openness, particularly when the circumstances of a death are already sensitive.

Operational challenges for large organisations

Large healthcare organisations face particular challenges in meeting disclosure obligations. Information is often held across multiple digital systems, archives and governance structures. As a result, clinical records may sit in one platform, incident reports in another, and internal reviews, audits and email correspondence across separate repositories. Retrieving and reviewing this material requires careful coordination across teams and can involve thousands of pages.

This complexity increases the risk of both under and over disclosure. Missing key documents can undermine the coroner’s confidence, while providing unfocused or excessive material can obscure what is important and delay the process.

Impact of delays or gaps

Delays or omissions in disclosure can affect everyone involved. Families may experience additional distress to what is an already stressful process. Coroners can face disruption to case management and may need to issue directions or express concern publicly. For organisations, perceived opacity can damage relationships with regulators. Importantly, coroners assess compliance with legal duties rather than the operational pressures that may sit behind delays.

Approaching disclosure as a governance discipline

Meeting disclosure obligations in a large organisation requires structure, clarity and early planning. Best practice includes:

• Early legal oversight to frame relevance and ensure proportionality

• A designated disclosure lead to coordinate searches and maintain consistency

• Centralised document control to reduce duplication and prevent omissions

• Documented search and audit processes

• Proactive communication with the coroner and their office when challenges arise

A transparent and collaborative approach supports both the organisation and the coroner.

Conclusion

Wide disclosure obligations exist to support a fair, transparent and thorough coronial process. For large healthcare organisations, the challenge is rarely a lack of understanding of the duty itself but rather the practical complexity of applying it across diverse systems, teams and information sources. A structured and well‑governed approach helps ensure that coroners receive the material they need, families feel respected, and organisational learning is strengthened. By treating disclosure as a core governance responsibility rather than a reactive administrative task, organisations can meet their legal obligations while contributing meaningfully to patient safety and maintaining public confidence.

This article was co-authored by Simon Davidtz, Registered Foreign Lawyer at Hill Dickinson.