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The life and death implications of a coroner’s call to the pharmacy

“The prospect of engaging with court proceedings is daunting”

How pharmacists should handle a coroner’s request for information about a death, revealed by Thorrun Govind and James Down

In our frontline community pharmacy roles, we are very much removed from the court process. However, as Xrayser recently discussed, a call from a coroner’s officer really brings home the pharmacist’s role in the safe and effective supply of medicines.

As pharmacists, our work can have life and death implications. The prospect of engaging with court proceedings is very daunting, no matter how long you have been qualified. Hempsons law firm has supported numerous clinicians through the coronial process.

Coroners are independent judicial officers who employ other officers to assist them. Coroners are appointed by the local authority to establish who the deceased was, as well as how, when and where they died when the cause is unknown or where there is reason to suspect the death may not have been due to natural causes.

If you are contacted to assist the coroner, it is likely that you will be corresponding with the coroner’s officers, rather than the coroner themselves. While the coroner’s role is not to attribute blame, it is important as the responsible pharmacist to let your superintendent pharmacist know that confidential information has been requested so you can follow company procedure, while being mindful that you have a duty to the court. You should also let your indemnity insurance providers or legal team know you have been contacted so that they can guide you through the process.

With pharmacy services to provide alongside the additional pressures of COVID-19, it might be all too easy to place a request from the coroner at the bottom of the pile. The time spent gathering the information will depend on what exactly has been requested. Don’t be tempted to put it off.

While it may feel removed from your usual day role, as healthcare professionals we have a duty of candour. Our engagement with the coronial process is an important part of helping the bereaved seek answers and closure. It is as much a component of our role as counselling patients.

Although during the pandemic, coroners have been sympathetic to the need for frontline healthcare professionals be unhindered by the coronial process, a simple unwillingness to engage is not acceptable. Coroners have a wide discretion to require evidence to be given or produced, including the power to require witnesses to attend court. They can also, in certain situations, impose criminal sanctions – including a fine or imprisonment.

The coronial process begins with information gathering in order to narrow down the issues for the coroner to consider. Data you could be asked to provide might include data from the patient medication record as well as communications with other healthcare professionals and internal policies.

While your notes might not necessarily be in the clearest writing, or even in full sentences, don’t be tempted to amend or make additions, even if you believe they might provide clarification. If you don’t have documentation it is better to be honest and upfront as soon as possible, rather than delaying the coronial process.  

Additionally, you and your colleagues may be asked to provide a written witness statement. This is your opportunity to write a factual report detailing the care you provided, with your recollection of events.

You should put in as much information as you can accurately recall, as the coroner may request further information if your statement lacks detail. If your statement is not in dispute it will likely be read at the inquest, otherwise you may be requested to attend the inquest to provide oral evidence to further explain the contents of your statement. Pharmacists are well-versed in talking to patients, but it is important to prepare for attending the coroner’s court as a witness. Legal support will make the process less daunting and helps to provide you with options should a claim of clinical negligence result.

In December 2019, a coroner’s report raised concerns about instances where pharmacists order repeat prescriptions without the involvement of patients.  This followed the death of a patient who had received supplies of Oramorph, despite never having requested them or having had a consultation regarding the repeat prescriptions. The coroner’s court plays an important part in preventing future deaths.

Thorrun Govind is a pharmacist and trainee solicitor at Hempsons law firm, where James Down is a partner and expert in inquests and coronial law.

For further information contact [email protected] or [email protected]


Ex Pharmacist, Community pharmacist

I don't think this article is very necessary at all. It just goes without saying as to what is required when another professional comes knocking on our window. Get confirmation. Get SI input. Write what is required, send off required details. Job done. Alot of words for no reason Imo

Leon The Apothecary, Student

I think this article further pushes the importance of keeping comprehensive records and notes.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Actually, that's probably the way forward - spend all our time keeping records, leaving none for actual dispensing, therefore no dispensing errors, no dead people and no coroners calls! Winner!

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

And all this for the pittance we get paid! Not worth it chaps.

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