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Coroner’s inquest – Disclosing report to family of deceased


Dr X worked as an A & E Registrar. In 2020, a patient with a complex previous medical history came into A&E with severe abdominal pain and vomiting. An examination was performed on the patient and it was thought that the patient had gastritis, so Dr X prescribed Ondansetron and fluids for symptomatic relief to the patient and also to hydrate the patient. Dr X also ordered an abdomen and chest X-ray. On reviewing the X-rays with the A&E Consultant, there was no sign of obstruction or perforation, and so it was decided that the patient would be discharged following observation. Dr X was not aware of any concerns or escalation regarding the patient whilst under observation, and the patient was discharged. Unfortunately, the patient passed away in the early hours of the next morning and a post-mortem report found small bowel perforation. As such, the doctor was requested to make a statement to the Coroner and was subsequently summoned to attend the Coroner’s inquest into the death of the patient.

Dr X received the Coroner’s report which was critical of the Trust and some aspect of Dr X’s care. They discussed this with their revalidation officer who advised them to immediate self-refer to the GMC in line with Good medical practice. Dr X self-referred and and the GMC decided to open a provisional enquiry into the matter to gather more information in order to determine whether further investigation was required. However, a decision-maker at the GMC, known as an Assistant Registrar, determined that the concerns did not raise any questions regarding Dr X’s fitness to practise, and so no further action was taken on the matter

The matter was then re-opened by the GMC in early 2022, as the family contacted the GMC to ascertain further information regarding the Assistant Registrar’s decision. The information was disclosed to the family with no objection and no further action was taken.


MDS assisted Dr X in drafting their statement for the Coroner’s inquest, and then also assisted with Dr X with their self-referral to the GMC by providing advice and helping Dr X to draft the self-referral and collate the correct supporting documents.

When the matter was reopened by the GMC, MDS advised Dr X not to object to the disclosure of the Assistant Registrar’s decision to the deceased patient’s family on the basis that it was likely that the GMC would find it in the public interest to do so anyway and any objection had the potential to prolong their suffering.

No further action was taken by the GMC in their provisional enquiry, however the GMC were grateful for Dr X’s honesty in providing them with this information following the Coroner’s inquest and explaining the steps that had been taken to follow the standards in Good medical practice. Likewise, no further action was taken following disclosure of the Assistant Registrar’s decision to the deceased patient’s family.


  • Self-referral may be necessary for doctors as part of Good medical practice where a Coroner’s report has been critical towards their care of a patient.
  • The family of the deceased can check whether a doctor has self-referred to the GMC and may request further details from the GMC regarding a case outcome in which case we would normally advise members to cooperate with these requests, although this would need to be considered on a case-by-case basis.