An inquest can be an acutely stressful environment. This case emphasises the importance of organisations and individuals engaging properly with the inquest process.

On 4 May 2016 Sophie Bennett, a 19 year old mentally ill young woman, hanged herself at Lancaster Lodge care facility, a specialist care home for people with mental ill health. Duncan Lawrence oversaw her treatment in her final months but was no longer working at the care home at the time of her death. In January 2019, an inquest into Sophie’s death was held. Despite receiving a summons to attend the inquest, Duncan Lawrence failed to attend the original inquest and a number of subsequent hearings. In May 2019, this failure to attend the inquest or to provide video link evidence prompted the assistant coroner John Taylor to fine him £650 in accordance with schedule 6 paragraph 6 of the Coroners and Justice Act 2009. The assistant coroner also referred the matter to the police and the Crown Prosecution Service.

Duncan Lawrence was subsequently charged with intentionally withholding evidence from an inquest contrary to schedule 6 of the Coroners and Justice Act 2009 and on 30th October was jailed for four months.

District Judge Andrew Sweet said "There is a good reason why people should attend or provide documents to a coroner when carrying out such an inquest, and that is expected to be done with full co-operation and without delay…. You frustrated that process."

The family of Sophie Bennett said “We welcome the sentence passed today. However, we take no comfort from it because it still does not give us what he owes us: an honest account and the withheld evidence of what happened to our beautiful and much-loved daughter.”

Practical advice for health and social care professionals attending an inquest as a witness

Role of a witness

  • The role of a witness in an inquest is to assist the coroner in the conduct of his investigation. Witnesses will be asked to produce a witness statement. If the coroner requires further information from the author of the statement, they may require that witness to attend the inquest in person to give oral evidence.

Before the inquest

  • Consider whether it would be helpful to go to see the court on a day before the inquest starts.

Your statement

  • Know your statement and any other relevant documents. Make sure you are familiar with the medical records so that you can easily find your notes and key documents e.g. observations chart, fluid balance chart, prescription chart, risk assessments.
  • Although a copy of your statement will be provided when you are giving your evidence, take a copy of your statement with you in case you want to check anything before you are called to give evidence.

On the day

  • Arrive in good time.
  • Ensure you have the contact telephone number of your legal representative (if represented) or the coroner's court just in case you get lost or are running late for any legitimate reason.
  • Dress appropriately.
  • Witnesses waiting to give evidence sit in the courtroom and listen to the hearing.

Giving Evidence

  • Witnesses at an inquest must be either sworn in or give an affirmation. It is best to decide beforehand which of these you will choose. In either case the court officer will assist you.
  • Always refer to the coroner as Sir or Ma'am.
  • Think carefully about the question you are being asked and answer that specific question. Ask for the question to be repeated if needed. If the coroner wants further information, they will ask you another question. Keep your answers short and factual which will help you stay focussed on the question and not lose your chain of thought.
  • If you do not know the answer to the question, you must say so. Remember, you have taken the oath or affirmed so you must be careful that the evidence you give is accurate.
  • Be honest and try not to be defensive. You are there in your professional capacity to assist the court ascertain the facts.
  • Show compassion. The family of the deceased may have been waiting a long time to ask their questions, and they may not be used to asking questions in court. Some questions may not be appropriate however and may fall outside the scope of the inquest, but the coroner will indicate if it is a question you should not answer.

After giving your evidence, you may or may not be formally dismissed. If you are formally dismissed you may leave the court and do not have to return. If you are not formally dismissed this will be because the coroner feels that you may be able to help with clarifying further points after other evidence has been heard.

How can we help?

Our Bevan Brittan inquest team is able to offer levels of support tailored to the level of complexity. We have vast experience in representing a range of organisations for inquests, including the NHS, local authorities, independent health and social care providers, fire authorities, housing providers, prisons, regulators, schools and individual professionals.

  • Screening – It can sometimes be difficult to know whether legal representation is necessary. Therefore we provide a screening service for inquests where we review preliminary papers, check reports and statements for onward submission to the coroner and provide preliminary advice. This is also an opportunity for us to transfer skills to your staff in categorising difficult inquests.
  • Witness support – We can support witnesses through the process to ensure that they are properly prepared and to enable them to deliver their evidence confidently and competently.
  • Advocacy – Where legal representation is required an experienced advocate will be provided.
  • Related issues – We can deal with other issues which may be linked to inquests such as the police or multi-agency investigations and we can help you manage an internal inquiry or incident investigation.
  • Inquests can be a very daunting process and we provide inquest training to staff.

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