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How to write an expert's report for a coroner's court - Dr Mark Burgin

27/01/23. Dr Mark Burgin explains how to simplifying the expert’s report can improve performance in a coroner’s court.

The coroner must read many written submissions and build a story of how the death occurred. They are trained to disregard complexity and instead will focus on the key events. This approach is in conflict with the medical and lay understanding. In the coroner’s court whether something caused a death does not include ‘more than minimally contributed’.

There are other differences for instance an act of omission is of lesser importance than an act of commission. The relatives and experts will put equal weight on a failure to provide necessary care and giving the wrong care. The coroner simply cannot consider the omission unless the rules say that the care should have been provided or they are the most basic type.

Causation works differently in a coroner’s court because the coroner starts with the death and works backwards. This means that they do not consider any systematic problems unless Article 2 of the Human Rights Act has been activated. Unless a single person can be identified who made an error then even the grossest delay cannot be challenged.

Why complex is bad

There is a tendency for experts and interested parties to try to explain what happened. This leads to a complex narrative and unnecessary details. The coroner does not like this type of document as it creates a narrative at odds with other reports and the coroner’s own narrative. The ability to simplify is therefore valued by coroners but makes the report writer anxious.

The more anxious the report writer is the more words that they write which increases the risk of a complex thought. To the barristers who attend the coroner’s court on behalf of the interested parties complexity is like the smell of blood to a shark. Cross examination makes the report writer more anxious and increases the risk that they will say something that can be used by one of the other sides.

The relatives will have their own team, each of those mentioned in the reports will have their own team sometimes including experts. The coroner tries to restrict the number of interested parties as the court can become crowded. Experts can assist by identifying a single mistake that was the proximal cause of the death rather than mention every mistake that those involved made.

How to keep things simple

It often said that it takes twice as long to write a simple report than a complex one and there is some truth in this saying. There will usually be many weak points but rarely more than one great point that the decide the case. The report should be written around that best point and reduce any comments to other points to foot notes.

To achieve this the report writer should consider each event and whether it was within the window of opportunity or not. Many events happen before the person became ill and whilst would have prevented the illness are not causative of the death according to the coroner. Equally events that happen close to death would not give the medical team the opportunity to give the treatment before death.

Some events have a bigger impact than others and the report should focus upon the biggest events and relegate smaller events to postscripts. Sometimes there are no events that are a ‘great point’ and the writer should avoid the temptation to switch to another point. If the evidence indicates that there are no ‘great points’ then the report must be negative.


Coroners are not medically trained and do not do their own research on the medical condition so the first step for any expert is to summarise the natural history of the condition. Generalist experts cannot depend upon the specialists to provide this and should copy a brief summary from the internet. This will become the framework that the rest of the report will rely upon.

The next step is to summarise each of the sources of data (witness statements, medical records, tape recordings and other practitioner records). The pattern of assessment and treatment described will indicate a particular diagnosis. These allows easy comparison for instance ‘the medical records indicate gastroenteritis and the audio indicates a seriously ill patient’.

The risk of stating ‘what would have happened’ next is that the expert moves outside of their expertise and makes the report too complex. The best approach is to treat any further examination or investigation as a black box and repeat what the internet summary says. The assumption that further assessment would have been performed correctly is a fiction but it is for the defendants to make that argument.


Coroners depend upon their experts to only deal with the material issues and not to provide a detailed and comprehensive report. For those experts who feel (correctly) that this conflicts with their duties addition of a summary can solve both problems. The temptation to explain should be resisted as the coroner’s role is not to explore this.

The coroner is only interest in who the deceased person was and how, when and where they died. This means that any questions as to why can be ignored, the expert simply does not need to explain why the doctor made a mistake. The coroner may question whether the action was actually a mistake but will not ask why the mistake occurred.

This may to some appear to be a weakness in the coronial system as the why questions are how people learn from their mistakes. The truth is that the coroner simply cannot go down every rabbit hole looking for explanations of why we err. The responsibility for asking why is perhaps for writers and thinkers rather a matter for a coroner to consider.

Model report summary for coroner’s court

Perforated bowel

What are signs of a perforated bowel?

If you have a gastrointestinal or bowel perforation, you may experience:

· Abdominal pain or cramping, which is usually severe.

· Bloating or a swollen abdomen.

· Fever or chills.

· Nausea and vomiting.

· Pain or tenderness when you touch your abdomen.

Assessment at 17.34 on 05/06/2028

GP telephone advice recorded consistent with viral gastroenteritis.

Nursing home recorded consistent with long standing bowel problems with acute worsening and unwell.

Telephone records indicate that the nursing home mentioned previous problems.

What should have happened.

An urgent home visit should have been arranged to assess the patient.

Transfer to hospital as category one (immediately life threatening) or category 2 (serious) is necessary in bowel perforation.

The treatment for gastrointestinal perforation is resuscitation to stabilise the patient’s illness.

Then emergency surgery to repair the holes and antibiotics to treat any infection.


There is an inconsistency between the three sources of information on the 17.34 assessment.

Any reasonable doctor who was aware that the deceased had long-standing bowel problems and / or was unwell would have arranged a home visit for further assessment.

There were missed later opportunities to arrange an urgent home visit and symptoms prior to the acute illness.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website

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This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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The opinions expressed in the articles are the authors' own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand. 

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