Self-referral to regulatory bodies following an inquest

This guidance note addresses the professional obligations of doctors, nurses and midwives, Health and Care Professions Council (HCPC)-regulated professionals and social workers to self-refer to their regulatory body following an inquest. 

This note is for guidance purposes only for individuals working in England. Individuals should seek advice from their employer, their union or their medical defence organisation on their specific case before making a self-referral.

1. Doctors 

The General Medical Council (GMC)’s “Good Medical Practice” (2024) guidance, paragraph 99 states as follows:

99. You must tell us without delay if, anywhere in the world: …

d) you have been criticised by an official inquiry

An ‘official inquiry’ means a public or formal inquiry or a tribunal in the public domain. This includes an inquest.

The GMC’s “Reporting criminal and regulatory proceedings within and outside the UK” (2013) guidance expands upon this further. At paragraph 6, it explains that a doctor must inform the GMC of any criticism if:

• it relates to serious matters that could call a doctor’s fitness to practise into question, and 
• it is given by the person leading either a public/formal inquiry, or a tribunal in the public domain.

Therefore, a doctor must self-refer to the GMC if they have been criticised during an inquest by the coroner, and if the criticism relates to serious matters that could call the doctor’s fitness to practice into question.

What counts as sufficient "criticism"?

The term "criticism" in this context requires careful interpretation. Doctors can and often are asked difficult questions at an inquest about their practice or clinical decision-making, but that does not mean the self-referral obligation is triggered. There needs to be explicit and serious criticism about a doctor’s practice, that could call their fitness to practise into question. 

Although a coroner is not permitted by law to apportion blame or civil liability during an inquest, they can in certain circumstances record healthcare failings or omissions in their conclusion as to how the deceased came by their death. This may be based on the coroner’s own opinion after hearing the evidence, or an expert opinion. Further, a coroner can also add a rider of neglect to a conclusion – although the threshold for this is very high. 

In our view, when a coroner includes a substantial failing or omission in their conclusion that relates to an individual doctor, or adds a rider of neglect that is directly attributable to the actions or omissions of a specific doctor, then the doctor in question has a professional obligation to self-refer to the GMC. The same would apply if the coroner does not include the individual, serious failings or omissions in the inquest conclusion but records them as part of their “findings of fact” at the end of the evidence. 

A doctor will also need to self-refer if a coroner finds that they have deliberately provided fabricated evidence or if they have concealed relevant information. Simply preferring another person’s evidence over the doctor’s does not meet this threshold. For example, if a coroner favours a family member's description of a patient's condition on a particular day over the doctor's recollection, that doesn’t automatically indicate fabrication. However, if a coroner determines that a doctor intentionally concealed pertinent information or lied about events that occurred, then the duty to self-refer would be triggered.

Seek advice before self-referring

Giving evidence at an inquest can be a stressful and daunting experience, and a doctor may not fully understand the coroner’s findings and conclusion. Before a doctor self-refers to the GMC, they should always consult their own or their employer’s legal team present at the inquest, and their medical defence organisation if they have such cover in place.

2. Nurses and midwives 

The Nursing and Midwifery (NMC) Code (updated 2018) does not contain a provision specifically requiring nurses and midwives to self-refer if they have been criticised by an official inquiry in the same terms as Good Medical Practice. Further, whilst the NMC guidance on “Making a self-referral” (2022) sets out some instances where failing to self-refer would be in breach of the Code, these circumstances do not include criticism by a coroner at an inquest. 

The self-referral guidance goes on to state that there are some circumstances where a registrant may choose to self-refer concerns about their practice to the NMC. It also says that employed nurses and midwives should tell their employer about any concerns relating to their practice, so that these can be dealt with locally. Employers are encouraged to take action locally before the NMC becomes involved.

Practical considerations

Following an inquest in which serious criticism of a nurse's or midwife’s conduct is made, the following considerations arise:

• The NMC's general position is that if a nurse/midwife is employed and there's a concern about their fitness to practise, their employer should act first. Therefore, if the inquest findings raise a fitness to practise concern (e.g. the criticism relates to serious individual failings in patient care), the nurse’s/midwife’s employing organisation should take responsibility for investigating these concerns, unless the risk to patients or the public is so serious that the NMC needs to take immediate action.

• There is no specific need for a nurse or midwife to tell the NMC if they are being investigated locally for a complaint or concern as this is being dealt with by their employer, however, the employer may still make a referral to the NMC as part of this process.

• If the nurse’s/midwife’s employer is not going to investigate the concern, or there is no employing organisation that can deal with the concern (e.g. if the nurse or midwife is an agency worker), this may be an appropriate reason to self-refer. Legal or union advice should be sought as to whether a self-referral is warranted.

3. HCPC-regulated professionals (e.g. paramedics, occupational therapists)

Under Standard 9.5 of the HCPC's Standards of conduct, performance and ethics (2024), there is a requirement to inform the HCPC of the following:

1. Criminal charges, offences or cautions. 
2. Actions or findings by another regulatory body.
3. Employer restriction, suspension or dismissal because of concerns about conduct or competence. 

Like the NMC Code, there is no express obligation to self-refer following criticism at an inquest. However, HCPC-registrants may choose to tell the HCPC about such criticism, particularly if it relates to serious, individual failings or omissions.

Similar to nurses and midwives, HCPC-regulated professionals should seek advice either from the HCPC itself, or from their employer, legal representative or union about whether a self-referral is warranted in any given circumstance.

4. Social workers

There is no explicit, specific rule in Social Work England's Professional Standards that directly mirrors the GMC's requirement for doctors to self-refer following criticism at an inquest or official inquiry. However, a social worker's broader professional obligations, particularly Professional Standard 6.6, may well require a self-referral depending on the nature and seriousness of the criticism received.

Standard 6.6 of Social Work England's professional standards requires a social worker to: 

"Declare to the appropriate authority and Social Work England anything that might affect my ability to do my job competently or may affect my fitness to practise, or if I am subject to criminal proceedings or a regulatory finding is made against me, anywhere in the world."

This is a broad, catch all provision. Further, Social Work England’s guidance on Safe and effective practice declarations and fitness to practise self-referrals (2023) states that registrants are required to declare anything that could affect their ability to do their job competently or their fitness to practice. This includes circumstances where a registrant’s actions, or inactions, have placed someone at risk of significant harm.

Whether criticism at an inquest will trigger a self-referral duty will be fact-specific and will depend on the nature and gravity of the criticism. If a coroner makes findings that directly criticises a social worker's professional conduct or competence, calling their fitness to practise into question (particularly where significant harm has occurred), this may well amount to something that affects their fitness to practise and may need to be self-referred. 

Key practical points

1. Doctors have the most explicit obligation: Paragraph 99(d) of Good Medical Practice 2024 creates a clear duty to notify the GMC of inquest criticism. However, not every critical question constitutes “criticism” for this purpose – the coroner must have made serious, critical findings in relation to an individual clinician, which calls their fitness to practise into question. 
2. Nurses, HCPC-regulated professionals and social workers have no equivalent express rule: requiring notification to the NMC, HCPC or Social Work England of a coroner’s criticism. Serious inquest criticism may nonetheless justify voluntary self-referral if it calls an individual’s fitness to practise into question, and advice should be sought.
3. All professionals should seek advice before self-referral: from their medical defence organisation, trade union or employer before deciding whether to self-refer following an inquest.