Shared Insights: Coroner's question time

24 March 2026

This Shared Insights forum took place on 24 March 2026.

This session of Coroner's question time, chaired by Nicola Evans, covered three main topics: tips on preparing for inquests, the legal test and threshold for a finding of neglect, and the circumstances in which a coroner might refer an individual to their regulator.

The discussion opened with practical guidance on what individuals and organisations can do to prepare for an inquest. Preparation should begin as early as possible and as soon as it becomes apparent that there will be an inquest. The panel then addressed the issue of neglect, emphasising that this is in practice a rare finding with a high threshold. The test for neglect was explored and examples given of inquests where a neglect finding has been made.

Finally, the panel considered the circumstances in which a coroner might refer a clinician or other individual to their regulator. It was emphasised that such referrals are rare, with the primary triggers being falsification of records or serious misconduct in court.

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Nicola Evans

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