Post-Mortem Access and the Coronial Process: A National Survey of Clinician Perspectives to Inform Learning, Safety,...

Post-mortem examinations are central to coronial investigations in the United Kingdom. However, treating clinicians do not routinely receive post-mortem findings before submitting statements unless granted Interested Person status. While this approach safeguards investigative independence, its practical impact on clinicians' engagement, learning, and professional well-being remains underexplored.

A national, cross-sectional, anonymous survey of UK clinicians across grades and specialties was conducted. The survey examined experiences of coronial processes, access to post-mortem findings, perceived effects on statement accuracy, reflective learning, clinical behavior, and support for bereaved families. Quantitative data were analyzed descriptively, and free-text responses underwent inductive thematic analysis.

Eighty-six clinicians responded, representing a range of specialties and seniority. Among applicable respondents, 83% reported that post-mortem reports were not consistently available before statement submission. Limited access was associated with difficulty drafting accurate factual witness statements and clinical reports requested by the Coroner's Office, increased stress and uncertainty, reduced opportunities for reflective learning, and behavioral changes consistent with defensive practice. Clinicians also reported reduced confidence in communicating with bereaved families when post-mortem findings were unavailable. The majority supported structured disclosure models, including redacted summaries and multidisciplinary learning discussions.

Clinicians perceive timely access to post-mortem findings as important for accurate reporting, reflective learning, and meaningful family engagement. Proportionate and structured disclosure practices, while preserving coronial independence, may strengthen collaboration between clinical and coronial systems and support patient safety.