by Dr Jeremy Lewis
The inquest into Samantha Davis, actress and wife of Warwick Davis, was held on 14th April 2025, subsequently ruling that her tragic death was not a result of failings in care.
Senior coroner, Professor Fiona Wilcox, found that Samantha died of arrhythmic cardiac arrest, following post-surgical complications. During the inquest, however, expert witnesses did not all agree on the precise cause of death. A pathologist suggested that a collection of blood found in Samantha’s chest may have been responsible, though clinicians felt this was more likely to have occurred during resuscitation attempts and would not have caused her death in itself.
Medical experts play an important role in aiding investigations into unexplained or unexpected deaths, but complications can arise during inquests when differing expert opinions are presented.
This article explores the nuanced role of the expert witness in the Coroner’s Court, and the broader implication for patient safety, systemic learning and clinical accountability.
The role of the Coroner’s Court
An inquest is a fact-finding inquiry held to answer the statutory questions of who the deceased was, and how, when and where they died. Whilst the Coroner’s Court is not the place to determine civil or criminal liability, issues relating to care standards can emerge. These are often the focus of a bereaved family’s attention, and gaining clarity can help a family find closure.
Findings from Coronial inquests are not designed to place blame, but they can help identify areas of the healthcare system that can be improved, or instances when practices fell short of what is expected. They can be a powerful lever for change in the health service.
When and why experts are needed
Not all inquests involve expert witnesses when the Coroner is able to draw conclusions based on evidence given by professional witnesses of fact. Coroners may instruct independent expert witnesses to provide opinions beyond the experience and knowledge of the court. This is likely to be increasingly common with advances in healthcare meaning more complex treatments are provided to patients with greater burdens of disease.
Experts are most likely to be called to cases where pathology and clinical narratives diverge, as seen in the inquest into Samantha’s death, in complex cases, or where rare conditions or treatments are involved. They may also be sought where the Coroner contemplates a Prevention of Future Deaths (PFD) report and needs authoritative views on systemic risk.
Delivering a balanced expert testimony
In Samantha’s case, differing opinions on the cause of death created challenges in drawing a definitive conclusion.
As with medical decisions in life, it is critical to interpret pathological findings in the clinical context. By drawing from a spectrum of opinions, Coroners are able reach a balanced opinion of the cause of death and any issues of care.
In these situations, it is imperative that the expert report and testimony is clearly presented and any limitations in knowledge are highlighted. They can, and should, describe a range of reasonable opinions before justifying their own. Opinions must be supported by evidence and relevant guidelines from the time in question.
By ensuring balanced arguments are presented, Coroners and bereaved families can be assured that a truly independent examination of events and subsequent opinion has been provided to inform the verdict.
Learning from loss
For clinicians contemplating expert witness work, the Coroner’s Court offers a uniquely impactful arena. By translating complex medicine into clear, impartial evidence—as the Samantha Davis case demonstrates—experts enable Coroners to answer the most fundamental questions: how did this person die, and can the living be better protected?
Dr Jeremy Lewis is a Consultant in Acute and General Medicine and is happy to be instructed in both Claimant and Defendant law firms in personal injury and clinical negligence cases. He has prepared reports for HM Coroner and has given evidence at a number of inquests.
To appoint Jeremy, please contact: 0161 218 0223 or email contact@exp-w.com.