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What happens during an inquest at the Coroner̵...

What happens during an inquest at the Coroner’s Court?

As part of my nursing home placement, and to get a bit of something different going on, I took the opportunity to contact my trust’s Coroner’s Court to learn a bit more about what goes on, when a death might be referred to the Coroner’s Court, and what happens on the day. It was absolutely fascinating to see, and I learnt some very important lessons about nursing notes and documentation, as well as what happens when a task is delegated to HCAs or other support staff.

If you’re a nursing student and wondering whether it’s worth a punt trying to book some time out of placement, or a reader interested in my (kinda) reflective experience, here’s a rundown of what goes on and why. Just a note: the case I attended was the self-suspension of a man who committed suicide so please read with this in mind. If you don’t want to read about the case itself, stop after the second image.

What happens when someone dies

When someone dies, the death must be registered. This is done in two ways: by a doctor who can confirm the cause of death and verify someone has lost brain stem activity, and if not by a doctor then by the coroner through a series of processes I\ll talk about below. Anyone who has a Deprivation of Liberty Safeguard in place (pretty much anyone in a nursing home will have a DOLS in place), as well as prisoners, anyone who has died a violent or unnatural death, or anyone who has died suddenly and without a known cause, will be referred to the coroner.

Typical cases include sudden death, suicide, industrial accidents and illness, clinical negligence and mistakes during blood transfusions, alcohol poisoning and self-neglect or neglect by others.

What does the coroner do once a death has been reported?

If the person who has died was under the care of a doctor, but still died suddenly, for example, the coroner may be happy to authorise a burial using the Pink Form A after a chat with medical professionals. If that’s the case, no post-mortem need take place, and once the death is registered the body can be released to next of kin.

If there is no medical professional to, in essence, ‘vouch’ for the cause of death, an autopsy or post-mortem will be issued. This means a pathologist will examine to body, from the skull to toes to determine a cause of death. If the cause is natural and the coroner is happy there is nothing unnatural to take into consideration, a Pink Form B is issued and the body can again be released.

If the pathologist deems the person to have died unnaturally or cannot find a cause, the coroner will hold an inquest to find out more details. At this stage, if the Pink Forms have been issued in lieu of inquest, next of kin are permitted to bury the deceased. As inquests can take years, sometimes, to come to fruition, this allows the family some semblance of closure. At the inquest – which is non-criminal so no one will be charged with a crime, even if they may have been involved in the person’s care – the coroner will seek to find out all the facts from as many sources as possible.

If the death arose as a result of police action, if it happened in a prison, or was an accident at work a jury may be summoned to hear the case, ask questions, and help decide who may have been at fault. The case below was one of the many, many rare cases where a jury was called.

Inquest verdicts

Once the coroner has all the facts about the case, they will give a verdict. Most are fairly self-explanatory, such as illness or old age, but sometimes the verdict will be ‘narrative.’ This means that the coroner will describe the events as a way of conclusion to the case. Others are ‘open verdict’ where it’s just simply not possible to determine how the person died and no evidence has been given to judge it as misadventure, unlawful killing, suicide etc.

What happens at a Coroner’s Court with a jury-based inquest?

After meeting the officer who kindly arranged the day for me, we were seated in a small room with about twenty other people. The case was for Richard Wade, a young man who committed suicide in a mental health inpatient facility by using a ligature point and a dressing gown cord in self-suspension. This all happened about two years ago, so was a long time coming for all.

In attendance were the Coroner, Richard’s parents, the family’s barrister, the trust’s legal team, and representatives from the centre he was being held in:

The nurse in charge
The staff nurse looking after Richard
The HCA who supported his care
The nurse who gave CPR

The Coroner had also requested an independent psychiatrist to review all notes from the case, and give his professional opinion on where failings were that allowed Richard to kill himself.

There were also media and journalists, as well as those who had an interest in the case. Anyone may attend the Coroner’s Court (as long as they’re dressed smartly) and it’s a fairly relaxed kind of formal.

The day started by hearing from the nurse who was looking after Richard. The Coroner asked her to the desk and she swore that everything she said would be truthful. After then, the coroner questioned her relentlessly on documentation, delegation, and her role in the entire matter. The nursing notes were below par, and once the coroner had asked all questions, the barristers from the trust were invited to ask any questions. With nothing to add, the family’s barrister laid into the nurse – it was intense. He asked why proper admission documents hadn’t been filled in upon admission, why there were gaps in notes, why Richard’s personal belongings weren’t checked, and why he was allowed to be alone for such an extended period of time. Her answers were that she had tried to promote dignity by allowing him his own clothes and that the cord of the gown was part of the outfit and so wouldn’t be removed. As for notes, well, they were picked apart!

At this point, the Coroner’s Officer turned to me and whispered that while the Coroner’s Court isn’t going to see anyone thrown into prison, the outcome may influence regulatory bodies, such as the NMC or GMC, as well as civil proceedings that may happen once a reason (or blame) has been given.

Once the barristers had asked all their questions, the jury was invited to ask theirs – they are all provided with a bundle of papers that they were directed to look at, such as nursing and doctor’s notes, floorplans, policy guidelines and the like. As they are laypeople, literally people selected at random who have no medical experience or prior relationship with the deceased, their questions were often much simpler, and more directed at the failings of the trust. ‘Can you give a good reason why you allowed Richard to keep his dressing gown?’ ‘Did you not consider it might be an issue?’ ‘Walk me through what happened on admission.’ ‘Why did the HCA not check on him sooner?’ ‘Why was he allowed to use the bathroom on his own?’

This was then repeated for the nurse in charge, the HCA, and the nurse who performed CPR.

It was, well, intense. Richards parents showed an incredible amount of strength given the circumstances, and after two long years would get as many answers as they could. The inquest was held over a week and wasn’t resolved on the day I attended, but a little research afterwards showed there were failings by the trust and the staff in charge that contributed to Richard’s death. They said: Richard’s risk of suicide was not properly and adequately assessed and reviewed. Adequate and appropriate precautions were not taken to manage Richard’s risk of suicide.

Reflections on attending the Coroner’s Court

If I didn’t think nursing notes and documentation was important before, I do now. Aside from the failing of the trust, who knows how Richard’s life would have panned out if that cord was taken away from him or his full needs were assessed right from the start. The nurses and medical teams weren’t directly responsible for his death, but the notes showed they lacked diligence from the moment he was admitted. Of course, the psychiatrist was well aware where there’s a will there’s a way, but even still, had the notes been accurate, well-detailed, and written on time not retrospectively, the nurse would have been able to say she was fully competent in his care.

The biggest lesson? Write what you actually do, not what should have been done. Complete observations and care rounds on time, and document accurately. There’s no need to write every single interaction, but anything that your gut tells you might not be quite right, just make a note.

The Coroner Court is open to all members of the public to attend and you don’t need an appointment, so I’d urge student nurses to go at least once, and understand how it all functions. We know nursing is life as well as death, so if nothing else you’ll get some insight to bring into practice.

Images via shutterstock.com


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