Emma Ryan shares her experiences and advice for giving evidence at a coroner's inquest into a sudden death on a ward.
An unexpected death on an acute orthopaedic ward can be a bit of a shock. From the crash call, the following investigation and the inquest, it’s a daunting task and something that you never think will happen to you. My own experience taught me some valuable lessons.
The first stage is the crash call de-brief, when the entire team discuss and analyse areas for improvement. After this the serious incident reporting investigation (SIRI) starts. This involves regular meetings with senior hospital staff to investigate what happened, what could have been done better, and whether anything was missed.
Our team were asked to write a report about our involvement with the patient from start to finish, which would become the basis for all the questions that would be asked in court. It had to be written in a format we weren’t familiar with, and it was re-written several times, and everything fact checked alongside the medical records.
Up until this point we had sought any advice we could from colleagues who had previous experience of this situation but, working in a small trust, it was hard to find people with any experience of the coroner’s courts or the process. The only formal guidance we received was a meeting with the trust’s barrister the night before court.
- Ask for help, search for it - it won’t find you.
- Can you defend your colleague’s notes? We had to and that was a massive learning curve.
- Take your time writing the report – it’s referred to throughout court.
- Document everything: if it’s not in the notes it didn’t happen, even if you remember it did.
- Keep up to date with clinical practice – you will be questioned on your knowledge and qualifications.
- Expect the unexpected questions.
- The coroner is not a medically trained person, but a legally trained person.
The coroner had two pieces of feedback for us, the Trust and the medical profession:
1. The SIRI should be completed by someone of a similar field from another Trust for it to be robust.
2. If you did something, anything, write it down.
Emma Ryan is Physiotherapy team leader for Orthopaedics on the Isle of Wight
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