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You are an ST1 doctor in A&E on a week of nights. You see a 43-year old patient with chest pain which does not sound cardiac. All bloods and the ECG are normal. The patient is discharged home with an outpatient exercise test. The following night you are informed that the patient died later at home. You are asked to provide a report for the Coroner. How should you go about it?
Coroners are seeking a factual report detailing the care you provided. They are not trying to catch you out – they simply want to find out what happened.
The MDU's 24-hour medico-legal advisory helpline is available to assist with cases such as this. The adviser will provide initial guidance on drafting a statement for the Coroner and ask you to send it to us for review.
As an employee of the hospital trust, you are indemnified by the trust. They will usually support and guide you through a Coroner's process too, so you will be advised by the MDU to liaise closely with them.
It is often helpful to make an anonymous record of your memory of events as soon as you know you will need to write a report. Memories fade with time and the sooner you can jot down your honest recollections the better. You can include your recollections in your Coroner's report, providing you state this is what they are.
Any report to the Coroner must concur with the clinical notes you made at the time you cared for the patient. Request a copy of the notes from the trust so that you can review them when you write your report.
Never be tempted to amend the records when you go back to review your own notes to write a Coroner's report, even if with hindsight you feel they are not complete or clear.
If you haven't included every single detail of the care you provided, consider your normal clinical practice. It is quite acceptable to include a comment on your normal practice in your report.
Being under the spotlight of the Coroner is stressful. Discuss the care you provided with a senior colleague or mentor to obtain feedback and support throughout the process.
We all learn from cases – such is the nature of clinical medicine. Use an experience such as this to reflect on what you did well in the case and what you can improve on for the future. Document these reflections in your portfolio and act on any shortcomings that may be exposed.
There is likely to be a deadline for submission of your Coroner's report. Act early, get advice and don't leave the report until the last minute.
This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.