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Practice dilemmas: Summons to an inquest

One of my patients has died of an overdose.  He was being treated by the local Community Mental Health Team and the circumstances of the overdose are unclear.  The coroner’s officer tells me I need to attend an inquest hearing and that the patient’s parents have complained to him that I should not have provided my patient with painkillers.  I am unsure whether the overdose involved prescribed medication.  What should I do?

When a patient dies unexpectedly GPs are commonly asked to provide a report to help the coroner establish the cause of death at inquest.  When dealing with the coroner it is important to be risk aware.  If there is criticism of your care, or if as a GP you feel vulnerable about an issue, such as communication between different services, it is important to speak to your medical defence organisation to get advice about how best to approach the problem.  In some situations a low key approach will be best, but in other cases legal representation at inquest may be advisable. 

The inquest scene has changed a lot over recent years under the influence of both human rights case law and also Government reforms.  With the new chief coroner taking office last month, over the medium term we can expect some of the idiosyncrasies of local coroners to be ironed out.  When looking at risk issues it is important to keep a sense of proportion.  Factors which perhaps should concern you include whether the family will be legally represented, whether they have made a complaint, or if there has been any publicity about the death, and perhaps even your own local knowledge about how your coroner tends to work. 

Merely being asked to attend to give evidence, rather than having your report read by the court, is not in itself a reason for concern, but could indicate that further enquiries need to be made to protect yourself. 

John Holmes is a partner at Hempsons

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