Case report: A guiding hand through the inquest process

Dr T, a new qualified consultant haematologist approached Medical Protection for support with an inquest statement. She had not previously written such a statement and during her training had never had the opportunity to be involved in the inquest process.

Dr T was concerned because following the request from the Trust legal team, she realised that when documenting the clinical encounter some of the information, including the dose of the medication, was incorrect.

The patient had a history of thrombophilia and Dr T had been consulted while on call, after the patient had had a routine right knee replacement. Although apixaban had already been prescribed, the patient was noted to have declining renal function. While Dr T felt the dose was appropriate, she documented the incorrect dose in the medical records.

Dr T initially contacted the Medical Protection advice line and spoke to a case manager who talked through the case and explained the inquest process. Dr T had been advised by her Trust that they would support with the process. The case manager explained how Medical Protection could review the statement and provide guidance on how to structure a report.

Dr T expressed her concern about the accuracy of the records. A medicolegal consultant at Medical Protection provided further advice about what the coroner would expect in a statement and how the error could be conveyed to make it clear that the patient had received the correct medication dose. Dr T was also advised that she could use her professional clinical judgement and experience to explain the chain of events as requested by the coroner.

Dr T received further written advice from Medical Protection, including resources on writing a statement for the coroner and giving evidence at an inquest.

The Trust PSIRF report for this case had not identified any learning outcomes relevant to the haematology input on this case, which was reassuring.

Dr T was initially listed to attend to give factual evidence but, following review of statements provided by other clinicians and the statement from Dr T, the coroner decided to admit the evidence under Rule 23. This allows the written evidence to be admitted without the witness needing to attend.