Select country
Membership information
0800 561 9000
Medicolegal advice
0800 561 9090
Refine my search

Case study: Providing a formal report to the coroner

Post date: 15/02/2023 | Time to read article: 2 mins

The information within this article was correct at the time of publishing. Last updated 13/09/2023

When Dr Mark Brushford*, an NHS consultant psychiatrist from Birmingham, was asked to provide a formal report to the Coroner, Medical Protection stepped in to support him.

Dr Mark Brushford* contacted Medical Protection for assistance with a statement requested by the coroner. He had been involved in a Mental Health Act assessment of a 25-year-old patient with severe depression and anxiety.

The team decided that the patient was not detainable under the Act and arranged for input from the Crisis team. Tragically, shortly after the assessment, the patient jumped from a railway bridge and died. 

What happened next?

As a psychiatrist, Dr Brushford had been involved in a number of inquests previously and was used to seeking advice from Medical Protection regarding statements. He was, aware that it was generally best to remain under the Trust’s umbrella of support and representation at the inquest, but on this occasion, he was alarmed to be informed that the Trust would not be assisting him, as Section 12 work was considered as separate to his contract with the Trust.

He had informed Medical Protection of this role and called the advice line to ask for assistance. 

How Medical Protection helped

A case file was opened and Dr Brushford’s statement was reviewed. His team at Medical Protection liaised with the coroner’s office and determined that he was being called as an ‘Interested Person’ (IP) and as such was entitled to legal representation. The medicolegal consultant (MLC) representing Dr Brushford asked about any concerns raised regarding his care and was provided with a copy of a letter from the family that asked a number of questions.

The coroner requested that these questions be addressed in Dr Brushford’s statement.

With Dr Brushford’s permission, the MLC instructed a legal adviser from Medical Protection to represent Dr Brushford and a meeting was arranged to review the draft statement and discuss the family’s concerns. These included the fact that the team had not reviewed the patient’s records fully, and that the father’s account of the patient’s recent behaviour had not been given due consideration.

How did it end?

The solicitor from Medical Protection attended the inquest with Dr Brushford to support him throughout. Unfortunately, Dr Brushford was criticised by the coroner (along with the other healthcare professionals involved in the assessment) and was subsequently advised to self-refer to the General Medical Council (GMC) in accordance with paragraph 75a of Good Medical Practice.

Our expert team provided advice on how to carry out reflection and re-education and advised on the self-referral notification. The GMC was satisfied that the concerns had been suitably addressed and closed the case.

Take aways

NHS consultants like Dr Brushford, while generally represented by a Trust’s legal team at an inquest, are still able to receive advice from Medical Protection when it comes to providing a statement for the coroner or on giving evidence.

In situations like this, the Trust’s legal team may not always be able to support its employees, whereas Medical Protection can offer advice tailored to the individual member.

By Dr Lucy Hanington, Medicolegal Consultant at Medical Protection

Not a member already? Click here to join.

*Names and locations have been changed to protect member confidentiality.


Share this article

New site feature tour

Introducing an improved
online experience

You'll notice a few things have changed on our website. After asking our members what they want in an online platform, we've made it easier to access our membership benefits and created a more personalised user experience.

Why not take our quick 60-second tour? We'll show you how it all works and it should only take a minute.

Take the tour Continue to site

Medicolegal advice
0800 561 9090
Membership information
0800 561 9000

Key contact details

Should you need to contact us, our phone numbers are always visible.

Personalise your search

We'll save your profession in the "I am a..." dropdown filter for next time.

Tour completed

Now you've seen all of the updated features, it's time for you to try them out.

Continue to site
Take again