The author is a junior doctor who completed their foundation training in Scotland. Some identities and details have been changed to protect the confidentiality of those involved.
From the author:
Attending a coroner's inquest was not something I had expected to happen so early on in my career. I think that involvement in a significant incident is something that is not shared enough within the medical community. I want to share my experience of this inquest, the different stages I went through, and the support I received from the MDU. There are no conflicts of interest.
The scene
A patient was admitted with a drug overdose during a night shift. Soon after arrival onto the ward they wanted to self-discharge. I completed an admission assessment and we then discussed self-discharge. I concluded the overdose was accidental, and that they had capacity to self-discharge and were not detainable under the Mental Health (Care and Treatment) (Scotland) Act 2003.
Almost a year later, working in a different job and in a different hospital, I received an email from a solicitor who was representing the hospital. She explained that the patient I had reviewed had died by suicide in England, a few days after self-discharge, and that there would be a coroner's inquest. This was the first time I had been made aware of the death.
Stage 1: chaos and accident response
I received this email in the middle of a shift and remember immediately feeling overwhelming shock, panic and fear. I went into a private room and cried. I had not yet received the clinical notes and didn't remember much of the case, so I immediately assumed the worst and wondered if I was responsible for the death. A senior registrar was present and was very supportive. She calmed me and helped construct a reply to the solicitor and advised me to contact my medical defence union.
Initially I was apprehensive in calling the MDU; I had never done so before and wasn't sure what to expect. The person I initially spoke to was a medical professional and could empathise with my experience and concerns. They were kind, informative and alleviated much of my anxiety. I was encouraged to contact them at any time and was reassured they were there to support me.
I contacted my educational supervisor, who assured me over the phone that this was standard procedure, and did not think it was necessary to meet in person or go through the clinical notes. No other medical professional reviewed the clinical notes with me, so although I felt like I had documented my assessment well, I think receiving reassurance about this from a senior or supervisor would have been helpful.
The solicitor informed me that the hospital had been made a 'properly interested person'. This required all members of staff involved in the patient's care to be contacted. Statements were required from myself, another doctor and nursing staff. The first time I had any contact with the other staff during this investigation was at the inquest.
Within a few weeks of receiving the email, I met with the solicitor. She asked me questions and recorded my account of events, which formed my draft statement. After the MDU checked the statement and advised a few changes, I sent my completed statement to the solicitor, who forwarded it to the coroner. I did not have any direct contact with the coroner until the date of the inquest.
Stage 2: intrusive reflections
Throughout this process, my confidence was affected. I took longer in assessing patients who had mental health complaints and I feared they would all take their own lives. At times I felt distressed and often called my family for personal support. I felt like this even though I knew I had made a good and safe assessment of the patient. I still questioned whether I was to blame and whether there was something else I could have done.
![E-learning: Writing a report for the coroner]()
The person I initially spoke to was a medical professional and could empathise with my experience and concerns. They were kind, informative and alleviated much of my anxiety.
Stage 3: restoring personal integrity
I had friends working in Scotland who had been through a similar situation, and sharing our experiences provided me with key source of support. However, they were concerned that I had been called to attend a coroner's inquest. Fatal accident inquiries (the Scottish equivalent of an inquest) are rare and we didn't understand the differences in law and procedure between Scotland and England - the patient died in England and therefore the case was investigated under English law.
The MDU explained the relevant differences and this helped ease my anxiety. They also emphasised that the purpose of inquest proceedings are inquisitorial rather than adversarial. The MDU reassured me that following a suicide, a coroner's inquest is standard procedure.
Stage 4: enduring the inquisition
It took around five months to arrange a date for the inquest when all involved could attend. In the weeks preceding, the MDU gave me detailed advice on how to present myself at the inquest and how to answer questions appropriately, which helped with my confidence in court.
The solicitor representing the hospital was receiving advice from English solicitors, and it was these solicitors who would be representing the hospital in court. I met them the evening before the inquest and we went through my statement and potential questions I could be asked.
On the day of the inquest, I watched three staff members go through their statements and reply to questions before I was called. I was on the stand for one hour receiving questions from the coroner, the solicitors representing the family, members of the family and the solicitor representing the hospital.
Although the purpose of the inquest was to gather information and not to place blame, at times the solicitor representing the family was aggressive. The questions were sometimes long and poorly worded, and it often felt like he was trying to catch you out.
It was very reassuring that the coroner was quick to interrupt and say if the question was inappropriate or unnecessary. I was especially nervous about answering family members' questions, but appreciated how important this was for closure.
Stage 5: obtaining emotional first aid
The solicitor contacted me a few weeks later saying the coroner had made some recommendations to the hospital and that I could 'put it behind me'. The effects of this experience have, however, stayed with me.
At times I felt isolated during this process. Family and friends were a great source of comfort and personal support, and while I felt there was a lack of senior medical support, the MDU provided the professional expertise and support that I needed.
As a medical professional, it is an extension of your role to be involved in coroner's inquests, but this is a part of my job I had not fully appreciated. The experience highlighted my lack of knowledge of medical law and procedure and I am now interested in learning more about it.
I later attended an MDU course on the duty of candour. It was here I learned about 'the second victim', a term first introduced by Albert Wu in 2000. The patient and family are the first victims of a significant incident, but the 'second victim' also recognises the impact of the incident on the healthcare provider.
...this is a part of my job I had not fully appreciated. The experience highlighted my lack of knowledge of medical law and procedure and I am now interested in learning more about it.
Just as there are stages of grief, there are also stages of 'second victim recovery'. I was surprised to learn about this term and these stages, because they accurately described what I had been feeling and going through from the moment I received the email several months ago.
I have highlighted these six stages throughout my experience of the inquest within this article. I feel this is something that should be taught in medical school and emphasised in foundation years, as even having the awareness of 'the second victim' could help a doctor involved in an incident.
Stage 6: moving on
I realised on this MDU course that I was at this stage of recovery and had a choice: to drop out, survive or thrive? In my experience it is not uncommon during foundation years to question if being a doctor is really what you want to do. I was already having these thoughts and when I received the email it raised further doubts over my future career.
Over the course of several months I have rebuilt my confidence and decided to continue my medical training. I wanted to share this experience, in the hope that it could help other doctors in a similar position. Without the personal and professional support I received, I may have made a different choice.