As a Nurse I’ve got to…attend a coroners court. Part 1.

This blog covers the events leading up to and including a coroners inquest. I was already blogging when it happened but I needed to be sure that publicly writing about this was the right thing to do.

This was an emotionally charged journey, All of the events were about a man who died at the Trust I used to work for and the subsequent inquest.

I don’t want to divulge information in this that would identify the patient or the family. The only details I want to include are those that help define the impact upon the family. This was all focused on the events linked to a man who presented to hospital with abdominal pains and died less than 3 months later. A man who died very shortly after retiring, who had led business and family affairs with great success and on his death left a gaping whole.

Leading up to the inquest there were many meetings with the family and friends of the deceased. Over the course of each meeting the difficulty in communication got steadily worse. Each time we met, relationship broke down further, despite the efforts of everyone involved.

As a group, both the family and representatives from the Trust did all we could to resolve the concerns raised from each question was answered. Despite the efforts of several senior multi disciplinary staff the answers we gave were refuted. No answer was enough, no explanation was believed.

This man died of an illness that despite advances in medical care has the same mortality rate now as was recorded 40 years ago, 30%. In other words 3 out of every 10 patients who present with this condition will die despite receiving all the correct treatment at the correct time. The suddenness of this death really impacted upon the family. They were left with a great many questions.

We held, as any good Trust would, several meetings with the family and had independent experts reviews of case notes and test results. At each meeting we had all the experts and supportive people in the room. We answered every question and spent time exploring many different ideas and discussions. But nothing we could say or do could reassure the relatives that we had done the right thing. By early on in the investigation we knew that the death was to be investigated by the coroner.

As we drew closer to the hearing date, each meeting was becoming more and more tense. Relationships, which at the beginning had been very good, were breaking down.

At the final meeting, I shared my findings and my colleagues presented their feedback, but every answer was challenged and the responses to them were becoming personal. This was not a simple case, but the questions that kept coming back to us were points of fact, not opinion. In other words what had been documented was disbelieved, where timings were recorded these were challenged. The more supportive and understanding each one of us became, the less we were believed.

It was at this point that I began to see that the questions we were answering were from someone not ready to hear the answers. Someone, who was not able to grieve or to start to process their loss and so every sinew of their body was fighting against anything that went against the loss being anything other than someone’s fault. This was not expressed with sadness but with anger, frustration and blame.

I had to ask for this to stop. I had to state what I felt to be true. That grief was driving these responses.

That no matter what we said, we could not bring back this person, turn back time or change any of the decisions that had been made. I wanted to point out that grief needs to be allowed to begin, no matter how painful that may feel. I could also see my colleagues becoming visibly upset by the course of events.

In a room full of people more senior and experienced than myself I needed to check myself for a moment. Was this the right response in an already emotionally charged room?

Before I’d decided, I was talking. Before I’d chosen some useful phrases or words, I was already committed to the conversation.

I said what I felt needed to be said.

No matter what we do here, we can not bring back this person.

Everyone did their best.

No one person or group of people were to blame.

That what we need to do know is to help to start understanding and accepting the emotions that this tragic event has brought.

This didn’t work, It didn’t help. I think it may have even made things worse. The remaining questions were answered and assurance we would write to the family surmising the morning. A colleague reiterated my statements and reflected back that we were not moving forwards and maybe he best way now is for the coroner to impartially review this. The meeting was drawn to a close.

I left the room and with a colleague, found a quiet room to cry.

I had never experienced such raw emotion. To feel like everything you were doing was not enough, everything you said pushed back as untrue or false and any empathy or understanding given perceived as an attempt to undermine.

We were joined by another senior nurse who had been in the room. Talking through the meeting and the months leading up to it we both expressed our sadness and anger that we were unable to resolve this, that we could do no more. I’d never felt so emotionally rung out.

2 thoughts on “As a Nurse I’ve got to…attend a coroners court. Part 1.

  1. Hi Paul
    Having read your blog re ‘As a nurse….attending an inquest’, I feel compelled to respond.
    I’ve been in that position on a number of occasions often as a nurse and also once as a grieving relative.
    I won’t patronise you by saying how ‘feel your pain’ but instead with empathy, I offer these observations.

    Your blog gives a very candid account of the experience that you encountered and also the effect that impacted on you personally. I hope I’ve interpreted it accuarately.

    I don’t think we should ever underestimate the true effect that grief has on us as professionals and of course the relatives.
    I think you were right to listen to your instinct and halt proceedings when things were getting tough at the Trust meeting.

    No matter what training we have in our armoury, there is often nothing that can adequately prepare us to deal with every event. You did well to make use of your ‘built in’ coping mechanism when you felt able to release those personal emotions.

    Our training tries to prepare us for dealing with these situations but gauging the appropriate time is never an easy one. Often memories and emotions are far too ‘raw’ to even hope for a resolve and of course even while expecting answers, people will often put up the shutters while they go through that grieving process. In situations like this the barrier will be impenetrable for some time. With the best will in the world It’s difficult to gauge an appropriate especially with inquests because the timing of that event is out of our hands and of course people search for answers and even blame.

    I know personally, as a grieving relative who was confronted by an arrogant registrar, that after 4 years. I still feel the anger but time is allowing me to cope and the anger level is less.

    Even though professional staff have the experience, knowledge and skills and no matter how well explained, the facts often will not penetrate the unintended invisible barrier that will inevitably exist between medic and relative at a time of loss.

    I hope this helps.
    All the best to you Paul.



    1. Thank you Glynn for taking the time to read and respond. I thoroughly agree with your views and hopefully that’s what I’ve captured in the blog.

      As a huge lumbering organisation a hospital relies upon individuals to make and maintain relationships in extremely difficult circumstances, despite whatever external pressures it is under. The support for those staff, you are right is often not on hand. Both for staff and relatives.

      I too have been in the position of being angry following treatment by individuals within the NHS. It’s took me a number of years before I was brave enough to consider seeking it’s help again.

      I hope you continue to feel the anger subsiding as I have now.



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