Before the inquest, we were asked to meet with legal representatives from within and outside the Trust. They gave the advise to seek out colleagues who had been to an inquest to understand what to expect. The solicitor challenged me on each of my statements, in a kind way but ensuring I knew what my answers meant and how to expand them further.
On a hot summers day I attended the local town hall for the inquest. I felt lucky that I had worked and known all of the other staff presenting for 5 years and more.
The inquest room was deep in the bowels of the town hall. We were informed before the event to make sure we had a drink beforehand and brought a packed lunch, that we could not eat in the room but a bottle of water would be fine. We were all to arrive early and be ready to listen to and present evidence for the whole day.
The inquest room itself was a cold white and brown room with school classroom seats. The coroner had her own entrance door, the family sat on one side and we the other. It was a civil, polite sharing of the room, but it still felt very cold as the Coroner set out the aim of the day, to identify the cause of death. Not to apportion blame or seek fault.
Each of us requested to speak were requested to do so in turns. The majority of the day was spent listening to impartial experts and then the 3 consultants who were involved in the case.
My evidence was short and easy to give. By the time I spoke many of the questions that I had expected to receive had already been answered. I was able to assure the Coroner of the quality of standards and nursing care in the ward. How my area of responsibility was well supported on the ward and embedded in practice, but by then it was a moot point. The focus had shifted from these concerns. The Coroner, by stepping slowly through each point of care or treatment, had been able to establish that this had met with or exceeded many of the international standards.
One of the consultants presenting had not been in our meetings. He captured the room with his visual explanations of each step of each treatment that were planned and why they needed to be timed in the way they were. He drew demonstrations of why the treatment needed weeks before it was the right time to do so, he also explained why we could not rush in and why, unfortunately the patient died.
After a full day the Coroner took her time to review all of her findings. Stepping back into the room she summarised the questions she had been asked to find out and the answers to those the court had been called to resolve.
The coroner found no fault. I think each of us knew that would happen.
What I didn’t expect was the reaction one of the consultants got following his testimony. As the family listened, I could visibly see them realise that what we had been telling them had been true. That what all along we had said, matched with expert opinion, including that of the coroner. I could see their body postures change as the possibility of peace, grief and understanding entered their minds. Anger had been replaced by grief within the room. The relief was palpable. I think he had allowed a door to open for the relatives for them to consider the events in a different way. To allow anger and denial to move on and acceptance, or at least understanding to begin.
But what was the cause of this. What could we do differently next time to prevent this from occurring. All that trauma. All that emotional effort from all parties involved. In my opinion I can’t fault anyone in this, the circumstances contrived against us.
We left the family having long and deep conversations with staff they had argued with.
The inquest ended at just after 6 in the evening. We had been there all day. I said my goodbyes and walked for a while to find a little headspace. I sat by this tree for some time and breathed, I was relieved. Both for myself and for the family.
I felt at the end though something of benefit had come from this.
We often send patients home who are medically fit for discharge, but they go home still needing recovery and support. It’s important that we check there is someone capable both physically and emotionally to deliver this.
I know I could look after a relative at home. I’m used to dealing with body fluids, illness and the unknown but that’s not true of most of the population.