A Clinician's Brief Guide to the Coroner's Court and Inquests

Dr Gabrielle Pendlebury is a Child and Adolescent Psychiatrist and was previously a medico-legal adviser. She has valuable experience of supporting doctors with inquests and navigating the personal and professional challenges that arise. Professor Derek Tracy is the Chief Medical Officer of South London and Maudsley NHS Foundation Trust, an honorary Professor at Brunel University Medical School and a Senior Lecturer at King's, Imperial and University College London. He has published over 130 peer-reviewed scientific papers and 15 book chapters. He is also the Editor for public engagement at the British Journal of Psychiatry.

Foreword H. H. J. Teague KC and Dame Clare Gerada DBE; The aim of this book Gabrielle Pendlebury and Derek Tracy; 1. Introduction Gabrielle Pendlebury and Derek Tracy; 2. History of Coroner's court Arif Naqvi and Gabrielle Pendlebury; 3. The role of the Coroner Lydia Brown; 4. Patient safety incident response framework and inquests Elaine Chung, Eva Ferlez, Christopher Hilton, Shaun O'Connell and Derek Tracy; 5. Notification of deaths to the Coroner and the decision to investigate: when and who should contact the Coroner Karen Hall and Gabrielle Pendlebury; 6. The scope of the investigation Gabrielle Pendlebury and Carol Seymour; 7. Interested persons Gabrielle Pendlebury and Derek Tracy; 8. Deaths involving suicide and unlawful killing (homicide offences) Gabrielle Pendlebury; 9. The statement (or Report) for the court Gabrielle Pendlebury; 10. Pre-inquest Review Hearing (PIRH) and rule 23 Gabrielle Pendlebury; 11. The professional as witness Gabrielle Pendlebury; 12. Expert witnesses in the Coroner's court Keith Rix; 13. On the day: Giving evidence Mark Tarn and Gabrielle Pendlebury; 14. Giving evidence: Nursing perspectives Stephanie Bridger, Sonya Clinch and Gillian Kelly; 15. The roles of advocates and the jury in the Coroner's court: a legal perspective Emma Galland; 16. Outcomes, including regulation 28 reports – Prevention of future death Derek Winter and Gabrielle Pendlebury; 17. Managing adverse outcomes, including referral of professionals to regulatory bodies and developing a professional development plan Gabrielle Pendlebury and Derek Tracy; 18. Managing the emotions around the Inquest process and the Coroner's Court Sian McIver, Sunita Shridhar and Shirley Tench; Appendices; References.