Under the spotlight: supportive guidelines to maintain psychological wellbeing for staff involved in patient–coroner investigations

Feryad A Hussain is a consultant clinical psychologist with North East London NHS Foundation Trust, and has worked in a wide range of health psychology services for over 20 years.

‘The siege is a waiting period
Waiting on the tilted ladder in the middle of the storm.
Alone, we are alone as far down as the sediment
Were it not for the visits of the rainbows.’
– Under Siege by Mahmoud Darwish

The experience of a patient death by suicide is traumatic for everyone involved. While families are supported through their grief both practically and emotionally by friends, relatives, and healthcare staff/organisations. This is not the case for healthcare professionals themselves.

A coroner’s investigation is required in any patient death by suicide and for the families it can often be an important part of the bereavement process in facilitating some form of closure. However, for healthcare professionals involved in the patient’s care, their sadness is soon overtaken by fear, suspicion, guilt, and dread. Feeling under siege and isolated from any conversation regarding their role in patient care, the memory of the patient very quickly becomes a distant memory as they are advised the death is under coroners’ investigation, and by default, so are they.

The literature on staff experiences of the coronial process is seemingly absent — the distress, however, is not. The impact of the process, irrespective of any accidental wrongdoing, is significant, and the related absence of emotional support and guidance can significantly increase related anxiety.

While there is local trust policy guidance on protecting organisations, there appears to be little to protect staff. Medical bodies appear to be one of the few professions that have been active in supporting their members with practical advice specific to the coroner’s investigations and guidance around witness statements and attendance at the inquest; however, again, the emotional support is rarely mentioned.^1,2

This brief article aims to draw attention to the experiences of staff who are involved in the coronial process following the death of a patient by suicide. In doing so, the hope is that organisations will consider the impact and implement support strategies for their staff at this crucial time.

The author’s experience of staff involved in coronial processes is centred around offering emotional and psychological support under generic staff support services, during and after the investigation and at the request of the staff members themselves.*

Statistics and prevalence rates for NHS coroner investigations

There has been an overall decrease in the number of deaths reported to the coroner by 5% compared to 2020, with figures being the lowest since 1995 for the UK. However, there has been a 7% rise in post-mortem examinations over the same period, with a 2% increase in coroners’ inquests.³

Deaths recorded as accidental, by suicide, and unclassified, had the largest increases by 2%, 8%, and 24% on 2020, respectively. The time frame to process the inquests has also increased from 27 weeks in 2020 to 31 weeks in 2021.³

These figures are important in not only the numbers of staff affected by coroners’ investigations but also the extended time frame involved. Aside from the deaths themselves, both the increase in suicide and time frame are notable sources of concern in the context of staff support.

Basic coronial procedures

The aim of a coroner’s inquest is to independently investigate any death that appears to be due to violent, unnatural, or unknown causes, and to identify circumstances of death (where, when, and how). This includes any death that occurs as a result of accident or suicide during and/or shortly after medical treatment where the cause for death was unknown.

At the end of the inquest the coroner verifies the cause of death. This conclusion does not appoint blame, as the aim is to ascertain a verdict of death. Where there are any concerns regarding professional competency and misconduct, these are referred to professional organisations and employers.^4–6

Stages of the coronial procedure for NHS investigations are as follows:

1. Initially the coroner considers the information to decide whether an inquest is required.
2. If an investigation is required, the coroner will perform a post-mortem to establish probable cause of death. If this sufficient, the case will be concluded.
3. If an inquest is necessary, the coroner will review all available evidence and make a decision as to whether there are criminal issues or whether a referral to police or Crown Prosecution Service is required.
4. At this stage the coroner may arrange a pre-inquest review with all relevant parties including family, professionals, witnesses, for example, to discuss relevant concerns, and will request further evidence, including clinician/witness statements, clinician notes, and medical records, for example.
5. A timetable of events is then agreed.
6. In cases where the witness statements offer enough information for the coroner to make their decision, staff do not need to attend a public inquiry.
7. Once all relevant information is collected the inquest date is fixed and witnesses may be invited to attend and give evidence and answer questions.
8. An inquest can take anywhere between 3–6 months for all investigative procedures to be completed and a decision to be reached.

Experiences of staff under patient–coroner investigation

The author, in her capacity as an experienced clinical health psychologist, has worked extensively with healthcare professionals, many of whom have been involved in coroners’ investigations. Her role has been to support staff throughout the coronial process as well as after the case is closed. The following information is sourced from her clinical practice.

Staff experiences

Staff are often unprepared both emotionally and practically for the processes of the investigation, and since this is carried out by an external body it is common for team members, even managers, to be unaware of what is involved, leaving them unable to support or guide the staff member. Consequently, staff support is offered by generic organisational support services that may vary according to local resources.⁷

Staff presenting at such support services often feel that they are preparing to present as witnesses in a legal trial and it is rare for staff to advise that this is not the case with coroners’ investigations.

Emotionally, staff may experience: panic (about their own competence/decisions); fear (about being struck off); guilt (usually without cause); heightened anxiety and distress; obsessive thinking about the case and the manner of death; and obsessive re-reading of notes and conversations regarding the latest updates, as well as seeking missing information, where there may be none.

As time goes by staff can become increasingly mistrustful and insecure about their work and management relationships, at which point the stress becomes unbearable and staff will often be advised to take time off sick due to the distress. Unfortunately, due to a lack of routine and activity during this time, emotions can be heightened with an additional lack of sleep and appetite adding to their deteriorating emotional state.

Additionally, it is common for staff to feel isolated, having been advised not to discuss the situation. As such, they feel restricted in their contact with peers for fear of being questioned, blamed, and often experience a notable sense of shame at being seen as possibly ‘unprofessional’ in their conduct.

At this point staff are offered very little practical and/or (even less) emotional support from their managers, who are often equally unaware of the details of the procedure or indeed what their staff are going through.

Staff have also reported feeling that they are on trial and responsible for the image of the trust, and are ultimately responsible for the patient’s death. These emotions and cognitions often appear without any evidence and tend to be the result of overthinking and isolation coupled with an absence of ongoing support and/or mixed messages regarding witness statements.

In spite of all the distress described staff are largely forced to manage the situation independently, seeking advice and counsel through private or generic staff support services.
What is clear is that there is a notable absence of care and concern, giving the impression that the reputation of the trust is prioritised over the staff who work there, irrespective of any actual wrongdoing.

Guidelines and recommendations for staff regarding coroners’ investigations

Available resources suggest that supportive guidelines for staff undergoing coroners’ investigations are limited and appear to be dependent on individual professional standards and bodies. It is of note that, similarly, staff under investigation within the NHS are also lacking in support, again with very poor levels of input, suggesting a wider problem with the NHS.⁸ As mentioned previously, available guidelines are offered seemingly by the medical profession alone.^1,2,9–12

While this advice is incredibly valuable it centres on practicalities and offers little consideration to emotional distress and the impact this has, not only on the professional themselves but their witness statement or indeed presentation at the inquest.

The author’s experience of working with staff has resulted in a number of supportive recommendations that build on existing guidelines from Health Education England regarding actions, but with a focus on the parallel process of managing and containing emotional distress.

Maintaining psychological health

Practical measures that will add to a feeling of mastery and emotional containment:

• Call the coroner’s office for clarity of information rather than answer the questions yourself/ask colleagues who may not be qualified to give you a clear answer. This is important and it is often fear that results in staff avoiding this, which then adds to their uncertainty and doubt about the process.
• Contact your manager and ask what help is available to support you through the process. This alerts them to your needs and allows an opportunity for even ad hoc support to be arranged.
• Contact your professional bodies/union if required. There is no harm in being prepared.
• Ensure that you have a circle of support around you that centres on your needs. This is best done by family and friends who are less likely to focus on the coroner’s report/your actions and related circumstances or the actions of other staff involved.
• Ensure that you make time to eat, sleep, and work on any action/witness statement, for example, appropriately. Absenting food and sleep at the expense of the task will only increase your distress unnecessarily and impact on the quality of your thinking/statement.
• Ensure that your daily conversations include content other than the investigation. It is very common for the proceedings to take over and this only feeds in to your anxiety and may even increase and/or introduce new worries.
• Ensure that you leave the home and continue with your social activities even though these may not feel the same. Connecting with the outside world will offer a good balance to the internal world that can be all-consuming.
• Do not write any statements when you are feeling anxious as this will affect the style of your response.
• Do not write your answer/statement defensively as this feeds in to the idea that you are being attacked — you are not.
• Ensure that you do not over-read or overanalyse what you have done, rather take this to your manager.

Emotional/cognitive reminders:

• Distressful emotions are not a sign of professional misconduct.
• Accept that any distress and anxiety is an understandable reaction to your situation.
• This is not a court case, and you personally will not be found guilty of a crime.
• Remember that knowing the patient has died by suicide will drastically change your perspective. Try and put yourself at the point at which you worked with the patient and the decisions that you made while they were alive.
• It is quite acceptable to stick by the decisions that you made at the time. They are unlikely to be the reason for the patient’s actions and they are not necessarily wrong because of the patient’s actions.
• Consider your actions in the context of common clinical practice not suicide.
• Avoid following any chain of thought that starts with I should have/I could have/if only I had. Hindsight is always a wonderful thing but not for past events, only for the future.
• If you felt at the time that you made the right decision, it is likely your response would not change given the same circumstances (and if patient was still alive). This means that even in hindsight your course of action was correct and that you have done nothing wrong.

These cognitive responses aim to ameliorate unnecessary distress, help to focus, and to complement the aforementioned practical recommendations.

Conclusion

Involvement in a coroner’s investigation is a challenging time. The absence of psychological support within the NHS in general creates unnecessary and additional stress for staff at a time when they require increased emotional containment and support. Awareness of staff experiences may go some way to initiating changes in local policy and create an improved support system.

*Information is specific to situations where behaviour was within professional standards and there were no concerns regarding decisions taken. Investigations involving professionals whose conduct falls outside of safe clinical practice and involves any degree of wilful/criminal negligence is beyond the remit of this brief article.

References
1. NHS Resolution. Inquests: a guide for health providers supporting staff to prepare for an inquest. 2020. https://resolution.nhs.uk/wp-content/uploads/2020/03/Inquests-films-and-guide.pdf (accessed 28 Sep 2022).
2. NHS Resolution. Watch how to prepare for an inquest. 2020. https://resolution.nhs.uk/resources/how-to-prepare-for-an-inquest (accessed 28 Sep 2022).
3. Ministry of Justice. Coroners statistics 2021: England and Wales. 2022. https://www.gov.uk/government/statistics/coroners-statistics-2021/coroners-statistics-2021-england-and-wales (accessed 28 Sep 2022).
4. UK Government. When a death is reported to a coroner. https://www.gov.uk/after-a-death/when-a-death-is-reported-to-a-coroner (accessed 28 Sep 2022).
5. Dean E. Coroner’s inquests: what you need to know if you are asked to give evidence. Nursing Standard 2021; 36(4): 26–28.
6. Ministry of Justice. Guide to coroner’s statistics. 2022. https://www.gov.uk/government/statistics/coroners-statistics-2021/guide-to-coroners-statistics (accessed 28 Sep 2022).
7. Charles A, Cross W, Griffiths D. What do clinicians understand about deaths reportable to the coroner? J Forensic Leg Med 2017; 51: 76–80.
8. Hussain FA. Kafka lives: consideration of psychological wellbeing on staff under investigation procedures in the NHS. South Asian Res J Nurs Health Care 2022; 4(3): 45–49.
9. Burns B. Lessons learned from the coroner’s court. Nurs N Z 2014; 20(8): 21–23.
10. Health Education England. Supporting doctors in training attending coroners’ inquest. https://www.hee.nhs.uk/sites/default/files/documents/Supporting%20doctors%20in%20training%20attending%20a%20Coroners%27%20Inquest.pdf (accessed 28 Sep 2022).
11. Health Education England. Coroners’ inquests — a guide for trainees. 2021. https://www.hee.nhs.uk/sites/default/files/documents/Coroners%E2%80%99%20Inquests%20-%20A%20guide%20for%20Learners%20_0.pdf (accessed 28 Sep 2022).
12. Health Education England. Coroners inquests. 2020. https://peninsuladeanery.nhs.uk/about-us/policies-and-guidelines/coroners-inquests (accessed 28 Sep 2022).

Featured photo by Gift Habeshaw on Unsplash.