Mental Health Clinicians as Inquest Witnesses

A clinician working with mental health patients may be called as a witness to the coroner’s inquest after losing a patient to suicide. A consultant psychiatrist can expect an average of five patient suicides over the course of a 15-year career (that number will vary, depending on the psychiatrist’s specialism). It seems likely that at some point, a psychiatrist will be called as a witness to the inquest. Inquests after suicides of those in the care of mental health services may be more complex; for instance, what is commonly known as an ‘Article 2 inquest’ has a wider remit if the state is implicated in the death.

For mental health clinicians, the death of a patient by suicide can entail a complex grieving process. Clinicians may feel the loss personally. Research suggests that professionally, clinicians who lose patients to suicide may, at least temporarily, question their own decision-making ability. Some start to practise ‘defensive psychiatry’, becoming less inclined to take therapeutic risks with patients. Examples of this include a greater likelihood of prescribing a patient medication or admitting them to hospital. 

Sometimes, the aversion to positive risk-taking arises from a fear of being unsupported by their employer in the event something goes wrong or feeling blamed for a patient’s death either by their organisation or during the inquest. When the clinician does not feel adequately supported to do what they feel is in the best therapeutic interests of the patient, there are clear implications for patient care. 

Attending the inquest is an important part of patient loss through suicide. Yet our understanding of that experience is extremely limited. Alongside my supervisors, I reviewed studies that had been conducted on clinician experience of attending a coroner’s inquest. Although there was not a lot of material, we found three common experiences ^[1]:

1) Clinicians could feel extremely anxious at the prospect of attending an inquest. This anxiety was made worse if they experienced being blamed for the suicide either by their employing organisation or during the inquest.

2) Clinicians often did not know what to expect from the inquest or what they needed to do to prepare. The coronial process was described as obscure, complex and often delayed. These characteristics were made worse by only intermittent communication regarding the inquest by their employing organisation.

3) Clinicians often reported inquiry recommendations as unhelpful and disconnected from the realities of clinical working, making them difficult to implement.  

In the reviewed research, better inquest experiences were defined by good support, clear communication and a fair attitude adopted by the coroner. Asked about support received, participants in these surveys reported a varied experience, but many felt under-supported. Cultural recognition of the importance of supporting clinicians through inquests after patient suicide is a foundational requirement for organisations. The precise form of support may be secondary to this principle. Based on these findings, simple procedural changes at an organisational level such as consistent, clear communication by management and supporting the witness in their preparation may be psychologically containing for individuals involved.  It seems highly probable that a clinician who is well prepared and well supported – by both their organisation and during the coronial process – will be in a stronger position to assist the inquiry.

1. Tamworth, M., S. Tekin, J. Billings, and H. Killaspy. "What Are the Experiences of Mental Health Practitioners Involved in a Coroner's Inquest and Other Inquiry Processes after an Unexpected Death of a Patient? A Systematic Review and Thematic Synthesis of the Literature." Int J Environ Res Public Health 21, no. 3 (2024).