My experience in a coroner’s court – a nurse perspective

Summary

This is the story of a nurse's experience when attending a coroner's court and how the Trust supported them through this difficult time.

Content

We have all heard of the terrible stories of nurses going to the coroner’s court. These stories have been fed to us by our seniors, our mentors, our lecturers since we were students.  

"If you don’t document properly, you will end up in the coroner’s court, you might even get struck off!"

These stories strike the fear of god into you. No one wants to go to coroner’s court, no one wants to be criticised for the work they have spent years training to do. No one wants to be publicly humiliated. 

This is my story of what happened when I attended a coroner's hearing on a patient who was in my care.

I was a band 6 at the time. It was a usual day on the medical ward. Busy. I had a bay of six patients. Three of them were fit for discharge, but no community placement for them to go to, two medical patients and one who was a surgical patient.

The surgical patient was under the medics and the surgeons. He came with abdominal pain; he was waiting for a surgical review.  Many patients are under numerous teams on the medical ward. One of my roles is to ensure that they get seen by each team every day to ensure a plan for treatment.  

Today was no different. The patient was seen by the medical team who said "await surgeons". I chase up the surgeons, but they are in theatre. From experience I know that they will be out of theatre by late afternoon – so hopefully I can catch them then.

In the meantime, the surgical patient becomes unwell. His blood pressure drops, his NEWS of 5 from 0. He is tachycardic. I call the medics who attend – they want me to call the surgeons… no answer.

Intensive care team arrive – to this day I’m not sure how they knew to come, perhaps one of the medics called them?

The intensive care doctors I hear raging down the phone at a poor surgeon who is in theatre. The surgeon comes to the ward and soon realises the gravity of the situation. 

There are discussion that are being had away from the bedside – I’m not sure what was being said or plans that were being made. I was not part of the process. I’m busy doing observations every 5 minutes as requested, plus trying to look after my other five patients.

All of a sudden we are going to theatre. I’m still unsure what’s going on. What’s he going there for? The patient looks really scared. I bet I look scared too! I help wheel him down to the operating theatre. As soon as we arrive in the anaesthetic room he has a cardiac arrest. We try and resuscitate him to no avail.  

I went back to the ward; bewildered, sweating from doing chest compressions, confused and with tears in my eyes. I have a quick cup of tea and I’m back out on the ward again.

Three months later my manager asks to see me in the office. ‘What have I done wrong?’ When anyone asks for you to come to the office, its usually bad. They ask if remember the surgical patient who arrested a few weeks back. Of course, I do. I had been thinking about it ever since. I had been worrying about it. I felt it was my fault. They tell me that the case is going to the coroner's court and I was to be called as a witness.

I cry. That’s me done then. I’m going to be struck off. I’m going to be found out that I am a rubbish nurse.

My manager was amazing. They had experience in these hearings. They explained the whole process. From what would happen from now until the end of the hearing.

That afternoon I was contacted by the Trust investigation team. They were lovely too. They asked me exactly what happened and help me write a statement. They put me at ease. It was made clear that what happened was not my fault and that they want to find out what happened to prevent it happening again.

The next week or so I had contact with the Trust legal team. I had never spoken to a legal team before in my life. I did feel as if I was a criminal at first. The legal team were also brilliant. They spoke through the actual process; who was in the room, the layout of the room, what questions I might be asked, what the outcomes often are. They gave me advice on how to answer questions; answer what you know as fact, not opinion. If you don’t know, say you don’t know. Be honest.

I had two further meetings with the legal team and the investigating team. This was to check I was ok, to make sure I was supported. For what could be an extremely stressful period of my career, was made so much easier by people taking the time out just to check I was ok. I carried on working throughout this period and working with confidence.

The hearing came. 

I knew what to expect. I knew the layout of the room. I knew the patient’s relatives were in the front row, I knew I had to swear an oath, I knew I had support from my Trust. I was able to speak freely – even the bad bits; no covering up or making excuses for others.

I was asked what happened that day. I was honest. I didn’t know what was going on. I didn’t know what was wrong with my patient. I was not used to caring for surgical patients. Admitting that I ‘didn’t know’ was awful. I should know, shouldn’t I? When I was saying this, I could feel the eyes of the patient's widow bore into me. I had let my patient down and I had failed.

The coroner asked me many questions related to escalation of care to seniors, the policy, my adherence to the NEWS policy – to which I had followed. My part was over in a flash. The next was the surgeon, who got most of the grilling. Why was he not there, where was his documentation, why did he not come when asked repeatedly? It wasn’t his fault either. He was in theatre with another patient. He can’t be in two places at once. I felt really sorry for him. I hope he got the same support I did.

The outcome of the hearing was to issue a regulation 28. This ensures that a report is sent to the government by the Trust as the coroner believes that action needs to be taken can to prevent future preventable deaths.

So, what happened then?  

I went back to work and carried on as usual. The ward where I worked no longer takes surgical patients. They made a new unit called the ‘surgical assessment unit’ where surgical nurses care for this cohort of patients.  

I wanted to share this – yes, there are many issues surrounding this, but the point I wanted to get across is that the investigation team, my manager and the legal team supported me through this difficult time. I am not sure if other Trusts have this level of support for staff attending coroners court.