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Into the Unknown – Attending an Inquest


Dr X is a specialist trainee in Trauma and Orthopaedics. They reviewed an older patient in the Emergency Department referred with a hip fracture following a fall on returning home from regular dialysis. The patient was also being treated for heart failure. Dr X reviewed the patient and after discussion with the Orthopaedic Consultant on call, it was decided that the patient should be transferred to another hospital that could provide dialysis as well as operative treatment, renal care not being available at the hospital. Dr X handed over the care of the patient to the Consultant at the receiving hospital.

D X had no further contact with or communications regarding the patient but was saddened to hear that they had suffered from a cardiac arrest a few hours after arrival at the receiving hospital in the early hours of the next morning. An RCA was conducted by the receiving hospital, and the matter was referred to the coroner for an inquest hearing.

Having written a statement for the coroner before contacting MDS, Dr X was called to give evidence at the inquest and asked MDS for advice about this. 


Initially MDS needed to be aware of the full case details thus Dr X provided copies of the hospital notes and, after a formal request, MDS were able to view the inquest bundle including the RCA report.

It transpired that the patient had developed worsening hyperkalaemia during their 12 hour ED stay which was not recognised on arrival at the receiving hospital. This was the presumed cause of the cardiac arrest. Treatment for hyperkalemia had been given by the ED team and advice sought from an ICU Consultant regarding the patient’s renal status. ED had made a medical referral and a remote renal physician had been made aware of the patient. The RCA concluded that the referring hospital teams had not been aware of how to access appropriate acute renal support and that there had been a lack of a comprehensive handover resulting in undertreatment of hyperkalaemia and a delay in dialysis.

Dr X had never attended an inquest hearing before, and so MDS provided them with some general advice in relation to the inquest process and attendance at the hearing as well as speaking with Dr X directly to address their concerns. MDS advised Dr X, as a witness, to focus on sticking to the facts relating to their own involvement, actions and decisions in the case when answering questions.

As such MDS could reassure Dr X that their care was timely, involved confirming the Orthopaedic diagnosis and that onward referrals were made, after Consultant input, to an appropriate hospital in order to achieve the best ongoing care for the patient. Dr X could say that they were aware of the medical issues and referrals being considered by the ED but were not directly involved with these aspects of care or any issues regarding the safety for transfer.

Dr X followed our advice and the Coroner’s verdict was ‘death from natural causes’. Dr X contacted us to say that they were very grateful for the help and support that they had received from MDS.


Giving evidence at an inquest can be a stressful experience and it is best to ask for help and advice at an early stage in order to be well prepared. Thus, we would recommend asking for help from MDS in preparing statements for the Coroner before one might be called to give evidence.

The purpose of an inquest is to establish the facts and not to apportion blame. Those giving evidence as a witness at an inquest hearing are required to describe their involvement, decisions, and actions honestly.

The lessons one might draw from this case are that if a patient is under your care but also needs input for conditions outside your area of expertise then it is your responsibility not only to assume, but to ensure and document that all appropriate referrals and advice have been sought and actioned. This involves communicating and collaborative working with colleagues in other specialties. This case also highlights the importance of thorough handovers.