A Coroner’s Inquest – what an experience!

I won’t lie - this past week has been a scary old one. I’d known for a few months that I would have to attend the coroner’s inquest into our patient who died of sepsis last year, but what with the wedding and all, I’d tried to put it all out of my head.

I’d heard from some of my colleagues that they’d been to coroner’s before and they told me how scary it had been; how they’d been interrogated by the coroner and confronted by family solicitors, so I was fully prepared to soil myself, return my PIN to the NMC and report to the local police station to request my life sentence.

I asked Steve if he could go instead of me. He told me he had been called as well so had to go in addition to me.

I asked Matt if it would be possible to bring our family planning forward so that I was in the midst of giving birth just at the time that I was due at the gallows. Once he’d stopped laughing, he said no.

So, there I was - ready to be fed to the lions, and I said as much to Carla. I was a bit shocked when she gave me a bit of (lot of) a bollocking. Told me that it was part of my role as a nurse to share information so that the circumstances around the death could be established. More than that, she said it was an opportunity to learn from mistakes, if there had been any, and how would I feel if someone else died from sepsis when we could prevent it, just because I was too frightened to speak.

That’s what I hate about Carla – she’s always right!

 

Both Steve and Carla said I needed to start looking at this differently. The thing is you can’t ‘unhear’ what you’ve already heard and so I’d already decided it was going to be a traumatic experience from all of the horror stories whispered in my shell-like.

Steve sat me down so we could both re-familiarise ourselves with the medical and nursing notes. Steve assured me that it would be fine (he had been called to a couple in the past as a witness) and that all the Coroner was interested in was establishing the facts. He said that the aim was to answer four main questions of who had died, when they’d died, where they’d died and how they’d died.

Well we already knew the answers to the first three questions, so it didn’t take Einstein to figure out that the main focus of the inquest would be how. Steve and I spent a full 3 hours reading the notes and cross-examining each other really about our own individual actions. It was a good opportunity for reflection and we felt that the only thing we could have done differently was been more alert to the possibility of sepsis and therefore kept an eye on it.

Steve decided that action on that was needed immediately so he discussed it with the Director of Nursing with a view to implementing something into the current observation checklist. Apparently, observations aren’t currently carried out religiously for those people who are just waiting to be discharged, but as we found out from our patient who died, they need to be.

The day of the inquest came. I must have looked a right sight as, despite the preparation and the reassurance from Steve, I was struggling to sleep at night and couldn’t quite rid myself of the thought that it was going to be horrendous.

It didn’t help that the setting was so formal and that I had to take an oath. When I was called, the Coroner smiled at me and asked me to state my name, qualification and position. I passed that with flying colours! But then he asked me to explain what training I’d had to become a Registered Nurse and my mind just froze. Was he trying to oust me as a fraud? He could see I was struggling so he assured me with a smile and said he would like me to explain for the benefit of the family the depth of knowledge that a nurse had to achieve before she was fit to be registered. I was ok then. I explained about my training and also the courses that I had completed following registration. I told him about the sepsis training that I had undertaken just weeks before the patient had died and that had helped me to pick up the warning signs quite early. He asked me whether we had identified any signs of infection prior to her becoming unwell and I answered as honestly as I could. I said that I hadn’t noticed any signs and that there wasn’t anything in her nursing or medical notes from my colleagues that indicated an infection.

The family didn’t have any questions for me, so I wobbled my way back to my seat – my legs were like jelly.

It was Steve’s turn next and he had to answer questions about the staffing numbers, skill mix and systems that were in place at the time. He looked so confident and answered very clearly. I wanted to shout out that he was a great leader and ran a very tight ship, but even I’m learning there’s a time to stay silent.

The medical staff were next and they discussed the difficulty in identifying sepsis at an early stage. They talked about prothrombin time and partial thromboplastin time (PT and PTT), platelet count, and d-dimer which lost me a bit. Basically, if your platelet counts are low this can mean that your body is forming many unseen clots in tiny vessels all over your body, which is an important sign of potential sepsis. They also said that because some of the initial symptoms such as difficulty breathing and fever were common to other conditions, sepsis couldn’t always be confirmed simply from these symptoms. The patient also had COPD so difficulty breathing was a symptom of her existing condition.

At the end of the hearing, the Coroner was able to establish the circumstances around her death. He felt that everyone involved had acted promptly and appropriately as soon as they identified a problem and was satisfied that Steve’s work with the Director of Nursing off the back of the death would help to ensure that systems were as robust and pro-active as possible.

I felt a bit ashamed at the end of it as I was relieved it was all over. I spoke to Steve and kind of fessed up that my worry for myself overrode everything else and I’d sort of forgotten the patient and their family in all of this.

Steve just rolled his eyes – told me I might want to take a day off from beating myself up all the time and that it was ok (sometimes) to have human feelings!

I doubt I’ll ever change!