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Advances in Psychiatric Treatment (2004) 10: 146-152
© 2004 The Royal College of Psychiatrists

The coroner’s court and the psychiatrist

Bill Calthorpe and Steve Choong

Bill Calthorpe is a specialist registrar in adult psychiatry at the Queen Elizabeth Psychiatric Hospital (Mindelsohn Way, off Vincent Drive, Edgbaston, Birmingham B15 2TZ, UK) and an honorary clinical lecturer in the University of Birmingham Medical School’s Department of Neurosciences and Psychiatry. Steve Choong is a consultant psychiatrist and a clinical director of the South Birmingham and Solihull Mental Health Trust, also at the Queen Elizabeth Psychiatric Hospital. He was formerly chairman of the Clinical Risk Management Group of the South Birmingham Mental Health Trust and is currently chairman of the Management Special Interest Group of the Royal College of Psychiatrists.

In psychiatry we are perhaps fortunate that the death of our patients is not such a regular occurrence as for our colleagues in other specialties or in primary care. However, when death does occur it is more likely to result from some unnatural cause such as suicide. Consequently, the prospect of being involved in a coroner’s inquest is a very real and anxiety-provoking possibility for many psychiatrists. This article considers the role of the coroner in England and Wales and the process of investigation of sudden and unexplained deaths, and offers some practical advice regarding such proceedings. It illustrates a number of issues that have been highlighted in coroners’ verdicts and have implications for the process of clinical governance. It also considers possible changes to the coroner system that have been proposed recently in several high-profile reports.




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P. S. John-Smith, A. Michael, and T. Davies
Coping with a coroner's inquest: a psychiatrist's guide
Adv. Psychiatr. Treat., January 1, 2009; 15(1): 7 - 16.
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