Narrative verdict at an inquest

(9 Posts)
plymouthmaid Sun 21-Oct-12 00:01:31

I have recently attended my Mum's inquest, after a wait of 17 months,the coroner recorded a narrative verdict. Can anybody help me make sense of this?

Northernlurkerisbehindyouboo Sun 21-Oct-12 00:05:24

I think a narrative verdict is used for the coroner to express complex views - so the cause of death may be one thing but there are other factors which the coroner feels should be public and which a simple verdict, as to the cause of death, would not express. Have you got a copy of the coroners verdict? What are the main points raised?

plymouthmaid Sun 21-Oct-12 00:27:43

Thankyou. Mum died following an operation to give her a tracheostomy and although she was very poorly it was expected that the operation would help her on the road to recovery.When Mum was being turned following the operation her airway was compromised and they were unable,initially, to re insert the tube. Two doctors tried and eventually they called a consultant who managed to re insert the tube, by this time Mum had suffered a cardiac arrest and they were unable to revive her. The coroner raised a number of points but says that Mum being rolled following the operation was the key factor in her deth. He was also critical of the trust in the excessive amount of time it took to eventully conduct the inquest.
I still cant believe that she isn't here. I miss her so much.

Thanks for your reply

t875 Sun 21-Oct-12 00:39:37

I can't answer the question Plymouthmaid, but wanted to say I'm so sorry for your loss, and all this confusion surrounding her passing. Hopefully things will become clearer for you the days ahead. I wild have hated this situation with my mum, although I still wonder why it took 4 hrs to tell us that my mum wasn't coming back from her stroke, when we still had hope.

My thoughts are with you at this awful time. X

madasa Sun 21-Oct-12 08:58:37

Thinking of you x

Northernlurkerisbehindyouboo Sun 21-Oct-12 09:39:06

Plymouthmaid - have you complained to the hospital about the care your mum received? You can use a complaint to find out more and most helpfully learn what the hospital are doing differently now. In your mum's case it sounds like the coroner has identified errors. Did the Trust respond to the verdict?

Lougle Sun 21-Oct-12 09:44:32

I'm sorry your Mum died unexpectedly. Have you asked if there are protocols about positioning after a tracheostomy operation? It may have been normal to roll, but unforseen complications arose, or not normal to roll, in which case either an error, or even an undesirable necessity.

janey68 Sun 21-Oct-12 10:39:15

As indicated above, there may be a narrative verdict when there is no single identifiable cause of death, and where no one individual is responsible. So, where there may be multiple factors, uncertainties and complex issues surrounding the death, a narrative verdict enables the coroner to describe the circumstances around and leading up to the death.

I'm sorry for your loss and that it's been compounded by such a long wait to try to find answers. It doesn't make it any easier for you, but maybe the exceptionally long wait was due in part to the complexity and needing to gather information from a lot of sources? Although it sounds as though various people dragged their heels too, as the time scale was criticised in the verdict.

Hi there - janey and northern are absolutely correct, a narrative verdict is one when a death is not simply explained, and the coroner wishes to provide more details. If the coroner feels that there is 'causative effect', in that actions or omissions directly contributed to a death, it may include words such as failure / neglect / incompetence or even negligence.

As in the case for my daughter, the coroner can stipulate a Rule 43 report on the trust to force them to review aspects of their care, especially if it is thought this can prevent future deaths. Did this happen? If not done at the time, it is possible for this to be stipulated later on if another similar situation arises.

Unfortunately, there is no standard timeframe for inquests to take place, which seems a little crazy to me, as time inevitably fades memory.

You can certainly place a complaint against the hospital about their care, and they are obliged to respond to you. The hospital should have done a Root Cause Investigation Report, and you can ask to see this, and write to the chief executive if you are not satisfied with the report or its recommendations. You might also have grounds for a compensation case too, if you wished to do this, but I am not a lawyer at all, so seek legal advice on this front.

In the end, none of it changes the fact that you have lost your lovely mum though, and you might want simply to leave things as they are.

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