Narrative verdict at an inquest

[plymouthmaid]

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]

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]

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]

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]

Thinking of you x

[Northernlurkerisbehindyouboo]

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]

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]

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.

[MiaAlexandrasmummy]

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.

[Elle8789]

My gorgeous 28 year old son was found dead october last year at the bottom of his apartments . its going all through the Chanel's at the moment the police did not investigate his death properly at all . there was suspicious circumstances .!! They just wanted an easy life put it down to drugs . my son was x army a personal trainer in London lived and loved life. I spent months getting a file together that none of the 3 men and woman that night statenents matched police did no check CCTV from his apartment they did nothing. That's why cppi have agreed with me . there's so much incompitence I can't even go into it. The inquest was a shambles the coroner would not let ask questions speak it was terrible. He would not listen to anything . Then he xamevup with a decision of a narrative verdict . I kept saying what in gods name does that mean ?? I left that court room in a daze . I was told by the coroner's officer put a complaint in this is not right . the following days I found myself having a nervous breakdown and I didn't want to be here anymore. That was 10 months ago I'm now ready to go after putting a formal complaint in about the disgusting behaviour of this coroner .my son was murdered that night and I will prove this. Does anybody know am I still able to do this 10 months later as it was due to I'll health I didn't do it straight was x

[endofthelinefinally]

Elle8789
Go and see your MP and take a summary of your records with you.
There will be a toxicology report and you are entitled to see it.
There are charitable organisations that can help.
I am so sorry about your dear son.

[Elle8789]

Hi
I did see it he tested positive for mild amphetamine. He had trained a client that day I had his gym pre work drink tested it tested positive for amphetamine like substance . The coroner wouldn't listen or read a letter from the olimpic board . He didn't have drugs in him . I will go to my mp about this coroner and now the crown prosecution better do there job . I have spoken to the court of human rights they have confirmed my sons liberty was taken from him everyone has the right to a full investigation

[endofthelinefinally]

Elle8789
There was a big scandal a few years ago where a coroner was sacked as a result of similar behaviour. A lot of cases were reviewed. It was awful for the families involved.

Sorry OP - don't mean to hijack your thread, but this is very close to home for me and I have been in a very similar situation to Elle.

[Elle8789]

There are no words for me losing one of my gorgeous boys its broken me and his brother is devastated . This should of gone straight to trial . This coroner needs romoving that day was disgusting in court. Now iv slightly got my brain functioning again I will deal with this. The coroner's seem to think there god iv read so much of this that families are put through even more pain. To them there numbers .These are our children that were taken way to young peoples husbands wife's parents sons daughters. Its not good enough by any means. I gave my son my word I will prove he was murdered