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A systematic review and critique of publicly available guidance for mental health practitioners called to a coroner’s inquest

Tamworth, Millie; Billings, Jo; Tekin, Sahra; Pitman, Alexandra; Jacobson, Jessica; Killaspy, Helen; (2025) A systematic review and critique of publicly available guidance for mental health practitioners called to a coroner’s inquest. Psychiatry, Psychology and Law 10.1080/13218719.2024.2416646. (In press). Green open access

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Abstract

Mental health practitioners may be called to an inquest after the unexpected death of a patient. Our review aimed to synthesise publicly available guidance written for practitioners working in mental health who are called to give evidence at a coroner’s inquest. We conducted both a systematic database and web search. We conducted a quality appraisal and data synthesis using the Framework Method. We found limited guidance specifically for those working in mental health. Guidance gave advice on preparing effectively including how to give oral evidence and write witness statements. Support was often assumed to be given by the employing Trust. Only a minority of guidance suggested means of psychological support. We identified a set of practically applicable principles for healthcare practitioners attending inquests. Many recommendations were not backed by evidence and lacked stakeholder input.

Type: Article
Title: A systematic review and critique of publicly available guidance for mental health practitioners called to a coroner’s inquest
Open access status: An open access version is available from UCL Discovery
DOI: 10.1080/13218719.2024.2416646
Publisher version: https://doi.org/10.1080/13218719.2024.2416646
Language: English
Additional information: © 2025 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
Keywords: guidance; healthcare; unexpected death; staff wellbeing; suicide; mental health; practitioners; homicide
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > Division of Psychiatry
URI: https://discovery.ucl.ac.uk/id/eprint/10203410
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