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

Psychiatr Psychol Law. 2025 Jan 6;33(3):532-567. doi: 10.1080/13218719.2024.2416646. eCollection 2026.

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.

PMID:42211415 | PMC:PMC13215423 | DOI:10.1080/13218719.2024.2416646