Learning from death

Reporting a death to the coroner by a doctor is not a statutory duty. It is, however, expected good practice. This article discusses some of the concerns arising out of current everyday practice that can lead to problems for doctors and their employing organisations. The author considers the importance of risk management, clinical audit and clinical governance in identifying what systems may need to be addressed within hospital and primary care trusts to ensure that deaths arising out of, or occurring during, medical care are investigated appropriately. As part of risk management and controls assurance, NHS Trusts should be able to demonstrate that lessons are learnt from adverse outcomes. This article explores the roles of postgraduate tutors, risk managers and the protection organisations in promoting good practice from the start of a doctor’s career.