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Advances in psychiatric treatment (2009), vol. 15, 17–22 doi: 10.1192/apt.bp.108.005512 INVITED Coping with suicide: a perspective from COMMENTARY Scotland INV I TED COMMENTARY ON … COP I NG W I TH A CORONER ’S I NQUEST † John S. Callender & John M. Eagles The investigation by the fiscal will begin by John Callender is a Consultant SUmmary ascertaining the cause of death. The fiscal has Psychiatrist and the Associate Medical Procedures following suicide differ in Scotland from elsewhere Director at Royal Cornhill Hospital, control of the disposal of the body until enquiries in the UK and we describe the investigation of deaths by Aberdeen. John Eagles is a Consultant are complete and has the power to instruct an procurators fiscal and fatal accident inquiries that may ensue. Psychiatrist, also at Royal Cornhill Hospital, and Honorary Professor in the Higher Scottish suicide rates, and possible reasons for these, autopsy. Statements (also known as ‘precognitions’) will be taken from relevant witnesses, who may of University of Aberdeen’s Department of are mentioned. Suicide risk cannot be accurately quantified in Mental Health. individual patients but psychiatrists should take the view that course include clinicians. These statements can Correspondence Dr John Callender, good management can collectively reduce the risk among all be taken by a procurator fiscal, procurator fiscal Royal Cornhill Hospital, Cornhill Road, patients. We comment on practical and emotional issues for depute or a precognition officer. In the case of Aberdeen, AB25 2ZH, UK. Email: john. clinicians who are coping with the suicide of a patient. suicides by patients under psychiatric care at the [email protected] time of death, case notes will be obtained as part DECLaration OF INTEREST †pp. 7–16, this issue. of the investigation. A police or sheriff officer is None. sent to obtain these, sometimes with little advance warning. It is therefore important to make a Within the UK, there are some significant photocopy of all records as soon as possible after differences between countries in official procedures the death. relating to suicide, and this article is intended to Fiscals normally interview the spouse or next complement that of St John-Smith and colleagues of kin of the deceased. They will be asked if they (2008, this issue). wish a fatal accident inquiry to be held and this view will be made known to the Crown Office. National differences A psychiatrist can also be involved in this investigation as an expert witness. A procurator Investigation of deaths in Scotland fiscal can commission an expert report into the In Scotland, procurators fiscal (‘fiscals’) are res- care and treatment received by the patient as part ponsible for investigation of deaths. Investigations of their investigation of a death. are conducted for a number of purposes (Crown Office 1998). These include the need to diminish the risk of undetected homicide or other crime, to BOX 1 Categories of reportable death that might be eradicate dangers to life and health in the public met in psychiatry interest, to allay public anxiety, and to ensure that full and accurate statistics can be compiled. When •• Any death due to violent, suspicious or unexplained cause the investigation is complete, the fiscal sends a •• Any death involving fault or neglect on the part of another report to the Crown Office, where it is decided •• Possible or suspected suicide whether a ‘fatal accident inquiry’ should be held. •• Any death by drowning Deaths in certain categories must be reported •• Any death by burning or scalding, or as a result of a fire or to the fiscal. Box 1 lists those that may arise in explosion connection with psychiatric practice. •• Any death resulting from medical mishap Incidents may also be reported to the police, who will then carry out an investigation and •• Any death where a complaint is received suggesting that submit a report to the fiscal. The fiscal can order medical treatment or the absence of treatment may have been a contributory factor a police investigation if this has not already taken place. In the case of in-patient suicides, the police •• Any death in legal custody should be immediately informed. As part of their •• Any death where a doctor has been unable to certify a investigation, the police can interview relevant cause parties such as clinicians. 17 Callender & Eagles The fiscal will usually request reports of inter- The organisation of fatal accident inquiries is not nal inquiries carried out by psychiatric services such as to promote equanimity in witnesses. One following the deaths of psychiatric patients. Many can expect to be kept waiting to give testimony for services are now applying the methodology of root many hours or even spend an entire day without cause analysis to this process. These reviews are being called. The hearing is formal and is presided sometimes seen as threatening by clinicians, who over by a sheriff. The case is led by the fiscal, who fear that they may contain information or opinions leads evidence from witnesses cited by him or her. that could be incriminatory. Our experience is that These witnesses can be cross-examined by other fiscals usually look for evidence that the service parties or solicitors and counsel representing them. has undertaken a serious scrutiny of the death, Relatives of the deceased are entitled to question that the relevant lessons have been learned and witnesses and can engage legal representation. any necessary changes instituted. If the fiscal is The fiscal can then re-examine these witnesses satisfied on these points, they may feel that the to clear up any uncertainties and ambiguities. public interest has been met and there is less need Other parties can call additional witnesses and the for a fatal accident inquiry. Fiscals sometimes same process of examination, cross-examination come under pressure from bereaved families to by other parties (including the fiscal) and re- recommend inquiries. An internal review can examination takes place. Professional and expert often give families an opportunity to express witnesses may therefore be in the stand for several concerns and to receive an account from clinicians hours at a time. of the events leading up to the death. This may The employing organisation, such as a National provide reassurance and diminish the likelihood Health Service trust or board, will usually have that families will press for a fatal accident a solicitor or advocate in court to represent its inquiry. interests. It is vital that the psychiatrist also has When the investigation by the fiscal is complete, individual representation, which is normally a report is sent to the Crown Office in Edinburgh. arranged by one of the medical defence unions. The final decision about whether to hold a fatal Psychiatric care is generally provided by multi- accident inquiry rests with the Lord Advocate disciplinary teams and a patient will have been in or the Crown counsel acting on his or her behalf. contact with a number of professionals prior to the Expert witness reports will make an important death. Each of these professionals will usually have contribution to this decision. legal representation. The role of these lawyers is not to contribute to a consensus or to a dispassionate Fatal accident inquiries search for truth. It is, quite explicitly, to protect These are statutory public inquiries and are held in the interests of their clients. a sheriff court. They often attract detailed coverage The main source of professional evidence is in the press. Most suicides will not result in fatal the patient’s case record (Box 2). A record that is accident inquiries, especially if an expert report comprehensive, accurate and legible is essential has raised no cause for concern: ‘Isolated incidents if clinicians are to defend their assessments and involving errors of judgment, for example, one- actions. An incomplete record can place the off medical errors … will not normally provide psychiatrist in a vulnerable position and healthcare sufficient justification for discretionary FAIs [fatal professionals should never forget the adage ‘if it accident inquiries]’ (Crown Office 2007: p. 16). ain’t in the case record, it didn’t happen’. A full If an inquiry is held, it need hardly be said that account of the events leading up to a suicide should this can be very stressful for clinicians who have been involved with the patient prior to the death. The process of adjustment to the death is prolonged BOX 2 Suggested medico-legal actions following a and made more difficult. Inquiries are often held patient’s suicide as long as a year after a death. In the time leading up to the inquiry, the psychiatrist will have to •• Make a detailed record in the patient’s case notes of events leading up to the death give statements to the fiscal and instruct solicitors acting in their defence and those representing •• Arrange for full photocopying of case notes their employing organisation. The fact that an •• Inform line manager (e.g. clinical director) and employer’s inquiry is being held at all indicates a degree of legal advisor concern on the part of legal authorities about the •• Obtain independent legal advice from defence union or circumstances of the death. The clinician faces other organisation if there is any possibility of a fatal the prospect of their management being closely accident inquiry or litigation scrutinised in a public arena. 18 Advances in psychiatric treatment (2009), vol. 15, 17–22 doi: 10.1192/apt.bp.108.005512 Callender & Eagles Coping with suicide be recorded in the patient’s case notes as soon as population during 2000–2004. This document possible after the event. also reports a reduction in the England and Wales If a psychiatrist has submitted a report as part suicide rate from a figure of 12 per 100 000 in 1997.

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