Inquests and inquiries expert witness reports

Conditions and presentations

• Deaths during section 17 leave

  Risk assessment and leave decisions.

• Deaths following discharge

  Including aftercare planning under section 117.

• Deaths from physical restraint

  Including positional asphyxia and acute behavioural disturbance.

• Deaths from rapid tranquillisation

  Medication choice, dose, and monitoring.

• Deaths from self-neglect

  Including capacity considerations.

• Independent investigation reports

  For NHS England and integrated care boards.

• Learning disability deaths

  LeDeR-relevant analysis of avoidable factors.

• Narrative verdict assistance

  Drafting input on contributory factors.

• Neglect and standard of care

  Whether failings amount to neglect within the coronial meaning.

• Prevention of future deaths reports

  Identifying systemic learning under regulation 28.

• Psychological autopsy

  Reconstructing the mental state in the period before death.

• Public inquiry evidence

  Including Article 2 inquiries into systemic failings.

• Substance-related deaths

  Where psychiatric care is in issue.

• Suicide in custody

  Prison and police custody deaths.

• Suicide in mental health detention

  Including the role of section 17 leave and observation policy.

Typical questions for the expert

• What was the deceased's mental state in the period before death?
• Was the standard of psychiatric care reasonable?
• What systemic learning is identified?

Reports provided

Reports for the coroner, addenda following disclosure, and oral evidence at hearing.

Experts owe their primary duty to the court under CPR Part 35 and equivalent procedural rules.

Related practice areas

Cases in this area often overlap with our work on clinical negligence, criminal proceedings, and mental capacity and court of protection. You may also want to read our full list of practice areas.