What Are the Experiences of Mental Health Practitioners Involved in a Coroner’s Inquest and Other Inquiry Processes after an Unexpected Death of a Patient? A Systematic Review and Thematic Synthesis of the Literature
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1. Introduction
A coroner’s inquest is held after an unexpected death. An inquest is an inquisitorial process tasked with answering four specific questions in relation to a death: (1) who, (2) when, (3) where, and (4) how. It does not seek to assign civil or criminal liability. When deaths are complex, for instance, when an individual has died whilst in prison, in police custody, or whilst detained in hospital under the Mental Health Act, the parameters of the investigation are widened to consider the broader circumstances of the death. In these cases, the investigation is much more rigorous [1]. In England, when a suicide or homicide involves somebody under the care of mental health services, there are additional formal investigation processes conducted by the mental health organisation and, in many cases, an independent inquiry.
Practitioners involved in the care of a patient who dies whilst under the care of mental health services may be called to give evidence at the inquest and other local and independent inquiry processes. Multiple stakeholders may be involved in these proceedings. At the inquest, family members, legal representatives for the family, legal representatives for the mental health organisation, and, potentially, the media may all be present. Despite a non-adversarial remit, the inquest process can identify actions of individuals or organisations as having contributed to the death. Biddle [2] describes the inquest as ‘inevitably’ involving consideration of human agency and motivation. This can lead to individuals or organisations being identified as potentially accountable in some way for the death and can contribute to a culture of blame [3].
Research conducted on the impact of inquests on family members following a patient’s suicide suggests it can be unhelpful for the grieving process [2,4,5,6]. This is likely due to the multiple functions that the process has to deliver: it must recognise and potentially contain the grief of those mourning an unexpected bereavement [7], manage the raw and often conflicting perspectives of different stakeholders, and, at the same time, establish the circumstances of the death and make informed recommendations [5]. Sudden deaths such as suicide are complex, and grief is often intensified since there has been no opportunity for preparation for the death [8]. In addition, different types of sudden loss present different challenges. In the case of suicide and homicide, the involvement of the media and the legal system can further complicate the impact on the person’s loved ones [8]. Suicide has been found to be the most stigmatising of sudden losses [9], with that stigma manifesting itself in blame and shame [10], sometimes felt by those who are left behind. Perceptions of preventability may also generate guilt and difficult emotions, including anger and blame [8].
Patient suicide also impacts healthcare professionals; practitioners may be considered as ‘second victims’ following these kinds of adverse events [11]. In a previous study, interviews with consultant psychiatrists revealed that patient suicide was often associated with practitioners feeling blamed, guilty, and professionally isolated, and some suffered a period of poor mental health as a result [3]. Whilst there is growing awareness of the negative impact of patient suicide on practitioners [12,13,14,15,16,17], there has been less acknowledgement in the literature of the impact on practitioners of attending the coroner’s inquest and other parts of the inquiry process.
This systematic review aimed to report on the published evidence in relation to mental health practitioners’ experience of the coroner’s inquest and other inquiry processes following a patient suicide or patient-perpetrated homicide. Our specific objectives were to identify the factors which make the process more or less difficult as well as assess the type and effectiveness of any support received.
2. Methods
We followed the recommendations of the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ (PRISMA) [18]. The study was registered in advance on the ‘Prospective Register or Systematic Reviews’ (PROSPERO)—CRD42023400310.
2.1. Search Strategy
Searches took place on the 3 February 2023 and were re-run in November 2023.
Eight databases were searched with no date restrictions: Medline, PsychINFO, EMBASE (all via Ovid), CINAHL Plus, IBSS, Pubmed, Web of Science and SciVerse Scopus. We also conducted a search across Dogpile, Google Advance and bibliographies for grey or unpublished literature. We used a combination of keywords and MeSH terms. The search was built around key search terms relating to three main concepts: (1) ‘mental health practitioner’, (2) ‘serious incident investigations, homicide inquiries, coroner inquest’, and (3) ‘experiences and expectations’. Search terms can be found in Supplementary File S1.
After retrieving articles, we transferred them to Endnote and removed any duplicates. Articles titles and abstracts were then screened for inclusion by MT with a second reviewer, ST, screening a randomly selected 20%. Full text versions of all articles selected for second screening were then independently screened by both ST and MT. Any disagreement on whether the publication met inclusion criteria was resolved through discussion.
2.2. Inclusion and Exclusion Criteria
Qualitative and quantitative studies were included providing the paper had sufficient extractable findings relating to mental health practitioners and their experience of a coroner’s inquest or other inquiry processes after a suicide or homicide. Systematic reviews, scoping and other types of literature review and non-empirical studies were excluded.
We defined ‘mental health practitioner’ as including anyone who is currently or has previously worked with patients of mental health services, including but not limited to psychiatrists, psychologists, nurses, occupational therapists, social workers, support workers and any other recognised clinical role in a multi-disciplinary mental health team. This included staff working for statutory (NHS and Local Authority) and non-statutory (voluntary sector) organisations. Studies reporting on staff who were not working in a clinical role were excluded, as were studies reporting on other stakeholders who may be present at an inquest (e.g., employees of coroner offices, police, or bereaved family members).
Papers focusing on patient safety events which did not result in the death of the patient by suicide or patient-perpetrated homicide were excluded, as were papers focusing on investigations involving non-mental health staff.
2.3. Data Extraction and Quality Appraisal
MT extracted key characteristics of included papers, as defined in the PROSPERO protocol, into a table. When data were not available, the authors were contacted. MT and ST independently conducted quality appraisals of the included papers. Many of the included studies were cross-sectional surveys. There is no specific quality assessment tool with established validity designed to assess cross-sectional surveys [19]. We, therefore, decided to use an adapted version of the Mixed Methods Appraisal Tool (MMAT) [20], a critical appraisal tool specifically designed for systematic reviews that include studies using mixed methods. Studies are ranked on a one-to-four-star system, with higher-quality papers given more stars. All studies were independently assessed by two researchers (MT and ST), and any differences of opinion were resolved through discussion. This is a relatively new research area, and our aim was to report on the calibre of existing research as well as its content. Therefore, studies were included in our analysis, irrespective of quality. We acknowledge the risk that this distorts the review’s findings or leads to incorrect conclusions [21]. We have sought to counter this risk by conducting quality assessments for each study and reflecting on these in our discussion.
2.4. Data Analysis
Six studies were relevant to our review questions. Our choice of a thematic synthesis approach reflected our review aims and the nature of available evidence [22]. Five of the six studies were surveys, often with limited qualitative data, making integrative synthesis challenging. Studies were uploaded to NVivo 14. Studies were read and re-read to facilitate immersion in the data [23]. All data directly referring to our research question on experiences of attending the inquest or other inquiry processes was extracted from the studies, including direct quotes and comments by the authors. We followed the three-staged approach outlined by Thomas and Harden [24]. (1) MT coded the original data with descriptive themes. (2) These were then combined and organised into related areas and discussed by the research team. (3) Finally, the research team assessed how the themes related to the review’s stated research questions and what generalisable themes were evident. Our thematic synthesis balanced our objectives of staying true to the experiences reported whilst also facilitating the production of new concepts and interpretations [24], which may be considered additive to the overall body of evidence already published [22].
2.5. Analytic Rigour
We followed ENTREQ guidelines [25] to maximise reliability by making our work replicable [26] and to allow readers to assess the dependability of findings [25]. The ENTREQ statement consists of 21 items grouped into five domains (introduction, method, methodology, literature search, appraisal and synthesis of findings) [25]. We used team meetings to develop our conceptual understanding of participant experiences and ensure the validity of our themes [26]. We explored our own reflexivity within the team by reflecting on personal experience as healthcare professionals (HK, JB) and our academic interests in the subject (MT, ST, JB, HK).
6. Discussion
The aim of this review was to identify and synthesise what is known about the experiences of mental health practitioners involved in inquiries following a patient suicide or patient-perpetrated homicide. Our research objectives were to identify the potential factors that make inquiry processes more or less difficult, identify the type of support received, and determine whether it was useful. We identified six papers meeting our eligibility criteria. One of these used qualitative interviews and focuse exclusively on the inquiry experience. Five of the studies, all cross-sectional surveys with additional free-text questions, focused on the wider experiences of the practitioner following a patient suicide or patient-perpetrated homicide.
6.1. Main Findings of This Review
Inquiries were often experienced as a stressful and anxiety-inducing process. It was very common for participants to either fear being blamed or actively experience it through the attitude of other stakeholders involved in the process. This could include, but was not limited to, coroners, inquiry panel members, family members and the employing organisations. Being blamed appeared to be experienced as a cultural phenomenon rather than a discrete or isolated instance. This was one factor leading to negative psychological consequences for many of the participants across studies.
It was also common for people to feel underprepared for the inquiry process. The amount of formal support given varied. Not knowing what to expect contributed to the anxiety felt by practitioners. Education on what was expected of them and what they could expect from the process were frequently suggested areas for support. Even when sufficiently prepared, the inquiry process could still be experienced as obscure, chaotic and uncertain, with practitioners not knowing what was happening and often feeling professionally isolated. Some practitioners, most often those involved in homicide cases, felt their isolation was a manifestation of being blamed and a cultural need to scapegoat the practitioner.
Inquiry findings were rarely viewed as helpful and could make practitioners feel defensive. Findings were perceived as centering too much on individual action and not enough on systemic weakness. Participants in multiple studies described that the findings and recommendations of inquiries failed to recognise the clinical realities of their work. How findings were disseminated was a further issue, often reported as being conducted in a haphazard or ‘tick box’ way, with limited time for reflection or authentic learning.
Whilst the prevalent experience in the included papers was negative, there were some examples of both suicide and homicide inquiries that were experienced more positively. This tended to be when the reality of attending the inquest was better than feared or when practitioners felt supported by their employing organisation. In these instances, practitioners felt they had been treated fairly. Across these papers, there are select examples of good practices in employing organisations and coroner’s courts. In instances when practitioners felt supported and part of a clear and transparent process [27], the experience appears less likely to be damaging for those involved.
6.2. Wider Research
Previously published research in this area is sparse, but findings of the current systematic review can be contextualised within practitioners’ wider experience of patient suicide or patient-perpetrated homicide and by considering the literature on patient family members’ attendance at inquests.
Inquests can be actively harmful to those who attend. This has been evidenced in relation to families [2] and theorised for other stakeholders [5]. The papers in this review suggest that inquests may impact practitioners negatively, especially when internally held feelings of self-blame are, inadvertently or not, reinforced by the practitioner’s employers and in the inquiry processes. The exacerbation of self-blame and professional isolation further undermine the practitioner’s clinical confidence and has been reported to have a negative impact on their mental health and can even lead some clinicians to consider early retirement or to leave the profession [28,30]. However, these papers also report instances when the impact of loss is shorter-lived [27,28,32]. This may suggest that when practitioners do not feel blamed—by themselves or in the investigatory process—and the experience of loss is both recognised and responded to [33], the psychological impact may be less. This is in keeping with Stolorow’s work [34], which suggests that the impact of emotional trauma cannot be explained solely by the pain suffered in the event itself. Rather, the ability to bear the pain is determined by being understood and responded to by others. Thus, responding appropriately to the practitioner’s experience with psychological and practical support may be what allows the pain to be tolerated and processed. More research needs to be conducted to understand this dynamic more fully within this context.
6.3. Blame
Feeling blamed after a patient suicide or patient-perpetrated homicide has been written about extensively [16,35,36]. Self-blame has been found to vary between mental health professions. Malik et al. [15] conducted a critical interpretative meta-synthesis of the impact of patient suicide on doctors and nurses and found doctors tended to attribute the death to a failure of (their) doctor-patient relationship, whereas nurses tended to attribute it to a failure of protocol.
The psychological impact of blame can be far-reaching. Self-blame, placing oneself as the protagonist of the story, can be the immediate response of a practitioner following a patient death in a need to make sense of the inexplicable [37]. If this hypothesis holds, the coroner’s inquest, any surrounding inquiry processes and the experience of support received can either validate this narrative or, conversely, challenge it by reconsidering the role the practitioner played versus what they have come to believe. From this vantage point, the internal distress initially felt by practitioners when they hear about the incident can be made better or worse depending on the response of others, such as the employing organisation, colleagues, the patient’s family, and the coroner.
Interviews with consultant psychiatrists after a patient’s suicide or patient-perpetrated homicide explored these experiences by considering the impact on the clinician’s personal, professional, and organisational ‘self’ [3]. In this framework, a patient’s suicide may involve three different forms of loss. The first is a personal bereavement associated with the loss of that patient. The second is a sense of professional loss, often of confidence in clinical decision-making, particularly if the clinician feels they are to blame. The third form is in relation to the clinician’s self within their organisation and team members. Understanding the practitioner’s experience of these inquiries may help us to better comprehend the impact of blame on the practitioner’s ‘organisational’ self. For instance, if the practitioner perceives their value to their team or organisation as altered by the event that has taken place or if they perceive the level of support offered by their employing organisation during the inquiry to reflect their value in some way. It may be that inquiry processes, an intrinsic part of the wider experience of loss, challenge all three parts of the practitioner’s identity, potentially repeatedly.
A systematic review [16] of the impact on mental health practitioners after a patient’s suicide suggested that loss of confidence in clinical decision-making is common. For example, practitioners can become more risk-averse and less comfortable delegating. This can be problematic where the ability to fulfil one’s role effectively is contingent on operating as part of a multi-disciplinary team, as it is for consultants.
6.4. Not Knowing
In interviews with bereaved family members attending inquests [2], people often described themselves as part of an investigation process shrouded in obscurity. A combination of not knowing what they could expect the inquest to deliver and operational failings, such as delays or insensitive handling of information, meant the inquest could be chaotic, incapable of meeting expectations, and even prolonging the grieving process for families.
This sense of ‘not knowing’ is echoed in the experience of practitioners identified in this review. Improved support and better communication from the employing organisation may partially alleviate this. However, some practitioners, particularly those involved in homicide cases and subject to lengthier inquiry processes, described a more powerful phenomenon occurring, where they felt they were kept in a state of ‘suspended animation’, which was often experienced as punishing rather than simply frustrating. Practitioners often did not know what to expect next or when the inquiry processes would be over. This compounded the psychological impact of the incident and their sense of professional isolation. When thinking about what support is required, a consistent and clear communication process may prove very effective in helping practitioners challenge their own beliefs when they are stigmatised and professionally isolated. Such simple procedural changes might prove psychologically containing for both the individual and the wider organisation.
6.5. Limited Learning
Given the experiences reported, it is unsurprising that practitioners reported that it was difficult to receive inquiry findings constructively. The findings and recommendations were often experienced as critical of them and repeated the experience of feeling poorly supported by the employing organisation. This dynamic is consistent with Stanley and Manthorpe’s [38] observation that in a climate of blame, the ongoing fear of being held responsible prevents meaningful interaction. This may signal a larger cultural challenge of moving beyond a ‘who dunnit’ attitude towards one of openness and learning. In this environment, inquiry findings might lead to learning and system-change. In the current climate of blame, inquiry findings – content and delivery – carry two risks: the risk of exacerbating the feelings of blame and isolation repeatedly reported in these studies and the risk of failing to meet demands of change to the public services that are perceived to have failed families. Without these changes, no value can derive from their personal tragedy [39].
6.6. Strengths and Limitations of This Paper
To our knowledge, this is the first systematic review that looks at the mental health practitioners’ experiences of attending inquiries after a patient suicide or perpetrated homicide. We conducted a comprehensive search of three databases and searched reference lists of grey literature. We used two independent reviewers for screening, data extraction and quality appraisal. We conducted a thematic synthesis and identified themes prevalent across the underlying studies which help identify research gaps for future study. There were limitations in our approach. We only searched a small number of databases and restricted our papers to English language. Consequently, this review may risk publication bias. Owing to the underlying research base and the types of studies published, our thematic analysis was descriptive with only a limited development of themes. Additionally, owing to the paucity of material directly relevant to our research question, we did not weight our discussion towards higher quality papers.
6.7. Strengths and Limitations of the Included Literature
Within the included literature, there are six papers included in our review, five of which adopted a multi-method approach. The qualitative element of each of these studies enabled us to form an understanding of the practitioner’s experience of inquiry processes after a suicide or homicide and how that experience might differ depending on factors such as support received or the conduct of other stakeholders in the inquiry process. In four of the six studies, there were free-text responses which enabled participants to choose what issues were most meaningful to them without responding to directed questions [40].
Only six papers met the inclusion criteria for this review. Cross-sectional surveys are less empirically robust than other forms of research methods. Our quality assessment suggests that whilst the use of qualitative research is appropriate, none of the papers discussed in detail the research methodologies employed and how this might have impacted the research. As a form of qualitative research, optional, open-ended survey questions are less empirically robust than alternative qualitative methods owing to the risk that answers may be unrepresentative and self-selecting nature, making them less transferable to other study populations [41]. Whilst the papers all had open-ended text responses, some authors chose to report findings but did not include illustrative quotations [29]. Across the six papers, there were 634 participants, 502 of whom were psychiatrists, and 472 of those psychiatrists were consultants, leaving us with limited points of comparison to understand the difference in experience across professional fields and career stages. We also note that three of the six studies [28,30,32] came out of the same body in the Royal College of Psychiatrists. The structure of the three papers is similar, which might overstate the commonality of themes. Finally, there is a risk of response bias. People with negative experiences are more likely to have completed the surveys and shared their experiences.
6.8. Areas for Future Research
This area would benefit from more, high quality research to understand the experience and needs of mental health practitioners attending inquests and other inquiry processes.
More research is needed to understand the impact of negative experiences of formal processes on practitioners and the extent to which they influence the mental health practitioners’ own mental health and even potential suicidality. Future research should aim to understand factors within the experience that can make the processes more reparative and constructive for all parties and which of these factors may be addressed through practical support and realistic interventions.
Secondary questions are (1) how the experience of the inquiry process differs between patient suicides and patient-perpetrated homicides and other unexpected deaths, (2) how the experience differs according to the profession, and (3) how the clinician’s personal experience of loss over their lifetimes influence their experiences. These questions will help answer what support is needed for whom.
7. Conclusions
Grief after suicide or patient-perpetrated homicide can be complex for those involved in the patient’s care. Practitioners may be required to assist with formal investigations associated with the death. This systematic review identified limited research into practitioners’ experiences of the inquiry process following a patient suicide or patient-perpetrated homicide. The research that has been conducted to date has tended to be in the form of cross-sectional surveys with some ‘free-text’ questions and one small qualitative study. Most of this research has focused on psychiatrists’ experiences, and the experiences of other practitioners are currently not well understood. Whilst acknowledging these limitations, the findings suggest that a) practitioners often experience a sense of blame after the event (both self-blame and from other parties); b) the investigatory process is often experienced as lacking in transparency and persecutory in nature, which exacerbates the negative impact of the event; c) the identified learning outcomes from the investigatory processes are often perceived as unrealistic for implementation in the clinical setting. In addition, the type and usefulness of support received by practitioners after the event varied but was commonly reported as inadequate. The findings suggested some areas that could improve the situation, such as better communication about the inquiry processes and greater support from the employing organisation to prepare for these, but more robust research is needed to inform the nature of these.
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