Learning from preventable deaths - inquests and the Coroner's Court

Date: Monday 15 June
Time: 3.25pm - 4.40pm

Overview

Join us to hear the perspectives of 3 speakers, a coroner, a researcher and a psychiatrist. Exploring how coroners' inquests can be approached not only to reduce stress for clinicians but also to foster meaningful learning and systemic improvement. Drawing on the diverse expertise of our speakers - from advisory and clinical practice and coronial work to epidemiological research - this session will offer practical insights and real-world examples to help clinicians better understand the inquest process and its potential to drive safer care.

Dr Richard Brittain, medico-legal adviser and medically trained Assistant Coroner, he also has research interests relating to patient safety with publications such as Preventable suicides involving medicines: A systematic case series of coroners' reports in England and Wales. He will offer advice specifically for psychiatrists attending inquests from a coroner's perspective.

Dr Gabrielle Pendlebury is a child and adolescent psychiatrist and was previously a medico-legal adviser supporting psychiatrists going through these experiences and will share the experiences of psychiatrists attending inquests and an overview of the support on offer and the best way to prepare.

Dr Georgia Richards is the founder of the Preventable Deaths Tracker. The core purpose of which is to save lives by enabling learning from avoidable and premature deaths through evidence-based vigilance and prevention. 

One-fifth (approximately 125,000) of deaths are deemed avoidable in England and Wales and the coroners will investigate these deaths, with approximately 37,000 inquests a year. By law, coroners in England and Wales must write a report when they believe that action should be taken to prevent future deaths and organisations have 56 days to respond. The Preventable Deaths Tracker collates, tracks and learns from these reports, thus saving lives by disseminating learning. She will talk about how this valuable tool can be used by psychiatry.

In this session you will explore:

  • The Role of the Coroner: A unique perspective from a practising coroner and medical adviser on how inquests are conducted and how clinicians can engage constructively.
  • Demystifying the Inquest Process: Practical guidance on preparing for and participating in inquests, with tips to reduce anxiety and improve outcomes, from the author of a new book.
  • Prevention of Future Deaths Reports: How these reports can be used as a learning tool across specialties and jurisdictions.
  • Insights from the Preventable Deaths Tracker: An overview of the innovative work behind this tool, with examples of key findings in areas such as mental health and system-level failures from a leading expert in the field.

Speakers

  • Chair: Professor Derek Tracy, South London and Maudsley NHS Trust, London
  • A coroner's perspective
    • Dr Richard Brittain, MDDUS, London
  • Experiences of clinicians attending inquests
    • Dr Gabrielle Pendlebury, Independent Author, London
  • Learning from preventable deaths
    • Dr Georgia Richards, King's College London, London 
Register for Congress 2026

Please email congress@rcpsych.ac.uk or call 020 8618 4120 with any enquiries.