Workshop 3

Coroners, the Care Quality Commission and suicide prevention

The aim of this workshop is to discuss experiences of engaging with coroners and the Care Quality Commission (CQC), in relation to self-harm and suicide.

Recording of the workshop

Agenda

Download agenda for Workshop 3 (PDF)

Slides

Voicing loss: Bereaved people’s expectations and experiences of the inquest process (PDF)

Trauma and its impact upon risk management (PDF)

Moving from unacceptable risk prediction to relational safety (PDF)

Safety assessment and formulation (PDF)

Resources

Papers and reports

• Suicide by nurses: an update report (2011-2022)
• Voicing loss: how witnesses experience the inquest process
• A systematic review and critique of publicly available guidance for mental health practitioners called to a coroner’s inquest (Psychiatry, Psychology and Law, 2025)
• 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 (International Journal of Environmental Research and Public Health, 2024)

CQC and Coroner resources

• Extract from a newsletter sent by the Chief Coroner to all coroners on ‘Focus on Assessment of Suicide Risk’ (sent Summer 2022)
• Reducing harm from ligatures in mental health wards and wards for people with a learning disability

Resources for mental health professionals

• If a patient dies by suicide: A resource for Mental Health Professionals
• What the psychiatrist needs to know about the coroner’s court in England and Wales (BJPsych Advances, 2022)

Resources for inquest witnesses  

• Academy of Medical Royal Colleges guidance for healthcare professionals on acting as an expert or professional witness.
• General Medical Council guidance on providing witness statements or expert evidence as part of legal proceedings. 
• Health and Safety Executive guidance on work-related deaths, including in relation to liaison with other agencies, inquests and coroners. 
• NHS England advice and guidance to support trainee doctors who are required to engage with a coroner’s inquest. 
• NHS England medico-legal learning resource on writing a report or statement and giving evidence at courts, including at inquests. 
• NHS Resolution guide for health providers who are called to give evidence at inquests. 
• Royal College of Nursing advice guide for health care staff called to give evidence to inquests and other investigations.
• University of Plymouth resources providing tips and advice for medical witnesses at inquests. 

Other resources

• Presentation from Philip Pirie at the Royal College of Psychiatrists International Congress, 25 June 2025

This work was completed as part of the Culture of Care Programme. The work was supported by the National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Research Collaboration (GM PSRC) (Grant Reference Number NIHR204295). Leah Quinlivan is fully funded by the NIHR GM PSRC, Pauline Rivart was part funded by the NIHR GM PSRC, and Professor Nav Kapur is part funded by the NIHR GM PSRC.  The views expressed on this webpage are those of the authors and not necessarily those of NICE, NIHR, NHS, or the UK Department of Health and Social Care.