The three minutes that mattered when the coroner called

What do you do when the coroner contacts you asking for a report? Chances are you remember the case vividly, and have played it over countless times. Good outcomes rarely end up as a coroner's case.

I was in my first year as an accredited registrar – finally becoming the doctor I'd wanted to be – when an unbooked patient was referred to us at 36 weeks' gestation, with a breech presentation among other risk factors. Her prior pregnancy had ended in a normal vaginal delivery at term, and she was aiming for a home birth this time. The breech presentation meant that was no longer safe.

I reviewed her, counselled her on why we recommended a hospital delivery, and made sure we had a follow-up plan in place. I spoke to the birth suite consultant and the in-charge midwife, and documented all of it. Just days earlier, I'd happened to read an Avant factsheet on the importance of clearly documenting discussions with patients and disclosure of risk. I didn't think much of it at the time.

The patient was discharged home. Four days later, I received news that she'd delivered at home without medical assistance – a "freebirth" – with a devastating outcome.

Several months on, I was notified that the coroner wanted a report on my role in the case. I'd never done this before, so I turned to Avant. Their legal team talked me through it, gave me clear instructions, and offered to review my report once I'd drafted it. The hospital's legal team offered to review it too, but I wanted an independent set of eyes – someone whose only interest was mine – so I asked Avant to check it as well.

When the coroner's report came back, it noted that my documentation was clear and precise, and that the risks had been adequately conveyed to the patient. I was lucky to have read that factsheet when I did.

What I took from it:

• Document your discussions with patients about risk, clearly and as you go.
• Use your medical defence organisation – the hint is in the name. A simple call gets you clear guidance and certainty about what to do next, while keeping you protected.
• Read the factsheets. Three minutes could be the difference.

Avant's guidance gave me the certainty that they'd be there for the doctor I was becoming.

More information

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