Respecting the families’ euphoria and personal grief, I delayed this blog post on the Hillsborough inquest verdicts (the verdict came at lunchtime 26 April 2016). Let them savour their day in court, and well done to all on the Justice For The 96 campaign, especially Michael Mansfield QC, who has now got into a bit of a habit of shaking the conscience of our society and our complacency about our state agencies. 

What marked out this coroner’s inquest was the patient-centred approach taken by all. There was a dignified silence within the coroner’s court and outside on the court steps as Liverpool football club’s fans and the bereaved families sat listening to the sensitively presented coroner’s reports on the circumstances of each victim’s death.

The tone, language, and sensitivity of the narrative was quite different from the one used in the original documents and inquest 27 years ago. Maybe it is the patient-centred modern coroners’ courts, or the unbiased, well trained, and independent teams used on this fresh inquest that brought out very sensitive, personalised, and touching “cause and time of death” reports.

It started by simply calling each victim by name and not a letter or number (96 names in all were read out!) and each injury and the reason for asphyxiation was shared in a personal way.

The jury’s verdict was but an anti-climax after the coroner’s thorough findings into the tragic deaths all those years ago in the Sheffield Wednesdays’ Stadium.

Suddenly I realised that patient-centric post-mortems and inquests led by culturally sensitive coroners were just as important in restoring a deceased patient’s dignity and giving closure to the bereaved, as is patient centric healthcare when they were alive.

While all the development and innovation in health systems has been concentrated upon frontline services, everybody has forgotten about the coroners. The Coroner and Justice Act 2009 creates a unique chimera of a doctor-lawyer (the coroner) who has to investigate each death that is sudden, unexplained, violent, or within a state institution and care facility. If there is a hint of “unnaturalness” about the death that is not explained through a post-mortem, then the coroner has to hold an inquest. This is an open public court hearing held to establish who died and how, when, and where the death occurred. Actions later follow the verdicts of the jury as the Criminal Prosecution Service (CPS) and the police have to bring about criminal proceedings where deaths are declared unlawful.

We need investment in patient centric coroner’s services. A patient should have their rights respected even when dead. There is a great need to train medical personnel who conduct post-mortems on how to write about the cause of death, injuries, and any adverse pathology related to the death, sensitively and in a personal way.

Lastly and most importantly, it is incumbent upon the coroner and the police to ensure that they show dignity, respect, and sensitivity towards the patient as if they were alive and sitting in the dock. If they don’t feel the presence of the patient, rest assured that their family and friends do.

Kawaldip Sehmi is CEO of the International Alliance of Patients’ Organizations.

Competing interests: None declared.