AvMA - Inquest new client form

Please try to complete all sections, especially those indicated by an *. This will enable us to assist you more effectively.
Contact details
Full name (including title)*
Address (including postcode)*
Phone (home)
Phone (work)
Phone (mobile)
Email

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Details of the incident
Name of the deceased*
Date of birth of the deceased*
Your relationship to the deceased (e.g. parent, partner, sibling)*
When did the incident occur?*
When did you first realise that the deceased had suffered an injury as a result of the incident?*
On what date did the person die?*
Which hospital(s) or practice(s) were involved?
Which doctor(s) or other health carer(s) were involved?

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Your account of events
In order for us to provide you with detailed and appropriate advice and guidance, it would be helpful if you could include the following in your account of events:
- What illness, injury or other condition the deceased was being treated for
- What treatment the deceased received (e.g. medication prescribed, operations) including the dates if possible
- What problems you consider there were with their care
- The circumstances of the death, including the medical cause if known
*
Are you seeking assistance with anything else in addition to the inquest?
- Explanation and/or apology
- Disciplinary action
- Financial recompense

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Inquest new client form