Dr C had been contacted by the coroner to give evidence in an inquest concerning a patient who had died of metastatic bowel cancer. She had provided a statement some months ago without contacting Medical Protection, her medical defence organisation (MDO), for advice.
Dr C was subsequently called as a witness of fact to the inquest and had been halfway through giving her evidence when the coroner abruptly halted proceedings, and informed Dr C that her status was being changed from that of a witness of fact to an interested person. The coroner strongly advised Dr C to contact her MDO and announced an adjournment to allow her to do so.
On contacting Medical Protection for assistance, the medicolegal consultant considered it was necessary to instruct a solicitor, and arranged urgent representation for Dr C at the inquest. As the coroner had only adjourned the inquest for an hour, the solicitor contacted the coroner to ask for a longer period of time to obtain documents and meet with Dr C and the medicolegal consultant. The coroner granted a further hour and stated that Dr C had come to the inquest woefully unprepared to give evidence and could not explain the rationale for any of her clinical decisions in relation to the management of the patient, hence the decision to grant her interested person status. The coroner considered the lack of preparation disrespectful to both herself and the bereaved family, and had informed Dr C of this before adjourning.
A Teams meeting was arranged and Dr C sent through her statement and relevant medical records. The statement was very brief and consisted of a small number of copied and pasted consultation records. On discussing the statement with Dr C, she said that the practice manager had written it on her behalf and she had simply signed it. From the questions asked by the medicolegal consultant about the patient’s consultations, it became clear that there had been a failure to follow NICE guidance and a number of opportunities to refer the patient for further investigations for possible bowel cancer, had been missed. By the time the diagnosis was made, the patient already had metastases. Dr C accepted that the NICE guidance hadn’t been followed and that it would have been appropriate to refer to secondary care at a much earlier time.
The solicitor explained the purpose of an inquest to Dr C and the importance of a good initial written statement followed by appropriate preparation in the event of being called to give evidence. Dr C was not aware of the formality of the inquest process.
Dr C was advised how to approach the process of giving evidence and to outline what steps she would take in future in relation to a patient presenting in a similar manner. She and the solicitor then rejoined the inquest and proceedings resumed. Although the coroner expressed displeasure at Dr C’s lack of preparation, she accepted an apology and an explanation by the solicitor that Dr C had not appreciated the formality of the inquest process and would be much more prepared in future.
The coroner was critical of Dr C’s management of the patient, particularly the failure to recognise that a referral should have been made at an earlier stage, which meant that Dr C was required to self-refer to the GMC in order to fulfil her obligations laid out in Good medical practice. The medicolegal consultant and solicitor assisted in drafting a self-referral and warned Dr C that an investigation was likely to be opened.
The GMC subsequently commenced an investigation and this progressed to the Rule 7 stage, where formal allegations are put to the doctor. Dr C met with her Medical Protection team and a detailed response was drafted, setting out Dr C’s rationale for not referring the patient at an earlier time, but also making clear that she now appreciated further investigations should have been requested and what she would do in future if faced with a similar scenario.
Dr C also wrote a lengthy reflection for submission to the GMC. Testimonials were obtained from Dr C’s colleagues which set out that her clinical work was considered to be of a high standard and there had never previously been any cause of concern. Her colleagues also set out that she was approachable, friendly, and cared deeply for her patients. In addition, an audit of Dr C’s recent consultations was conducted and showed no cause for concern.
The GMC considered the material provided and closed the case with no further action. They stated that Dr C’s response and reflection were comprehensive, heart-felt, and honest, and demonstrated learning from the incident. Because of this, they formed the opinion that there was limited risk of repetition and it would not be possible to demonstrate that Dr C’s current fitness to practice was impaired.
Dr C was grateful for the assistance provided by Medical Protection and, when asked for a statement by the coroner for an inquest into the death of a different patient, approached us immediately for advice.
Learnings
An inquest is a formal court process and requires careful preparation – it is preferable to contact Medical Protection, or your MDO, at an early stage in order for your statement to be reviewed and advice provided before submission to the coroner.
Your statement should be written by you and not delegated to another member of staff to write on your behalf.
When giving evidence, know your statement and the medical records well, and be prepared to answer questions in relation to your rationale behind your clinical decision making.
If your management of patients has changed as a result of the case, it is appropriate to acknowledge this – the coroner will be seeking reassurance that the same situation is unlikely to arise again.
Be aware that if you are criticised by the coroner, self-referral to the GMC is likely to be necessary to fulfil your obligations under Good medical practice.
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