Dr X, an A&E Registrar, encountered a patient with a complex medical history presenting with severe abdominal pain and vomiting. After an examination, Dr X diagnosed gastritis and prescribed Ondansetron and fluids for symptomatic relief and hydration. Dr X also ordered abdomen and chest X-rays.

Reviewing the X-rays with the A&E Consultant revealed no signs of obstruction or perforation, leading to the decision to discharge the patient after observation. Dr X was not made aware of any concerns or escalation regarding the patient during their observation period, and the patient was subsequently discharged.

Tragically, the patient passed away in the early hours of the following morning, and a post-mortem report identified a small bowel perforation. Consequently, Dr X was asked to provide a statement to the Coroner and was later summoned to the Coroner’s inquest into the patient's death as an interested person.

Dr X received the Coroner’s report, which was critical of the Trust and certain aspects of Dr X’s care in relation to the patient. Dr X discussed this with their revalidation officer, who advised immediate self-referral to the GMC, in accordance with the Good Medical Practice guidance.

Dr X approached MDS for advice, and our advisors highlighted that Doctors should be aware that self-referral to the GMC may be necessary as part of Good Medical Practice if a Coroner’s report is critical of their patient care.

The team went further and assisted Dr X with their statement for the inquest, and their self-referral to the GMC by offering advice, but also helping to collate and complete the necessary supporting documents.

Dr X self-referred, and the GMC initiated a provisional enquiry to gather more information to determine if further investigation was necessary. The GMC’s provisional enquiry resulted in no further action. Furthermore, the GMC expressed gratitude for Dr X’s honesty and willingness to cooperate by providing them with information following the Coroner’s inquest and explaining the steps they had taken to adhere to the standards outlined in Good Medical Practice.

The GMC concluded that the concerns did not raise any questions regarding Dr X’s fitness to practice, and thus, no further action was taken.

Two years on, the GMC reopened the matter after the family contacted them to inquire about the decision of the Assistant Registrar that closed the investigation, and MDS again assisted Dr X to navigate this situation.

These are not unusual circumstances, as the family of a deceased patient can ascertain whether a doctor has self-referred to the GMC and may request further details from the GMC regarding a case outcome. In such instances, our general advice is to cooperate with these requests, though each situation requires case-by-case consideration.

In this case after reviewing the situation with Dr X,  we recommended cooperation. When the GMC reopened the case, we advised our member not to object to the disclosure of the decision to the deceased patient’s family. This advice was based on the likelihood that the GMC would deem it in the public interest to disclose the information anyway, and any objection could potentially prolong the family's suffering.

The information was therefore disclosed to the family without objection, and no further action was taken by the GMC.

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Key takeaways from this case

• Coroner investigations can result in further investigations, and they should be approached with care and possibly, professional advice.

• Self-referral may be necessary for doctors as part of Good medical practice where a Coroner’s report has been critical towards their care of a patient.

• The family of the deceased can check whether a doctor has self-referred to the GMC and may request further details from the GMC regarding a case outcome.

• Honesty, openness and goodwill can make a difference in how long proceedings last, and can work in your favour.
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