Cardiac arrest leads to inquest

Patient Mr A was a 40-year-old man who had been admitted to a psychiatric residential home (“the home”). Physical healthcare was provided to the home by a local GP practice, where our member Dr M worked as a salaried GP. Mr A had a past medical history of a personality disorder, schizoaffective disorder, and obesity.

Mr A attended a consultation with Dr M accompanied by a support worker from the home. He reported a four-day history of a cough productive of phlegm, shortness of breath and cold sweats. On examination, Mr A appeared relatively well. He had right basal crepitations on auscultation of his chest, a raised temperature and raised heart rate, and normal blood pressure, oxygen saturations and respiratory rate. Dr M diagnosed Mr A with a chest infection and issued a prescription for antibiotics to start straightaway. Safety netting advice was also given to Mr A and his support worker, with specific advice on what to look out for in sepsis. This was Dr M’s only involvement in Mr A’s care.

An inquest is held

This brought Dr M’s care under the spotlight of the coroner, where previously the focus had solely been on the care provided by the home.

How did Medical Protection assist?

We supported Dr M from the beginning by explaining the inquest process and his role within it. We instructed a lawyer to assist Dr M, together with the medicolegal consultant, in drafting his statement based on the medical records, his recollection of the consultation and his usual practice. This was to ensure Dr M’s statement was as detailed and clear as possible to set out his actions at the time and the rationale for them. 

We prepared Dr M for the inquest by discussing the possible risks, the process of giving evidence and how he might best present his position. 

On a clinical review of the case, the medicolegal consultant also identified that the heart rate figure on examination during the consultation fell both into the amber flag and red flag categories on the sepsis toolkit. 

Outcome

With Dr M’s consent, we instructed our own GP expert to opine on the care provided. This expert was more supportive of Dr M’s actions and did not feel that the heart rate alone mandated emergency admission to hospital. Based on the consultation, and Dr M’s assessment as a whole, they felt Dr M’s management with clear safety netting advice was reasonable. The expert also factored in that Dr M would have been aware that Mr A was being cared for in the residential home with staff there to monitor his condition.

Learning points

An inquest is not a trial, and the coroner is specifically prevented from reaching a conclusion that could suggest civil or criminal liability on the part of any named person. However, inquests are detailed fact-finding processes that require careful consideration and preparation. 

Dr M approached Medical Protection as soon as he had received a request for a statement from the coroner, which allowed us to advise and support him from the beginning of the process to best protect his professional position. Members are advised to contact us at the earliest possible stage for assistance with inquest matters.