Case study: A knee replacement results in a call to a coroner’s inquest

A consultant member contacted Medical Protection when she received a complaint from the wife of a deceased patient. Ms Thompson, a consultant orthopaedic surgeon*, had undertaken a total knee replacement, but two weeks later the patient died as a result of developing bilateral DVTs and a pulmonary embolism.

As the treatment had taken place during the junior doctor strikes, Ms Thompson had been the clinician writing the patients discharge letter. It was later found that she had accidentally discharged the patient without providing low molecular weight heparin, while the ward pharmacist checking the discharge letter, had also not spotted the error before discharge.

Furthermore, the patient had struggled to wear compression stockings while on the ward. His wife reported that the patient found them very uncomfortable and chose not to wear them at home . She alleged that they must not have been fitted properly in the first place.

Realising that the coroner would open an inquest into the death of the patient, Ms Thompson called the Medical Protection telephone advice line, whereby a case manager opened a case file for the member.

The member was required to respond to the patient’s wife’s complaint which Medical Protection could assist with, so Ms Thompson sent in her draft complaint response which was reviewed and finalised by medicolegal experts. Ms Thompson was also required to provide a statement for a Serious Incident (SI) investigation. Her dedicated case manager advised her to draft a single factual statement which could be used for both the SI investigation and for the coroner’s inquest.

When the statement had been finalised, some time passed before we next heard from Ms Thompson. The Trust’s SI report had been published and it was critical of the mistake made by Ms Thompson but, made no mention of the role of the ward pharmacist, nor the ill-fitting stockings that the patient refused to wear.

Ms Thompson’s attempts to ensure that the SI report was more balanced were rebuffed. Simultaneously the coroner listed the inquest hearing. During a meeting with the Trust’s solicitors, it became apparent to Ms Thompson that the Trust were not going to be able to represent her interests along with their own, so she returned to the case manager at Medical Protection for help.

After reviewing the documents, her medicolegal advisors determined that there was a risk of criticism at the inquest and applied to the coroner to request that Ms Thompson was made an ‘Interested Person’ in her own right, thus entitling her to legal representation. Medical Protection’s in-house solicitors were instructed to assist Ms Thompson with her preparation for the Inquest and to represent her at the Inquest.

When it was time for the inquest, Ms Thompson gave cogent evidence and advised the coroner of the changes to her practice, and those of the department, since this incident. The coroner’s conclusion was balanced, referencing the mistake by Ms Thompson, but also describing the system errors and circumstances of that day. Ms Thompson was content that it was a fair conclusion in the circumstances. 

As a result of the conclusion, which identified the failing in the care provided, Ms Thompson was obliged to self-refer to the GMC as per paragraph 75a of Good Medical Practice:

The self-referral which was reviewed by her medicolegal consultant and a legal adviser, was highly reflective.

The GMC decided to open an investigation, based in part on the self-referral and in part from a complaint received from the patient’s wife. In addition to the concerns raised about the discharge medication, the GMC complaint alleged substandard surgery and raised probity questions regarding Ms Thompson’s evidence at the inquest.

The GMC obtained an expert report. The GMC’s expert was critical of the member and referred to several aspects of the surgery which they felt fell below the standard expected.

In response to Ms Thompson’s concerns regarding the expert report, Medical Protection instructed their own expert. Using the expert evidence and Ms Thompson’s evidence and reflections, we submitted a ‘Rule 7 response’ to the GMC. 

After consideration by the GMC’s case examiners, the case was closed with no further action, citing the member’s reflections and the demonstrable changes to her practice, which were aided by Medical Protection's advice. Note was also made of the numerous testimonials that were provided and the excellent patient feedback that Medical Protection had included, as part of our robust defence of the member.

While NHS Trusts or Health Boards often provide support with inquests, on occasion, the direction that they want to take does not accord with our member’s interests or their reputation. As a result, consultants often need support from Medical Protection to help them navigate the SI and inquest process and when necessary, step in to represent the member individually when their career is on the line.

When the inquest is concluded, Medical Protection can also provide support with GMC investigations that may occur, including instructing a legal team and an expert to opine on the case. In this case, legal support, expert evidence and early reflection and remediation were key to ensuring that the case was closed with no further action.