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Cardiac arrest leads to inquest

15 August 2023


When Dr M is called before the coroner, we step in to assist – find out how. By Dr Beth Walker, Medicolegal Consultant, Medical Protection.

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.

Over the next few days, Mr A deteriorated in the home with difficulty breathing and increasingly deranged clinical observations. No action to escalate Mr A’s care was taken by the home. Very sadly, Mr A suffered a cardiac arrest at the home five days after seeing Dr M. A postmortem examination revealed a pulmonary embolus (PE) as the cause of death with no features of infection.


An inquest is held

An inquest was opened into Mr A’s death. Dr M approached Medical Protection for assistance with preparing his statement and support with the inquest process. A GP expert instructed by the coroner was critical of an aspect of Dr M’s care, which she felt could have led to Mr A being admitted to hospital on the day of Dr M’s consultation and which may have led to the PE being diagnosed and managed at an earlier stage. While the coroner’s expert accepted that a diagnosis of a chest infection (rather than a PE) was a reasonable one for a GP to have made, she highlighted that the raised pulse rate fell within a ‘red flag’ category for sepsis under the sepsis toolkit. The expert opined that the red flag symptom meant an emergency admission to hospital should have been arranged.

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.



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.

Medical Protection’s expert report was shared with the coroner’s expert, who changed her view and accepted that the heart rate was an amber flag and did not mandate immediate admission to hospital.

Dr M came over very well in giving evidence.

The coroner recorded a narrative conclusion, which was critical of the home and its staff. The coroner made no criticism of Dr M. There had been a risk of criticism of Dr M in this case, which was effectively managed by Medical Protection.


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.

Dr M’s records were also thorough, in particular on important positive and negative findings on assessment, and details of the safety netting advice that had been given. A significant amount of time had passed between the consultation and the request for a statement meaning Dr M had no recollection of Mr A or their assessment on that day. Dr M’s detailed, contemporaneous documentation of the consultation was key in this case in supporting his position at the inquest.