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Multidisciplinary care leads to inquest

01 December 2022
GP Dr S is called before the coroner after the death of a 13-year-old patient. By Mohammad Shahid, Legal Adviser at Medical Protection.

Dr S, a GP, appeared before a coroner in relation to the death of a 13-year-old boy, D.

D suffered from morbid obesity from a young age. He was later diagnosed with dilated cardiomyopathy. As a result of his morbid obesity, D was not eligible to undergo heart transplantation or any interim measures pending transplantation, until his weight reduced to a transplantable level.

D was hospitalised and was diagnosed with heparin induced thrombocytopenia, which was a further factor in D not being eligible for interim measures, including mechanical support of his heart. D sadly died two months later.

Dr S appeared before the coroner, along with other GPs and a wider multidisciplinary care cohort, including D’s school, his family and relevant state departments.

The inquest was complex not only because of the breadth of the parties involved, but also given the possible interplay between morbid obesity and cardiomyopathy and the issues of neglect and safeguarding, and the role of children’s services, which formed the crux of the coroner’s considerations.

How did Medical Protection assist?

We supported Dr S by explaining the inquest process: the nature of the coroner’s remit and the scope of his considerations, and Dr S’s role in the process. We explored Dr S’s involvement in detail, with the benefit of both the medical records and our in-house clinical expertise. We were able to advise on possible risks, explore how Dr S and her practice fitted into the wider multidisciplinary picture, and how she might present her position.

With Dr S’s instructions to hand, we were also able to contribute to the coroner’s consideration of the scope of the inquest, in terms of the issues and the witnesses that it would consider.

The Medical Protection legal team also used experienced counsel to assist with strategy discussions and preparations, and to represent Dr S’s best interests at the inquest.


The coroner concluded that D died from natural causes, contributed to by his longstanding morbid obesity, which itself significantly contributed to his death in that it rendered him ineligible to receive appropriate treatment.

In respect of the GPs in particular, the coroner found that appropriate care was given by the GPs, but that a failure to engage in weight management should have led to a referral to children’s services.

Throughout the inquest hearing, the coroner expressed his concern about the absence of a specific reference to ‘obesity’ in national guidance relating to signs and symptoms of neglect in children. The absence of such a reference was a matter of concern as to how obesity in children is viewed as a public health issue in comparison to malnourished or underweight children (which are both referenced as signs and symptoms of neglect). The consensus from the public health witnesses was that obesity should be included within national guidance as a sign and symptom of neglect in order to protect children at risk.

Learning points

While a coroner’s findings do not equate to civil or criminal liability, they are significant, statutory, fact-finding processes that require careful consideration and preparation.

This inquest in particular took a considerable amount of time to reach a final hearing, not least because of the breadth and complexity of the issues. Understanding how you fit into this often complex process and how you might best navigate it requires careful preparation, and indeed experience. We would encourage you to contact us if a coroner asks you to take part in an inquest, whether that is as a witness of fact (somebody who may be said to be more peripherally involved in the circumstances of an individual’s death) or whether, in the first instance, it is considered that you may play a more significant role in helping the coroner determine who died, when, where and how.