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Multiple jeopardy

A patient dies after amoxicillin reaction – we support GP through criminal investigation, inquest and GMC hearing.

Key fact: The new state-backed indemnity scheme will cover claims, but it is not expected to provide protection against a wide range of issues, such as (but not limited to) GMC hearings, complaints or inquests when it is launched in 2019.

Dr S, a GP, was asked to review a positive sputum culture result that seemed to indicate treatment with antibiotics was required.

The patient was Mr J, a 48-year-old non-smoker who rarely attended the surgery, but had been seen by a GP colleague (who was on leave when the sputum culture result was received) the previous week with a productive cough.

Dr S reviewed the records, which stated “defer antibiotic therapy until sputum culture results are to hand”, and decided to contact Mr J by telephone.

Mr J explained that whilst there had been some improvement in his symptoms, he continued to have a cough productive of green sputum. Dr S explained that the results of the sputum culture suggested that antibiotic treatment may help, and prescribed amoxicillin 500 mg, three times a day.

Unfortunately, the practice computer system was unexpectedly down. Dr S wrote a handwritten prescription and made himself a note to record this (together with a note of his telephone conversation) on Mr J’s records when the system was back online.

Mr J’s wife collected the prescription from the practice shortly after Dr S’s telephone call with Mr J.

Later that afternoon, the practice computer system came back online and Dr S realised that Mr J was allergic to penicillin. Dr S immediately called Mr J to prevent him from starting the antibiotics, but was informed by Mrs J that Mr J had taken his first dose of amoxicillin. It had prompted an anaphylactic reaction and an ambulance crew were in attendance.

Unfortunately, the resuscitation attempts were unsuccessful and Mr J passed away.


Dr S was invited to a police interview under caution to investigate a potential criminal charge of gross negligence manslaughter. Dr S immediately called Medical Protection and spoke to a medicolegal adviser (MLA) - a qualified doctor with additional legal training.

A solicitor, experienced in the field and familiar with the vulnerabilities that doctors face, was instructed by Medical Protection to represent Dr S at the police interview.

Dr S was naturally distressed at this development and was provided with details of the Medical Protection counselling service at the outset.

In advance of the police interview, the MLA and the solicitor met with Dr S and prepared an anticipatory statement. At the conclusion of the police investigation, the matter was referred to the Crown Prosecution Service but they decided not to pursue criminal charges.

The practice undertook a Significant Event Analysis (SEA) and the MLA, together with the solicitor, assisted Dr S in providing a statement. The SEA did identify that Dr S erred in prescribing amoxicillin, but also identified some mitigating factors (including the fact that the practice computer system went down) and made some recommendations to minimise the risk of a similar incident in the future. The incident was reported to the CQC.

The MLA advised Dr S to discuss the matter at his appraisal and directed Dr S to educational resources (including those provided by Medical Protection) to assist with remediation.

The family then made a complaint to the practice and the MLA assisted Dr S with the provision of the response.

Eighteen months after the incident, Dr S was called to give evidence at an inquest into the death of Mr J and Medical Protection instructed a barrister to individually represent Dr S. In order to prepare for the inquest, a conference with the barrister, the instructed solicitor and the MLA was arranged. In addition, the MLA involved the MPS press office to assist with any potential media attention: an anticipatory press statement was prepared in advance of the inquest.

Dr S came over well at the inquest and the coroner returned a narrative verdict referencing the fact that Mr J died as a consequence of an anaphylactic reaction secondary to the administration of amoxicillin. The coroner indicated that whilst he had considered making recommendations to prevent further deaths (under Regulation 28 of the Coroner’s Rules), he had not chosen to do so on the basis of the remedial action taken by both the practice and Dr S. The family were unhappy and asked the coroner to refer Dr S to the GMC – the coroner declined to do so, so the family referred Dr S to the GMC themselves.

A few months later, the GMC opened an investigation into Dr S. Medical Protection helped Dr S to prepare a letter to the GMC, which included reference to Dr S’s insight and the steps that he had taken to remediate.

The GMC subsequently closed their investigation with no action (other than some advice relating to the GMC prescribing guidance), on the basis that this was an isolated incident for which Dr S had demonstrated insight and had taken appropriate steps to remediate at an early stage.