Manchester Coroner’s Court 16-17th February 2011
This was an inquest into a hospital death, notable in that the coroner was persuaded to return a narrative verdict incorporating findings of neglect.
NB was 34, a longterm sufferer of epilepsy. He was not particularly compliant with his medication and would tend to take more than his prescribed dose when he felt a fit coming on.
On the morning of 2nd June 2006 his mother found him collapsed in an apparently post-ictal state. An ambulance was called and he was taken to North Manchester General Hospital. He remained essentially unconscious, with a Glasgow Coma Scale of 10. By now his mother was very concerned as he normally came around within an hour from his fits, and this was a very different presentation.
The consultant physician who examined him was concerned about a possible overdose of his anti-epilepsy mediation, carbamazepine and asked for his bloods to be checked. This was at 7.15pm
The hospital laboratory found that NB had levels of carbamazepine in his blood approximately 4 times over the therapeutic range. This is a life-threatening level. Patients with this level of carbamazepine toxicity require ITU treatment, intubation and exceptionally close monitoring and support, challenging and complex medical treatment.
The night shift SHO elicited the blood levels at about 7.30 the following morning and wrote them, and the normal reference range, clearly in the deceased’s medical records.
There was a dispute at the inquest as to whether the SHO had carried out any research into the implications of the findings, appreciated their significance, or informed senior doctors. The coroner found in fact that he did not appreciate the significance of the findings or inform his senior colleagues. The coroner also found that none of the clinicians who cared for NB thereafter read or appreciated the significance of the carbamazepine levels or heeded his deteriorating condition.
At 3.30am the following morning NB suffered a fatal cardiac arrest.
At the conclusion of the evidence it was submitted on behalf of the deceased’s family that a finding of coronial neglect was appropriate. Neglect in this context means a “gross failure to provide … basic medical attention … for someone in a dependent position who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show that he obviously needs it may amount to neglect” (emphasis added) R v N Humberside Coroner ex p Jamieson  QB 1 CA
It was accepted that the actual medical care NB needed was far from basic. However, it was argued that there was nevertheless a failure to provide basic medical care in the sense that what he initially required was active recognition that he had life-threatening levels of toxicity with referral to the appropriate senior clinician; that in fact was simple and basic – the SHO could have learned of the implications of the levels simply from consulting a readily-available database; the Registrar and Consultants who saw NB would have understood the significance of the blood levels; they merely needed to review his notes to see them; all clinicians caring for the deceased had access to his notes.
It was argued that this was a sufficiently significant failing to be rightly categorised as gross.
An expert in A&E and poisons was called by the coroner who gave evidence that, had the carbamazepine levels been heeded, on balance, with appropriate supportive and skilled medical care, the deceased would have survived.
The coroner returned a narrative verdict setting out his principal findings of fact, and concluded as follows:
“The deceased’s death was contributed to by
2. Inadequate and inappropriate medical record keeping;
3. A failure of communication between medical staff and nurses.”
The case is interesting for 2 reasons:
- In the writer’s experience, it is exceptionally difficult to persuade a coroner to make a finding of neglect in respect of professional medical care. Whether or not appropriately regarded as negligent in civil liability terms, coroners are most reluctant to accept that the exercise of clinical judgment can amount to a gross failure to provide basic medical care. It was perhaps successful here as it was possible to focus on the failure by clinicians to heed the abnormal results – this was capable of classification as basic, a basic failure to heed an obviously dangerous result and ensure that it was considered by a senior doctor.
- The coroner was happy to include the neglect conclusion in a narrative verdict. Some coroners have been reluctant to make such a combination, which can lead to the unsatisfactory result that families in submissions have to elect between a short-form verdict (such as accident or natural causes) to which neglect might be added, or a narrative verdict without such a rider. The narrative is generally more satisfactory in that it enables the coroner to express conclusions on the key aspects of the evidence, but obviously unsatisfactory if it is thought to prohibit the coroner’s ability to include a neglect finding. The broader, inclusive approach was endorsed by the Court of Appeal in R (P) v Coroner for Avon  EWCA Civ 1367, but that was a prison Article 2 death. It is heartening that the coroner was wholly prepared to combine a narrative with the neglect findings in this case.
Counsel for the family of NB