Seminar 6 - Iatrogenic Death and the Dr as the Accused Flashcards
Would a a doctor making a singular mistake warrant a FAI
No
These are only used for medical death in the setting of a systemic failure
Outline the events of the Adcock-Bawa Garba case
Jack Adcock was a 6 years old male with Down’s syndrome who died in hospital following sepsis and cardiac arrest
He presented , critically ill and unresponsive and was initially diagnosed with gastroenteritis and dehydration and he was treated accordingly.
Later blood tests and chest x-rays confirm a Group-A Strep infection and Jack was treated with antibiotics for the resulting pneumonia
However this was not enough to save him as he went into septic shock
The duty to attend and comply at court always requires a written court order - true or false
False
It is generally presumed without the need to resort to a written order
What are the most common complications due to medical devices
Infection, malfunction, haemorrhage and thrombosis
List common side effects of taking antibiotics
Anaphylaxis
Toxic epidermal necrolysis
Opportunistic infections
Which factors may be considered when determining whether the scientific methodology used in the expert witness’ testimony is valid
Whether the theory or technique can be and has been tested
Whether it has been subjected to peer review and publication
Its known or potential error rate
The existence and maintenance of standards controlling its operation
Whether it has attracted widespread acceptance within a relevant scientific community
What is the purpose of yearly appraisals
They provide information to the responsible officer so they can inform the GMC is the license can be continued
Is death certification a legal or medical process
A legal process
Who should you contact in cases of death due to complications from medical devices
It may be useful to contact the manufacturer of the device as they may have additional information such as demonstrating correct use/ placement or access to logs of electronic devices
What happens if you fail to attend court after being cited
You are in contempt of court
Can be charged or fined
On which subjects should you give expert testimony and opinions upon
Only on issues that are within your professional competence
What is preponderance of evidence
The standard of proof, commonly used in civil litigation, that requires the party with the burden of proof to demonstrate that an allegation or argument is more likely to be true than false.
Who is responsible for revoking medical licenses
The GMC
What is the role of Healthcare Improvement Scotland (HIS)
They investigates a sample of MCCDs (medical cause of death) to ensure adequate reporting to PF
This ensures professionals are reporting deaths correctly and reporting them to the PF when required
In court you should always understand exactly what questions you are being asked to answer - true or false
True
Must be clear what you are providing an opinion on
In the context of medical related deaths when would and wouldn’t a discretionary FAI be appropriate
Would - if there appeared to be systemic failings leading to the death
Wouldn’t - one doctor making a singular mistake resulted in the death
List some key features that should be looked for on internal examination of a technical operative/peri-operative death
Body cavities should be checked for collections of blood, purulent fluid or stool/ stomach contents
Relevant organs and tissues should be checked for signs of ischaemia, necrosis, infection, injury, or haemorrhage, both macro- and microscopically - patient’s will need to have survived for several hours for ischaemia to start to show
Nearby vasculature should be examined and wall integrity established, especially where there is evidence of haemorrhage - can use a large bore needle with water to uncover any breaks in vasculature
If there was an infected batch of blood products that caused the death of multiple patients would that warrant an FAI
Yes a discretionary one - sudden death and in public interest to do it
How should you approach your trade union once you’ve been informed your under investigation
Contact BMA Law/ HCSA
If GP inform the partners at your practice
Ask BMA Law/ HCSA to respond on your behalf
Don’t make comment until you have taken professional advice
What is the role of an expert witness
Help the court on specialist or technical matters that are within the witness’s expertise
A doctor found guilty of criminal negligence is likely to face what action from the GMC
Fitness to practice procedures
What was the hypothesis of the Independent Review of gross negligence manslaughter and culpable homicide in Scotland
Specific guidance and support for investigating CH in a medical context should be developed
The Scottish system was found to lack a body with the oversight and ability to enforce improvements - true or false
True
How did the Dr BG case cause other doctors to lose faith in the GMC
Many felt she was used as a scapegoat to protect the public image of the NHS.
Work hours and staffing issues have been in the news for many years and haven’t been addressed fully.
GP body expressed a vote of no confidence in the GMC and many others expressed their support for Dr Bawa-Garba (e.g. over £300,000 raised for legal fees via crowdfunding and 700 medics signing an open letter)
In what forms can evidence be offered at a trial
Live testimony (from the parties, expert witnesses or other witnesses that support or rebut the case);
Testimony that is recorded prior to trial;
Medical records;
Photographs; and
Videos
How should a witness express their certainty
Either use a published hierarchy or an explicit hierarchy
Published is best
What is the most used medical defence agency for indemnity cover
The MDU
Describe the outcome of the 2013 inquest in the Bawa-Garba case
Another paediatric consultant acted as expert witness and testified that if the mistakes hadn’t been made Jack wouldn’t have died.
This led to the case being referred back to the crown prosecution service.
List some key features that should be looked for on external examination of a technical operative/peri-operative death
Careful examination of surgical incision sites and any indwelling devices
Indwelling devices should still be in place if death occurs soon after surgery and should not be removed if death will be referred to coroner
Chest radiograph may be taken if pneumothorax or thoracic air embolus is suspected - can be AP or lateral
Doctors have a “professional duty of candour” - true or false
True
They must be honest in reflective logs
They should be able to admit mistakes to patients and apologise for them
Before Donoghue v Stevenson what was required for liability for personal injury in tort law
the presence of physical damage inflicted directly (trespass to the person) or indirectly (trespass on the case).
This did not include ingestion of noxious substances - which was the cause in this case
When do fitness to practice hearings occur
After referral from GMC
Carried out by the MPTS
What happens if a judge/jury are convinced beyond reasonable doubt that the defendant is guilty
This means the prosecutor has met the burden and proved the defendant’s guilt beyond a reasonable doubt
The defendant should be pronounced guiltu
List the 4 main categories that deaths that occur in hospital/ under medical care can fall under
Natural
Therapeutic
Accidental
Homicide
Preponderance of evidence is used in what type of court
Civil cases
What are the statements and reports used as evidence based upon
Contemporaneous notes
What causes malignant hypethermia
Autosomal dominant mutation
Triggered by inhaled anaesthetic +/- suxamethonium
Exposure to agent causes an increase in intracellular Ca2+ which drives an increase in metabolism, leading to increased temperature (up to 43’C) and metabolic acidosis
In order to act as an expert witness as a doctor what do you have to understand
The law and codes of practice that affect your role as an expert witness - you must also follow them
How to write a report that follows the procedures set out by the courts
How to give oral evidence
Why is it hard to monitor trends in iatrogenic death
Due to poor reporting
Especially when using ICD codes, as these do not always correspond to causes of death relating to human factors.
What services do the GMC provide for doctors to protect themselves against legal actions
They have a guide on what to do if reported to the GMC - important doc
They also support a free confidential emotional support service run by the BMA for doctors reported to GMC
What is the aim of the initial declaration of truth in a witness statement
to render the individual liable for criminal prosecution if they have lied
What is the role of a professional witness
Provide professional evidence of their clinical findings, observations and actions, and the reasons for them
What is the definition of medical duty of care
Refers to the relationship between doctor and patient
When a patient enters a hospital, a duty of care is created between the doctor and the patient
This can apply to any doctor who comes into contact with the patient e.g. if a patient collapses in the middle of a hallway then any doctor passing by owes them a duty of care
What are the 5 key actions of the GMC
They maintain the UK medical register,
Set the standard for the professional values, knowledge, skills and behaviors required of all doctors
Set standards for undergraduate and postgraduate medical education.
They make sure doctors stay up to standard.
They investigate and act on concerns about doctors.
How is Scotland going to improve the quality of its investigations into deaths occurring in medical care
HIS currently rolling out Quality of Care reviews aiming to guide organisations on their approach and learning from adverse events
What happens if the plaintiff fails to meet the burden of proof by preponderance of evidence
The defendant will not be held liable
The defendant can request the judge enters a directed verdict
Give an example of explicit hierarchy
I will use the following verbal scale to express the certainty of my results. It runs from definitely excluding to definitely including:
A did not come from B It is unlikely that A came from B There was nothing to suggest either that A came from B or that it did not A could have come from B A probably came from B A most probably came from B A came from B
List some causes of anaesthesia related iatrogenic death
Malignant hyperthermia
Complications of Intubation and Ventilation
Is being part of a medical defense agency free
No
Not a free service and membership is quote based ( usually free for students)
You can merge factual evidence with your opinion when giving expert witness testimony -true or false
False!
Should make clear what is factual evidence and what is your opinion based on your professional judgement and experience
What scheme is used for medical indemnity in Scotland
Clinical Negligence and Other Risks Indemnity Scheme
In which civil cases is clear and convincing evidence typically required as burden of proof
It is generally reserved for civil offenses that have special elements to establish such as:
Claims involving fraud
Claims involving wills and inheritances
Cases involving important family decisions such as withdrawing life support from a relative
List examples of medical negligence
Delayed diagnosis Failure to Diagnose Negligent prenatal care Birth Injuries Medication and prescription errors Surgical errors Anesthesia errors Failure to warn
What is the Daubert Standard based on
A supreme court case
What is a non-technical (peri) operative death
One due to other complications of surgery and/ or extended hospitalisation
(e.g. not a direct complication of the surgical technique itself)
Includes exacerbation of pre-existing disease and late post-operative complications such as bowel obstruction due to adhesions or fistulae formation
What mistakes did Dr Bawa-Garba make in the Jack Adcock case
It is alleged that her initial assessment was rushed, and that reassessment was inadequate
She underestimated how unwell Jack was after he responded well to initial fluids
She missed the abnormal urea and creatine when she finally got the results of Jack’s blood tests - apparently distracted by very high CRP
Which tool is often used to assign cause of death
WHO’s International Classification of Disease (ICD)
There is a lack of data data on the number of cases investigated for CH and GNM - true or false
True
Criminal conduct cases for medical manslaughter sit on a spectrum - give examples of this
At one end the fatal mistake can occur due to a momentary lapse of concentration or a misheard instruction
At the other extreme, the action is not a mistake but instead deliberate harm is inflicted on the patient (e.g. Shipman)
How common is the charge of medical culpable homicide in Scotland? What are the reasons for this?
It is not very common in Scotland - the data available indicates that there have been no doctors successfully prosecuted for CH in cases of alleged medical negligence
This is partly due to the requirement of “recklessness” in criminal Scot’s law, and the fact that decisions on prosecutions are taken with regard to the wider public interest
What does evidence of bilateral DVTS suggest in terms of cause of death
Evidence of bilateral DVTs suggests that immobilisation (eg. following surgery) was more likely to be a factor in thrombus formation
Describe the confusion which occurred when Jack Adcock went into cardiac arrest
After Jack arrested the crash call was sent out an Dr Bawa-Garba attended.
Originally doctors thought he was a DNR as another boy had been on the same ward and crashed earlier with a DNR.
Dr BG announced this which slowed resuscitation efforts.
Another staff member corrected her but once restarted they were unsuccessful.
What happens if you do and don’t meet Daubert standard
If met then the judge will accept the expert witness opinion
If non met then they wont
What must the plaintiff convince the jury of in cases using preponderance of evidence
Jury will need to be convinced, based on all the evidence, that there is a greater than 50% chance that defendant caused the harm alleged in the lawsuit
They will weigh the evidence and decided if preponderance has been met
What is the main difference between murder and culpable homicide (scots law)
Murder is considered a willful act - either you intended to kill or behaved recklessly and did not care about consequences
Culpable homicide is when you cause death but did not intend to and your behavior was not ‘wickedly reckless’
Is being part of a medical defense agency mandatory for doctors
Not mandatory to have one but HIGHLY suggested
Why must doctors engage fully with appraisals and revalidations
To protect themselves
To maintain their license
To better themselves as doctors to safeguard themselves against future medico legal issues
Impact of systemic failures is given little legal weighting - true or false
True
No consideration on how system affects human factors
Often leads to harsh outcome for the individual
The term public interest always refers to the entire UK population - true or false
False
“public” can relate to a relatively localised public e.g., a small community, or the wider public at large
What are the 3 stages of the 3 stage negligence test
Stage 1 – The person in question is owed a duty of care
Stage 2 – There has been a breach of that duty of care
Stage 3 – As a direct result of the breach, legally recognized harm has been caused
What is an acute haemolytic reaction
Occurs after blood transfusion
There is destruction of donor blood cells by host antibodies
What should you do if you change your view on any relevant aspect of a case you are involved in
You have a duty to make sure those instructing you, the other party and the judge are made aware of this without delay
You can ask the court or get legal advice in these cases
What is the highest standard of burden of proof
Beyond reasonable doubt
What is the Daubert Standard
The standard used by a trial judge to assess whether an expert witness’s scientific testimony is based on scientifically valid reasoning that can be properly applied to the facts of the case
What is the purpose of the GMC
The GMC is there to “protect patient safety and support medical education and practice across the UK”.
Who sets statutory law
A body of legislation e.g., government.
What is the English equivalent to Scots delict law
Tort Law
Civil wrongs that are actionable in court
What are the yearly appraisals base on
Good Medical Practice
What is tort law derived from
Latin verb ‘tortere’ which means to hurt
Therefore the idea of hurt is an important consideration in establishing negligence
What were the initial police charges brought against Bawa-Garba in 2012
Dr Bawa-Garba was informed that she was being investigated for manslaughter
However, this came to nothing and she was told there were no charges
Where do you get private indemnity from
Like any form of insurance there are many different providers
Probably best to go with one of the 3 medical defence agencies (MDU, MPS, MDDUS) as they provide additional benefits for the cost
How can you identify anaphylaxis post-mortem
Serum tryptase can be tested for post-mortem, but will be affected by survival time post event
For some medications such as penicillin, IgE antibodies against specific allergens can also be tested for
Histologically, sections of the airways may show submucosal oedema and/or mast cell and eosinophil infiltration
What do medical trade unions do
They will support and represent doctors in medico-legal issues as well as other diverse issues effecting the profession – equal pay, banding issues, NHS employment contracts
In criminal cases, the defendant is always presumed innocent - true or false
True
Innocent until proven guilty
The prosecution must prove this beyond reasonable doubt
Medical error is rarely the cause of transfusion related adverse events - true or false
False
It is the common cause
e.g. Blood being given to wrong patient due to identification errors
What is meant by a no blame culture
Not prosecuting individual doctors for one-off mistakes, but holding organisations accountable for systemic failures.
What is the burden of proof
The obligation to present evidence on the subject of the lawsuit or the criminal charge to prove or disprove a disputed fact
Parties have to convince the trial of fact of their position
Who sets common law
It is set by judges
Can be amenable if the circumstances are not suited to the common law.
According to the Independent Review of GNM and CH, how many expert witness should be sought to determine culpability for a CH prosecution of a doctor
More than 1
Obesity is a strong risk factor for complications from intubation and ventilation - true or false
True
This because there is difficulty intubating and decreased chest wall compliance
Who has the burden of proof in a criminal case
The prosecution
Have to prove them guilty beyond reasonable doubt
Did the resus interruption contribute to Jack Adcock’s death
It was later found that it hadn’t
However, the BP meds and antibiotic delay had
Standardization of expert witness selection would achieve what
Provide assurance on how recent an expert’s experience is in relevant field, their qualifications and relevance to the case.
Could standardise on skills, knowledge, training and how they should be quality assured
When do we use beyond reasonable doubt as the burden of proof
In criminal cases
Who has the burden of proof in clear and convincing and what court is it used in
The claimant (person making the original claim) Civil court
The Bolam test/standard is definitive - true or false
False
Sometimes the courts will go against the body of opinion e.g. case of Bolitho
Pathologists should have a basic knowledge of common surgical procedures - true or false
True
Should have good knowledge of the most common ones and their complications
Allows them to properly investigate operative deaths
If surgery is complex/rare then the surgeon can be consulted
Is it mandatory to have medical indemnity cover
Yes
Since 2013 it’s a legal requirement to have indemnity cover
A forensic pathologist giving opinions on the cause of death of the victim is what type of witness
Expert witness
What is meant by ‘beyond reasonable doubt’
Essentially the court has to be convinced that there is “no doubt” that something is true
List common medical devices seen at autopsy
Pacemakers
Orthopedic implants
Intravascular stents
What factors should be considered when assessing public interest in an FAI
The nature and gravity of the offence
The impact of the offence on the victim and other witnesses
The age, background and personal circumstances of the accused
The age and personal circumstance of the victim and other witnesses
The attitude of the victim
The motive for the crime
The age of the offence
Mitigating circumstances
The effect of prosecution on the accused
The risk of further offending
The availability of a more appropriate civil remedy
Powers of the court
Public concern.
What services does the MDU provide
Indemnity cover for clinical negligence claims and good Samaritan acts that meets GMC requirements and covers legal costs and potential claims
24hr medico legal advice
Support and defence for GMC complaints, inquests, disciplinary or trust hearings, criminal investigations relating to practise
Press support if involved in a high profile case
Access to case studies, ethical dilemmas, e modules, podcasts, videos, CPD accredited courses and webinars
Who needs to accept the statements and reports
Both defence and prosecution
How did the TFG review suggest improving the enforcement of changed from FAIs etc.
Create a regulatory body
A regulating body could enforce learning from FAIs/CIs within and across the Boards in Scotland
This would prevent recurrence of issues and improve patient safety
Describe the involvement of the patient’s family in their medical death investigation
The HIS have clear guidance regarding the involvement of the patient’s family/advocate in the investigation
However, the TFG review felt that it was not consistently followed
When does medical negligence become a criminal case
When a death occurs
Without death it tends to be a civil case
How do you access help from the medical protection society
24hrs telephone if emergency or online contact form ( make sure patients details are annon. if required)
What is the role of the HCSA
Advised and represents doctors in both NHS and private work
For clear and convincing evidence (burden of proof) the trier of fact needs to have a firm conviction or belief in its factuality - true or false
True
Would a medical death be a discretionary or mandatory FAI
Would come under a discretionary FAI
This only applies to deaths due to systemic failure and not a doctor making a singular mistake
E.g., Infected blood products from blood bank resulting in multiple deaths
How is the standard of the reasonable man used
The courts will use this hypothetical person to help determine if a party has acted as a reasonable person would
Acts as a human control of sorts
For example, in a civil action for negligence
What was the aim of the Independent Review of gross negligence manslaughter and culpable homicide in Scotland
Review the key aspects of the healthcare system in Scotland and Scottish law relating to culpable homicide
How often do revalidations occur
Every 5 years
What is a factual conclusion
A simple statement of fact
Conclusion drawn on analytical results are an inescapable fact
Basic scientific conclusion remains factual
Any legal implications flow directly from it
What should a professional witness base their statement
Based as far as possible on clinical records and notes made at the relevant period of time
What is the definition of duty of care
The legal obligation of an individual/company to adhere to a reasonable standard of care if they are performing an act/or producing a product that could potentially harm someone
List the main subtypes of iatrogenic death
(peri) operative - technical and non-technical Anaesthesia-related Medication Reactions Haemodialysis Transplant-/ Transfusion-related Hospital Acquired Infections Pulmonary Thromboembolism Complications from Medical Devices
What is malignant hyperthermia
An autosomal dominant condition often triggered by inhaled anaesthetic +/- suxamethonium
Leads to an increase in metabolism and therefore increased temperature and acidosis
What must any witness do before giving evidence in court
Take oath or affirmation that you will ‘tell the truth, the whole truth and nothing but the truth’
Must make sure if not religious use the affirmation not the oath
What is the point of medical indemnity
Insures that if a clinical negligence claim is made against you you don’t have to pay for it personally at the time
What is considered an adverse event in medical care
All events that could have contributed or did result in, harm to people or groups of people.
This includes harm to patients and service users, as well as harm to staff
When and where did the Bawa Garba case occur
Initial event was in 2011 at Leicester Royal Infirmary’s Children’s Assessment Unit
What were the creditable aspects of the Scottish system as found by the Independent Review of GNM and CH
Processes leading up to investigation
Inquiries by the PF/coroner were consistent
Police investigation and decisions to prosecute were transparent
If haemodialysis is likely to have contributed to a death, what should the pathologist look for
May want to focus on sites of bleeding, especially looking for signs of thrombosis, infection or aneurysm.
What is involved in the emotional support service run by the BMA for doctors reported to GMC
Service that provides emotional support, not legal support
Free for everyone even if not BMA member
Independent and confidential from the GMC
6hrs of telephone support, face to face support at hearing and orientation meeting morning of hearing
Describe the hospital investigation in the Bawa-Garba case (results are another card)
Immediate investigation launched
Police were also involved at this stage as it was an unexpected death of a child.
Two post-mortems were performed (in case it did become a police case)
Dr Bawa-Garba was asked to reflect on the case and her thoughts were recorded in her e-portfolio.
She was taken off the ‘on-call’ rota and sent to the PICU for further training.
Staff had previously raised concerns about staffing
Improving data collection on culpable homicide prosecutions involving doctors would address the staff’s main concerns - true or false
False
They are more concerned about the support and challenges present not the statistics
Outline the Bolitho case
2 year old Patrick Bolitho suffered respiratory, hypoxic brain injury and death secondary to croup whilst in hospital
After each croup episode the Senior registrar was called but did not attend and he deteriorated and died
Everyone accepted that the Senior Registrar had failed in her duty of care but the question was whether the damage was due to that breach
It was instead found that only intubation before the final collapse would have averted the tragedy and the judge accepted that even if she had attended after the episodes she wouldn’t have performed the procedure at those times.
However 5/8 expert witnesses said they would have intubated earlier - judge went against this, therefore breaking the Bolam standard
Why is causation hard to establish is medical negligence cases
It is actually very hard to establish where the harm actually occurred in relation to an episode of medical care
e.g. paralysis after aortic aneurysm repair may be caused by the surgery or the provision of epidural analgesia
In what situations would the BMA be able to provide
NHS, GMC and CQC investigations Appeals against license withdrawal Fitness to practise hearings 1st tier health tribunal hearings High court appeals Criminal charges If you are invited to give evidence to HM Coroner’s Office
What is a witness summons
When the court compels attendance
What additional information should be made available to the pathologist in the case of a technical operative/peri-operative death
Patient’s surgical history and the operative notes should be available to review prior to or during the autopsy
It may be helpful to have the surgeon attend, particularly following specialised or complicated procedures, or where the pathologist is unfamiliar with the procedure
What is meant by beyond reasonable doubt
The prosecutor must prove the case to an extent that no reasonable person could reasonable doubt the defendant’s guilt
What are the similarities between medical defence agencies and trade unions
Both give medico legal advice and representation (BMA through BMA law)
Neither are free
Describe the role of the Medical Practitioner Tribunal Service (MPTS)
The MPTS run the fitness to practice hearings.
They are a statutory committee of the GMC but are independent in their decision making and operate separately from GMC investigations - don’t take part in investigation itself
They can restrict or remove a doctor’s right to practice medicine in the UK.
If a party in a civil case believe that the evidence shows that no reasonable jury could conclude that defendant was liable what can happen
They can ask for a directed verdict against plaintiff
Why do most medical negligence cases focus on the individual
Because it is easier to take legal action against an individual rather than make an entire organisation (such as the NHS) legally accountable
When does a lawful act become a criminal one
When committed with a criminal state of mind
In an negligence case what must the claimant prove
They must establish on the balance of probabilities that negligence has occurred by the hospital or doctor
What is the difference between preponderance of evidence and clear and convincing evidence
Preponderance only requires a minimum likelihood of 50% that the person is guilty
For clear and concise you must be substantially more than 50% certain of guilt
How certain do you have to be about CoD before recording it on the death certificate
Officially you only have to be 51% certain (most likely cause)
Generally the doctors/pathologists are more certain!
Was Dr BG removed from the medical register
The GMC initially argued she should be an overturned the MPTS findings
However, Dr Bawa-Garba appealed this decision and was successful, she would instead serve her 1-year suspension
When is resipsa loquitur used
In the absence of any other reasonable explanation for a phenomenon and the evidence speaks for itself
e.g. the finding of a retained swab in the abdomen at laparotomy can only be assumed to be due to its negligent loss during a previous laparotomy
Can culpable homicide be committed inadvertently
No
A person cannot be guilty unless they are aware of the risks and choose to run with it.
e.g. drink driving (you know the risks and choose to do it anyway)
What type of culture does Scotland want to promote around CH investigations and FAIs
No blame culture
This would involve learning and reflective practice for doctors undergoing investigations when fatalities occur
When is negligence considered gross
If negligence occurs as a result of carelessness, and the carelessness has been so severe that it is judged to be ‘gross’
What are doctors mainly concerned about in relation to culpable homicide cases
Availability of appropriate support & supervision and the challenges and pressures of the working environment
If you are called as a professional witness but then are asked questions as if you were an expert witness what do you do
Ask the judge for clarity on what you are supposed to be answering and state that you may not be an expert witness in that capacity
i.e. your the pathologist in the case and are there as a prof witness but don’t know enough about the rare condition the individual had so you cant provide information about it and how it may have effected the case because you are not an expert in this
No doctors have successfully been prosecuted for medical culpable homicide in Scotland - does this mean there is a lack of accountability
No
Processes such as FAIs, civil claims seeking compensation, and health & safety legislation can address such errors.
If the blood tests had come back on time and been read properly what would’ve been seen
These results would’ve suggested Jack’s kidneys were starting to fail and that he required antibiotics
What does NHS indemnity cover
It only covers work included in the NHS remit and doesn’t include any work outside that remit, disciplinary issues or GMC referrals which would need private indemnity
How are patient notes used in cases of drug-related iatrogenic deaths
Medical/ nursing notes should be reviewed to establish a timeline regarding symptom onset following use of medication
And the dosages
Why would it be beneficial for the COPFS to have access to the GMC’s pool of experts for their expert witnesses
Provides another source of opinion and ensure the appropriate specialist advice is given.
What percentage of likelihood must you prove in cases using preponderance of evidence
At least 50% certain the defendant is liable for the harm alleged in the lawsuit
What category of law does medical negligence come under
A special category of involuntary manslaughter in criminal law.
Includes medical, workplace or in custody deaths
How can a defendant respond in a civil case
They often file a responsive pleas denying some or all allegations
Can you use antemortem tests in death investigations
Yes
Can be included in the results
especially microbiology as living more accurate than PM (bacteria naturally multiply after death giving false results)
What is the most common mechanism of iatrogenic drug-related death
Anaphylaxis
What happens if medical duty of care is breached
Liability for negligence arises
The victim can make a claim which may involve monetary compensation or even criminal prosecution
Who is a fatal accident inquiry held in front of
Just a judge
A jury is not present
If you can prove that the damage was the more likely a result of the negligence than another cause will it be sufficient to win a claim
Yes
If it can be shown that the breach in duty materially contributed to the damage or it is more likely that the damage was due to negligence than another cause is usually sufficient
What are delicts in Scots law
They civil wrongs which are actionable in Scottish courts
The right to information under the Freedom of Information (Scotland) Act 2002 is absolute (i.e. no exceptions) - true or false
False
In some cases, information is exempt from disclosure (i.e. withholding the information is more in the public interest than disclosing it)
What is the 3-stage negligence test used for
To determine if negligence has occurred
Give an example of a numerical scale
On a scale of 1-10
Which factors allow for consistency in CH investigations and FAIs in Scotland
Existence of a centralised investigation unit within COPFS, the SFIU and a National Homicide team
The Crown Counsel directs investigations and makes impartial decisions independently. These decisions are subject to national guidelines and instructions from the Lord Advocate.
Revalidation is a legal requirement of UK doctors - true or false
True
Should you train before becoming an expert witness
Not officially required
You can consider undertaking training for the role, where available
What signs may be seen on autopsy following a transplant/transfusion related death
Transplanted organ or bone marrow should be histologically examined for signs of disease.
Other organs may exhibit signs of damage, potentially due to opportunistic infections or as a consequence of rejection of the transplanted organ
How might a doctor provide evidence in a case
Through statements and reports (e.g. toxicology, classification of weapons, documents)
Attending court
What signs are suggestive of oesophageal intubation
Distension of the stomach and intestines
What does the HCSA provider advice and representation for
Grievances
Disciplinary issues
Health and safety at work issues
Claims and actions which need legal advice and representation
What are the most frequent contexts for gross negligence manslaughter cases
Death following medical treatment or care - offence committed by any healthcare professional
Deaths in the workplace - can be committed by anyone who is connected in some way to a workplace of any nature
Deceased may be employees, contractors, and members of the public visiting
Deaths in custody - offence committed by police or prison officers, custody assistants, and by healthcare professionals who are responsible for the care of the detainees.
Does the defendant need to prove their case in a criminal case
No
They technically don’t have to prove anything - presumed innocent
What is the role of a character witness
Give evidence about the good character of the accused in a criminal case to show that they are less likely to have committed the offence because they are a person of good character
Also used to give evidence about the good character of a person who has already been convicted of a criminal offence to help the judge decide which sentence to impose
Can you appeal a revoked license
Yes
Any doctor can appeal a revoked license with the help of trade union/ medical defence agency
Is monetary compensation sanctioned as a punishment or to account for damages
To account for damages
A treating clinician testifying the victim’s condition upon admission is what type of witness
Professional witness
What is the aim of compensation in negligence cases
It is supposed to return claimant to a position where they theoretically would have been if the incident hadn’t occurred
The amount of money will not just cover expenses incurred (e.g loss of earnings) but also to the pain and suffering endured as a consequence of the injury
How is the ICD used
This epidemiological tool from the WHO is used to monitor worldwide trends in causes of morbidity and mortality
Often used in primary care services and research
What are the roles of medical defence agency
Provide indemnity cover *
Aid in legal and ethical issues arising from practise
Aid in complaints, GMC investigations, disciplinary hearings and clinical negligence claims
What is the standard of the reasonable man
It is a law from the Victorian era
It involves a hypothetical person who is your average, reasonably educated, rational, non-descript person
The defendant’s conduct is measured against this ‘person’
Describe an accidental death that occurs in hospital/ under medical care
This is when there is unanticipated complications/ inappropriate treatments where there was no intention to cause harm
e.g. Medication dosage errors, complication of unnecessary diagnostic or therapeutic procedure
Should doctors have private indemnity
Yes
All doctors should be encouraged to have private indemnity as well as their NHS cover
Why is the Healthcare Improvement Scotland (HIS) system better than the Coroner’s system in the rest of the UK
HIS investigates a sample of deaths
The coroner’s system requires medical examiners to certify all hospital deaths not requiring a coroner’s PM or inquest.
What are the differences between medical defence agencies and trade unions
Trade unions help in other areas like fighting for equal pay and banding, diversity issues and aid with employment contracts (MDAs don’t)
Medical defence agencies provide indemnity cover - trade unions don’t
What is the definition of murder in Scot’s law
Murder is constituted by any willful act causing the destruction of life, whether [wickedly] intended to kill, or displaying such wicked recklessness as to imply a disposition depraved enough to be regardless of consequences
How might the current state of the NHS affect medical negligence cases (e.g. Dr BG case)
The state of the NHS in that region had been declining for many years and investigations found many systemic issues.
Improvements needed to be made across all aspects of health care.
Some argue that these issues go right to the top levels (i.e., the government and funding panels).
What does the Freedom of Information (Scotland) Act 2002 (FOISA) entitle us to
This act means a person who requests information from a Scottish public authority which holds it is entitled to be given it by the authority
COPFS commissions its own experts in criminal and medical death investigations - true or false
True
However, it would be beneficial if they could access the GMC’s pool of experts to provide another source of opinion and ensure the appropriate specialist advice is given
What is the definition of iatrogenic
Describing a condition or disease that has resulted from treatment and/or the actions of healthcare professionals
Give examples of a published hierarchy
... was written by ... ...there is a high probability that ... ...probably wrote ... ... could have written ... ...no conclusion as to authorship ... ...there is no evidence that ... ...there is no evidence and it is unlikely that ...
What is the supporting info that’s needed for appraisal/revalidation
info about practise info about health compliments for your work complaints for your work any reflection youve done any courses, inc med def unon, that you have done
List common side effects of taking corticosteroids
Hyperglycaemia
Decreased bone density - pathological fractures
The court has total authority - true or false
True
They can compel attendance
The quality of medical death investigations in the UK is consistent - true or false
False
It was found there was lack of training, support & experience for those undertaking investigations.
Describe a natural death that occurs in hospital/ under medical care
Exclusively due to the disease process
The medical therapy or injury does not contribute to death
How do you diagnose malignant hyperthermia
Via changes in levels of creatine kinase, CO2 and serum K+ pre-, intra- and post-operatively
Doesn’t have any specific signs on muscle histology changes, so not that useful
What type of reaction is anaphylaxis
Type 4 hypersensitivity reaction mediated by IgE
Criminal law needs to distinguish between deliberate and non-deliberate conduct - true or false
True
They focus on the intent and recklessness of the conduct
What are the 2 medical trade unions in the UK
BMA
HCSA
Who does the MDU represent
Represents everyone from student to consultant
How should you present your expert opinion in court
Give an objective, unbiased opinion and be able to state the facts or assumptions on which it is based
Summarize the range of opinions and explain how you arrived at your own view
What standard of proof is required in civil cases
Balance of probabilities
This means that the court must be satisfied that on the evidence, the occurrence of an event was more likely than not
Describe the trend in alleged medical manslaughter cases and the rate in convictions for this charge.
Cases alleging medical manslaughter appear to have risen over the last 20 years but conviction rates have remained low
A review found that 85 doctors had been charged with medical manslaughter since 1795 but 38 of these occurred after 1990 (45% of charges were in last 15 years of study)
What happens if a doctor is considered to have been grossly negligent
The doctor may be subject to a charge of criminal negligence
It moves from monetary compensation, civil courts, etc. to the domain of the criminal courts.
What mistake did the nursing staff make in the Jack Adcock case
One failed to observe and then inform staff of Jack’s deterioration
Lead to delays in treatment
Who has initial burden of proof in in cases using preponderance of evidence
The plaintiff (person bringing the original case)
Can you be called as a professional and expert witness at the same time
Yes
In Scotland
If you are asked a question outwith you competence in court, what should you do
Either refuse to answer or answer to the best of your ability but make it clear that you consider the matter to be outside your competence
Describe a therapeutic death that occurs in hospital/ under medical care
Occurs due to predictable complications of appropriate medical treatment
eg. Known surgical complications
What were the potential implication of the Dr BG on reflective practice
Dr Bawa-Garba educational reflection was not used as direct evidence but may have been shown to some witnesses and was mentioned in the trial (indirectly used)
If this had been used to attribute blame it could mean that other doctors are less likely to be honest in reflective pieces for fear of it being used against them .
Without being able to learn from mistakes, patient safety may suffer.
Sepsis is often diagnosed late - true or false
True
According to the UK Sepsis Trust, about 14,000 people die each year because it is not diagnosed or treated early enough.
What was the official PM cause of death in the Jack Adcock case
Systemic sepsis following streptococcal lower respiratory tract infection.
This is widely accepted to have a high mortality rate
What is the role of an eyewitness
To describe what they witnessed but make no assumptions
Must only state what they saw - keep it to the facts
What defines a ‘breach of duty’
Deemed a breach of duty if a competent person in the same role would’ve done something difference in the same circumstances and potentially had another outcome
Did the systemic failings or busy environment impact the CPS investigation of Dr BG
No
It did not negate her mistakes
Which legal case was the origin of ‘duty of care’
Donoghue vs Stevenson
Aka the “Paisley Snail” or “Snail In the Bottle” case
What is the definition of manner of death
The circumstances under which the death occurs
eg. natural, accident, suicide, homicide
The number of foundation doctors being prosecuted for gross negligence is decreasing - true or false
False
It is actually increasing
How do you access help from the MDDUS
Contactable via telephone or online form
The burden of proof is on the claimant in civil negligence cases - true or false
True
The claimant must prove that on the balance of probabilities, his/her case is true.
What is the prosecutors duty in Scotland
It is not to ‘prosecute to win’ but “in the public’s interest”.
Who is responsible for announcing your change of opinion in a case
YOU
You should personally tell your instructing solicitor who should then tell all other parties who need to know
However, if they fail to do this, you should tell the court about it
How is the Bolam standard used in practice
It expects a doctor to adhere to standards that are in accordance with a body of medical opinion (even if others differ in opinion)
If a doctor reaches the standard of a responsible body of medical opinion, then he is not negligent
Describe the outcome of CPS investigation in the Bawa-Garba case
She was charged with manslaughter by gross negligence in 2015 and was given a 2-year suspended sentence
What were the 7 main areas covered by the Independent Review of gross negligence manslaughter and culpable homicide
Processes leading up to a criminal investigation
The experience of patients and their families
Inquiries by a Coroner or Procurator Fiscal (PF)
Police investigations and decisions to prosecute.
The use of medical experts and the criminal proceedings.
The professional regulatory process.
Employment and support.
If you receive a medical complaint or is under investigation what should you do
Inform their medical defence agency immediately to receive support
If they don’t have one they can contact the BMA employment advisors
You should insure you have adequate medical indemnity cover
You may wish to contact the BMA for support including peer support and accesses to the UK wellbeing support directory
Ensure your employer has the correct confidentiality requirements in place
The standard of proof is lower in civil cases than in criminal ones - true or false
True
Under which circumstances would a discretionary fatal accident inquiry be carried out
If death was sudden, suspicious or unexplained OR it occurred in circumstances giving rise to serious public concern.
AND decides that it is in the public interest for an inquiry to be held into the circumstances of death.
If you can prove beyond reasonable doubt that medical culpable homicide has occurred what do you then have to decide
Whether its in the public interest to prosecute the individual
Outline the Bolam v the Friern Hospital Management Committee case
Mr Bolam was a voluntary patient at mental health institution run by the Friern Hospital Management Committee
He agreed to undergo electro-convulsive therapy but he was not given a muscle relaxant and he was not restrained
He flailed about violently before the procedure was stopped, and he suffered some serious injuries, including fractures of the acetabula
He sued the Committee for compensation. He argued they were negligent for not issuing relaxants, not restraining him and not warning him about the risks involved.
However, he failed to win the claim as the general medical opinion deemed they had not been negligent
What challenges were faced by the nursing staff in the Jack Adcock case
Shortage of permanent nurses meant agency nurses were relied on to monitor the child.
Agency nurses were prohibited from performing certain procedures which left that responsibility to a single staff nurse.
Is BMA support free
No it is a charged service
Discounted for BMA members (also have a membership fee
What is malignant hyperthermia
An autosomal dominant condition often triggered by inhaled anaesthetic +/- suxamethonium (paralytic drug often used before intubation)
Leads to an increase in metabolism and therefore increased temperature and acidosis
What were the potential implication of the Dr BG on junior doctors
Caused them to lose faith in the GMC
May have led to drs to fear prosecution over honest but unfortunate mistakes or missing something.
Many implications of staff not trusting their regulatory body
On what basis was Dr Bawa-Garba charged with manslaughter
She underestimated the severity, did not perform a proper assessment and did not follow up in a timely manner with appropriate sensor escalation. This was determined to be well within the capabilities of a paed registrar
Gross negligence cases almost always involve death - true or false
True
What is the main body responsible for both providing and revoking a medical license in the UK
The GMC
If a person is at work and their clothing gets tangled in a machine and they die, what’s the manner of death
Accidental
What is the lowest standard of burden of proof
Preponderance of evidence
What is burden of proof of clear and convincing evidence
The evidence being presented must be highly and substantially more probable to be true rather than untrue
e.g. substantially greater than an 50% likelihood of being true based on the given evidence
Trier of fact needs to have a firm conviction or belief in its factuality
Can the family of a deceased person demand a fatal accident inquiry
No
However, they can express a desire to have one which the PF will take into account
What does the gross negligence manslaughter charges mainly focus on
The criminalization and punishment of individuals rather than look at the system as a whole
When should toxicology be taken in an iatrogenic death
Where medications are thought to have contributed to death, but may be of limited use depending on clinical circumstances
Describe lawful act CH
Where there is recklessness and behavior displaying a complete disregard for any potential dangers which might result from the act
Also a complete disregard of what the consequences of the [lawful act] may be so far as the public are concerned
Not directed at the victim but the action still caused their death
Which countries use the term medical manslaughter
England and Wales
Why might the Scottish Courts & Tribunal Service not record culpable homicide data
Possibly due to small number, or lack of, cases
What are the potential outcomes of a revalidation
Recommendation to revalidate – up to date and fit to practice
Recommendation to defer – doesn’t reflect fitness to practice just means more time needed to reach conclusion
Recommendation of non engagement – either due to failure to engage fully or to comply with regulations – will result in the GMC revoking the license
Who is responsible for recording case outcomes in death investigations in Scotland and how is this data used
Scottish Courts & Tribunal Service
This data is used by the Scottish government to publish annual conviction rate stats. for a variety of offences, but does not include data on CH
What is an explicit hierarchy
When the witness explains the hierarchy scale they will use in their statement
e.g. I will use the following verbal scale to express the certainty of my results. It runs from definitely excluding to definitely including
What is the definition of medical manslaughter
Medically qualified individuals who are performing acts within their duty of care when the act or omission occurs
(act or omission leads to death)
What is a quantitative conclusion
When results are expressed as a numerical value or as one of a limited number of distinct types
Calculate the probability of a particular observation occurring
What must the prosecution prove in a charge of gross negligence manslaughter?
That under the same circumstances, a reasonably prudent person in the defendant’s position would have foreseen a serious/obvious risk of death arising from the act of omission.
That the breach of duty so reprehensible and fell so far below the standards to be expected of a person in the defendant’s position with their qualifications, experience and responsibilities that it amounted to a crime
A surgeon downs bottle of vodka before surgery and patient dies - what’s the charge
CH (gross med negligence)
The surgeon will have known that what they were doing presented a risk of death
Does the Bolam standard accommodate for different levels or experience/seniority
No
Both junior and senior members of medical staff have the same standard of duty
The juniors are just expected to consult a senior if they are unsure - if they are left to do a task alone and don’t seek help they are negligent (even if supervisor was aware they were alone)
How much is HCSA membership
£330 per annum
Doctor’s only get assed every 5 years for revalidations - true or false
False
They should also get yearly appraisals
What is the role of the BMA
It is a trade union
Provides emotional support and BMA law provides legal support
Why do criminal cases require a higher standard of proof (e.g. beyond reasonable doubt
The consequences of a person being found guilty in a criminal case are usually much more serious than the potential consequences in a civil matter
e.g. imprisonment
What services do the MDDUS provide
Medico legal advice and representation with matters referred to GMC, disciplinary investigations and hearings, inquests and fatal accident enquiries
Support regarding complaints from patients and their families
Indemnity for any claims brought against you
Support regarding employees if an employer
Access to online courses, webinars, articles, risk checklists and team training to reduce risk of future medico legal issues
Can you include your opinion in expert witness testimony
Yes you may include some opinion
Should be mainly based on the factual evidence
If in a criminal case there is reasonable doubt the defendant is at fault what is the outcome
Have to be innocent as haven’t met burden of proof
What causes malignant hyperthermia
Autosomal dominant mutation
Triggered by inhaled anaesthetic +/- suxamethonium
Exposure to agent causes an increase in intracellular Ca2+ which drives an increase in metabolism, leading to increased temperature (up to 43’C) and metabolic acidosis
Describe unlawful act CH
Charge is now confined to assault and similar cases where the conduct is in some way directed against the victim.
e.g. person meant to assault the victim but not kill them (but they die anyway)
Which law made it possible for an organisation to be to be found guilty of causing death
The Corporate Manslaughter and Corporate Homicide Act of 2007 made it possible for organisation (such as an NHS trust) to be found guilty of causing death by corporate manslaughter following serious management failures that resulted in a gross breach of the duty of care.
However, it is ambiguous and complex - hard to implement
List some of the systemic failures that may have contributed to Jack Adcock’s death
Blood results were delayed due to failings with the computer system - crashed and flagging system for abnormal results wasn’t functioning
There was no SHO or consultant supervising the ward
There were delays in informing Dr Bawa-Garba that Jack’s X-rays were available - had been available for hours before she saw them
There was a delay in administering the prescribed antibiotics.
What was the finding of the 2017 Medical Practitioner’s Tribunal in the Dr BG case
They found her fitness to practice was impaired and she was suspended for 1 year
What is the common risk when taking anticoagulants
Haemorrhage risk
What reduces the deterrent effect of compensation pay outs for NHS doctors
a standard fee for professional indemnity/ protection for NHS-employed doctors
How should you treat other professionals giving expert evidence
You must respect their skills and contributions
Do not allow their behaviour to affect your professional opinion
Donoghue vs Stevenson (Paisley snail case) was a landmark decision in what type of law
Scots delict lawandEnglish tort law
Which service is used in Scotland for revalidations
In Scotland SOAR is used to conduct revalidation
What qualifies a death as ‘gross negligence manslaughter’
If the action was not intentional or reckless, but the negligence has to be ‘truly, exceptionally bad’.
What processes can be used in CH or FAIs instead of charging every doctor with CH
FAIs
Civil claims seeking compensation
New health and safety legislation
If a PE occurs under medical care, what is considered the cause of death
The disease or injury which led to DVT formation.
What services does the medical protection society provide
Confidential counselling service for work place stress
Fact sheets, case reports, online learning facilities, workshops and courses on common medico legal issues
Advice and where needed representation regarding; clinical negligence claims, complaints, GMC enquiries, legal/ethical dilemmas, disciplinary proceedings, coroners inquests, criminal proceedings ( related to clinical practise) and fatal accident enquiries
Indemnity for clinical negligence claims and Good Samaritan acts
Risk management resources
Media assistance in high profile cases
What are the outcomes of a recommendation of non engagement from a revalidation
If you start to engage it can move to defer
If due to non compliance with regulation you hold place on the register without a license to practise
Most drug-related deaths will be the result of known risks and side-effects - true or false
True
A colleague of the accused, claiming that the accused is a calm, nice and polite person is what type of witness
Character witness
Did Mr Bolam win against Friern hospital trust? If so / If not, why?
No
The body of opinion went against
The way the doctors carried out the electroshock therapy was in line with practices at the time so was not deemed negligent
How can transfusion complications cause iatrogenic death
Infective or non-infective causes
Infective – Blood borne diseases eg. HIV
Non-infective – Acute haemolytic reaction, iron or fluid overload (TACO)
Does the NHS provide indemnity cover
Yes
All NHS bodies are financially responsible for their employees and so have indemnity schemes that cover NHS contracted work
This covers most cases and is automatically provided
How do you investigate a thrombosis death that occurred under medical care
Dissection of the vasculature in both legs can be used to indicate the underlying cause of thrombosis
Histology may be used to ‘date’ thrombi in the region of hours vs days vs weeks
Proving something beyond reasonable doubt applies in which cases
It is the standard of proof needed in criminal cases
It is considered a very high standard of proof but this is required as the consequences of conviction is much higher
The requirement to prove criminal negligence is a much higher - true or false
True
Must prove beyond reasonable doubt
Also the sanctions are considerably greater and may include a custodial prison sentence for any doctor found guilty
Give examples of criminal standards of conduct that have been seen in medical manslaughter cases
Teenage patient died from toxic cancer drug wrongly injected into his spine.
Patient given 6x required dose of diamorphine for migraine, following a call to an OOH GP service.
Patient died from DKA after misdiagnosis with depression following a call to an OOH GP service.
Any patient we come across in our professional environment is owed a duty of care - true or false
Not an official answer, probably true
Medical law academics have argued that this is the case but it has never actually been tested in a court of law
e.g. we would be expected to care for a patient who collapsed in front of us, not a good Samaritan act
How do you investigate a non-technical operative/perioperative death
Approach should be similar to that of a ‘standard’ autopsy
What happens if either the defence or prosecution doesn’t accept the statements and reports
The person who provided it is called to the court to give evidence in person and be cross examined
A fatal accident inquiry is carried out for every sudden/unexplained/unexpected death - true or false
False
This is not possible and not every death is in the wider public’s concern/interest
Is punishing an individual the most effective way to enact change in medical cases
Not really - even though that is the current main focus in most cases
Quality improvement must occur alongside this to fix the systemic failings.
Healthcare is a complex system and so requires complex solutions
How can you help other colleagues if they are called to court and you have experience of acting as an expert witness
If you have expertise and experience in acting as an expert witness, you should be willing to share your knowledge with colleagues who might be called to give evidence in court, to help build their confidence and willingness to give evidence in the future
List the circumstances under which a fatal accident inquiry can be instructed
Where the PF cannot establish the cause or circumstances surrounding a sudden/unexpected death
In certain cases a FAI is mandatory - e.g. workplace death, death in custody
Others are discretionary - based on level of public concern
what makes something medical culpable homicide over clinical negligence that’s civil
serious recklessness
seriously below what’s expected of you as a doctor
you have to have been aware of the risk of death when you went with the act/ omission - therefore it cant be a complete accident
What did the TFG review suggest to improve family involvement in medical death investigations
A trained family/patient liaison might be beneficial
What is the Bolam standard also called
The standard of comparable professional practice
Same standard used across professions e.g. engineers
Generally possible to agree a specific day on which your court attendance is required - true or false
True
Medical negligence is a branch of what law in the UK
Delict law in Scotland
Tort law in England
Describe a homicidal death that occurs in hospital/ under medical care
Very rare
Where there are actions intended to cause patients harm or extreme medical negligence (a “gross and wanton disregard” for patients’ wellbeing)
e.g. Shipman or unlicensed practitioner
What is a technical (peri) operative death
One due to direct complications of surgical technique
e.g. bowel perforation from endoscopy
Outline the “Paisley Snail” or “Snail In the Bottle” case
Mrs May Donoghue drank a bottle ofginger beerin a café inPaisley which had a decomposed snail in the bottle
She fell ill, and subsequently sued the ginger beer manufacturer, Mr Stevenson
The House of Lords held that the manufacturer owed a duty of care to her, which was breached, because it was reasonably foreseeable that failure to ensure the product’s safety would lead to harm to consumers
This decision created a new type of liability
What would be the benefit of improving data collection on culpable homicide prosecutions involving doctors
Would help inform them about the risk of prosecution
Does failure to diagnose count as gross negligence
Yes
In which types of trials can a character witness be used
Criminal cases - either for the accused or for someone already convicted
Civil trials
When considering a charge of medical culpable homicide, which questions must be considered
What is the CoD established by the PM?
What did the doctor do/not do in the case that resulted in the death?
Did the act or omission cause the patient’s death?
Was the doctor responsible for that act or omission?
What was the mental state of the doctor at the time?
Is there evidence to allow the inference to be drawn that this mistake meets the ‘legal’ requirement for lawful act CH?
Is there corroborated evidence of the key facts?
What is a qualitative conclusion
A matter of judgement for the scientist to determine whether 2 items matched and to what extent
Numerical scales are a good way to express certainty - true or false
False
It is very subjective
e.g. on a scale of 1-10 what I consider a 7 could be different to others
All iatrogenic deaths are a result of medical error or malpractice - true or false
False
Not all due to error or negligence
All should be investigated regardless
The Independent Review of GNM and CH found that Scotland was consistent in it’s investigations - true or false
True
How often did the TFG meet in the Independent Review of gross negligence manslaughter and culpable homicide in Scotland
4 times
How did Jack Adcock’s typical medication impact his case
He had an underlying heart condition and was on blood pressure medication as a result
This medication was initially withheld but his mum was allowed to give his usual dose later
It was later found that this medication may have contributed to his death
List some examples of culpable homicide
Any form of reckless driving (without license/banned from driving, drunk, etc.) that results in a death
Hitting someone on the head with an object not normally used to kill but they die anyway (not murder if no premeditation or intent to kill)
List common side effects of prolonged NSAID use
Gastric bleeding
Fear of litigation and punishment are major barriers to open disclosure - true or false
True
Independent studies from the USA and Australia have shown this
What are the subgroups of culpable homicide
Unlawful Act CH
Lawful Act CH
What is stated in the initial declaration h in a witness statement
That they must tell the truth
That there is nothing within the report that they know to be false
If a person dies from complications of intubation and ventilation what examinations should be done
If tube is in situ it should be checked to determine whether or not it was correctly placed
Lungs should be histologically examined for any pre-existing pathology, such as emphysema or fibrosis
Describe Dr Bawa-Garba’s background
She was a senior paediatric trainee and was responsible for Jack’s care
She had no previous incidents on her record
It was her first shift back on the intensive unit after 13 months of maternity leave but she had had no formal induction
She was covering for other colleagues at the time of Jack’s death and lacked senior supervision - worked a double and no consultant on ward
She missed a portion of morning handover as she was bleeped down to A&E to attend another patient.
What should you do if asked to give an opinion about a person without the opportunity to consult with or examine them
You should explain any limits this may place on your opinion.
You should be able to justify the decision to provide your opinion
A doctor makes a miscalculation with meds and a patients dies - is an FAI warranted
No
What types of statements and reports can be used at court as evidence
toxicology and drugs reports classifications of weapons autopsy reports accident investigation reports fire investigation reports etc
Why was Scotland considered to be consistent in its investigations of medical deaths
Due to the dual role of the PF
The existence of the SFIU
The role of the Advocate Depute in authorizing prosecution of culpable homicide
Public interest test in Scotland
Cultural differences (incl. a perception of greater consideration of systemic factors in Scotland)
The processes of death investigation and prosecutorial decision making in Scotland are available to the public - true or false
True
It is a transparent process
Surgeon is out the night before drinking and shows up to work still slightly worse for wear (not drunk) and patient dies - what’s the charge
Civil clinical negligence - lapse in judgement but not severe lapse and weren’t aware it could potentially kill so can’t be CH
e.g. didn’t know they were still under the influence
What were the findings of the hospital investigation in the Bawa-Garba case
It found 6 root causes for Jack’s death and listing 23 recommendations for improvement and 79 actions to minimise the risk of another child dying
What is the purpose of revalidation
It demonstrates to GMC that you are still fit to practice
It also acts as a learning opportunity for the doctor with regards to practice and patient communication
This potentially reduces future medico legal issues
What data do the COPFS not record in relation to deaths
The occupation of the persons potentially responsible for the death - would provide stats on medical deaths in comparison to other industries
Information about the proportion of cases in which the PF instructs the Police to investigate a death
Conviction rates for any category of offence
What is gross negligence manslaughter (England & Wales)?
The offence committed where a death is the result of a grossly negligent (but otherwise lawful) act or omission
Which country uses the term culpable homicide
Scotland
What does the public interest test decide
Whether, on balance, it serves the interest of the public better to withhold or disclose information
In context of the freedom of information act 2002
What are the main types of witness
Eyewitness
Character witness
Expert witness
Professional witness
How does a fatal accident inquiry differ from a inquest
FAIs are held in front of a judge and not a jury
What is culpable homicide (Scotland)?
An unlawful killing where the accused lacks intention to kill or such wicked recklessness
Circumstances are neither accidental or justified
Describe the epidemiology of iatrogenic death
In 2013, the overall incidence of Adverse Effects of medical treatment in the UK was approximately 175 per 100 000
Varies with age, gender and region
Study from BMJ suggests its the 3rd leading cause of death in US
How much does the MPS cost per annum
Its based on a quote not standard fee
Why didn’t the Medical Practitioner’s Tribunal remove Dr BG from the medical register
They felt it was disproportionate to her action
What happens when the defendant in a civil case files a responsive plea
The burden of proof will shift to them to prove their defenses
What is the BMA advice regarding indemnity
Understand exactly what your NHS duties are and arrange indemnity cover for anything out with
Get clarification from your employer or directly from the NHS indemnity scheme admin if you don’t know if you are fully covered by NHS indemnity
Acquire a membership to a medical defence agency for indemnity for areas not covered by NHS indemnity and the other benefits
Do factual conclusions from expert witnesses have legal implications in the case
No the witness just provides the facts
It is the lawyer that infers the legal implications of the fact
What are the major risks of haemodialysis
Haemorrhage from AV fistula site
Infection and allergic reaction
There may also be an association with spontaneous subdural haemorrhages
In the Independent Review of GNM and CH in Scotland were the TFG satisfied that doctors in Scotland know when to escalate a case and feel comfortable reporting to PF
Yes
Who should you contact if you believe that the wrong blood has been given to a patient
Contacting the blood bank can be very useful when investigating these cases
When should a death under medical care be reported to the Crown Office/Procurator Fiscal
When death is subject of concern to, or complaint by, the nearest relatives of the deceased - if they think medical treatment contributed
Where CoD might indicate fault or neglect on the part of medical staff or where medical staff have concerns
Where there is an indication that the failure of a piece of equipment may have caused or contributed to the death
When death is likely to be subject to an adverse event review
Death caused by the withdrawal of life sustaining treatment or other treatment to a patient in a permanent vegetative state
When a complaint about the death certificate is received which suggests that an act or omission by medical staff caused or contributed to the death
Circumstances of death which raise issues of public safety
What is the main cause of tortious claims for medical negligence not succeeding
They can’t establish that harm has occurred as a direct result of an act or a failure to act
This is because there are often a variety of possible explanations for the outcome
What must be established in a case of medical culpable homicide
Whether the act or omission which caused the death goes beyond simply being an error of judgement or an accident (with catastrophic consequences).
Often little debate about who caused the mistake or what the mistake was
Are you automatically part of a trade union
No
You have to join it yourself and it is not free
Highly recommended though
How long do you have to have worked in a specialty to be classed as an expert witness
10-15 years of experience
How do access help from the medical protection society
24hrs telephone if emergency or online contact form ( make sure patients details are annon. if required)
What investigation should you do if sepsis is suspected but not confirmed
Blood cultures
A woman who lives in the opposite building of the primary crime scene and witnessed the process of murder is what type of witness
Eyewitness
There is a very small difference between succeeding on the balance of probabilities and failing on the balance of probabilities - true or false
True
The plaintiff has the burden to prove the case by a preponderance of evidence - true or false
True
Must prove that an allegation or argument is more likely to be true than false.
What does “resipsa loquitur” mean
The thing speaks for itself
You don’t train someone properly on a machine at work and as a result of using they die - what is the charge
Negligence
What is a fatal accident inquiry
A type of court hearing held in public into the circumstances and cause of a death.
It is not a criminal trial and so no blame/fault is assigned to anyone
It is intended as a fact finding exercise and aims to find ways to prevent recurrence of this kind of death in the future
What are the 3 types of burdens of proof
Preponderance of evidence
Clear and convincing evidence
Beyond a reasonable doubt
Listed in increasing order of ‘strength’
How many prosecutions for medical culpable homicides have occurred in Scotland
There is only one unreported prosecution from July 2017
The charge did not reach a jury as the judge ruled there was not sufficient evidence to establish a case
Other data indicates that there have been no doctors successfully prosecuted for CH due to medical negligence
Who does the PF apply to in order to get a fatal accident inquiry
The nearest Sheriff Court
Who carried out the Independent Review of gross negligence manslaughter and culpable homicide in Scotland
Task and Finish Group (TFG) was assigned to review it
What is a subjective
conclusion
Forensic scientist was asked to express an opinion about the technical evidence
List the most fatal hospital acquired infections and explain how they are acquired
Pneumonia – May be a result of mechanical ventilation
UTI – May be acquired from urinary catheterisation
Line sepsis from indwelling devices such as cannulae, PICC lines
Colitis – Clostridium difficile infection due to antibiotic use
You have to be a member of the HCSA to use its services - true or false
True
Did the GMC accept the findings of the 2017 Medical Practitioner’s Tribunal in the Dr BG case
No
GMC appealed this and sought to remove her from the medical register
They argued that as a jury had found her negligence to be truly exceptionally bad that her actions were incompatible with good medical practice and therefore she should no longer be a doctor
Who presents the evidence at a FAI
The PF
What are the 3 medical defense agencies in the UK
Medical Defence Union ( MDU)
Medical Protection Society ( MPS)
Medical and Dental Defence Union of Scotland ( MDDUS)
What is probable cause
It is an additional burden of proof that doesn’t apply to the court but to the police
Basically means you need to have reasonable and trust worthy information that a particular person has caused harm before acting - allows the police to stop and serach
What must the prosecution establish in order prove gross negligence has occurred
The defendant owed a duty of care to the deceased
By a negligent act or omission the defendant was in breach of the duty which they owed to the deceased
The negligent act or omission was a cause of death
The negligence, which was a cause of the death, amounts to gross negligence and is therefore a crime
How should your written and oral evidence as an expert witness be presented
Should be clear and concise
Must be based as far as possible on clinical records and notes made at the relevant period of time
What are the steps of the revalidation process
Make sure designated body is connected to GMC online
Collect supporting info required
Have the appraisals
Have the revalidation
What was changed by the Donoghue v Stevenson case
Fundamentally created a new type of liability in law
Paved the way for the modern, current day laws of negligence
What is the burden of proof for medical culpable homicide
Beyond reasonable doubt because its a criminals case not civil
What is the definition of cause of death
The specific disease or injury that lead to death
e.g. MI, asphyxia, sepsis
How much does the MDDUS cost per annum
Membership is quote based
