There was a pre inquest review hearing yesterday but there’s a restriction on what can be reported, that also applies to discussions that take place when the jury aren’t in court. So I can’t tell you about them, which is irksome. We were due to start at 10am today, the jury weren’t brought into court until 11:20, and the day was spent hearing the testimony of Professor David Chadwick.
Prof Chadwick confirmed he has 40 years experience as a neurologist, training in London and Newcastle before being appointed as a consultant in Liverpool in 1979. He worked full time as an NHS neurologist with an interest in epilepsy until 1992, when he was appointed as Chair of Neurology at the University of Liverpool, a post he held until his retirement in 2006. He continued in clinical practice 50% of the time in his last role, before continuing clinical duties at The Walton Centre until 2012 when he stopped seeing patients as he was appointed as a Non Executive Director on the Trust Board. Since 2015 he’s been doing medico-legal work.
Prof Chadwick confirmed what reports and statements he’d had access to before responding to questions. He confirmed that he felt Gaia’s diagnosis of epilepsy was secure, elaborating that he had “no clinical doubt whatsoever as to the diagnosis of epilepsy”. His evidence echoed that of Professor Walker, who the court heard from last week, that he felt Gaia’s epilepsy was originating from the left hand side of her brain, the posterior part of the left hemisphere.
He regarded the key feature that was unusual in Gaia’s epilepsy was the fact that brain imaging did not find abnormalities, which he’d have expected to find given “the severity of her seizures and seizure frequency”. A further atypical feature of his epilepsy he felt was the fact that it did not respond well to anti-epileptic drug treatment, and he also felt it was relatively unusual that her epilepsy developed in early adolescence.
On questioning from the Coroner Prof Chadwick confirmed that he considered Gaia’s epilepsy was complex and unusual. When asked if it was rare he responded “I’d say she was unique in my experience”. Later qualifying that he’d not come across the features that Gaia presented with himself in his clinical practice.
He described treating epilepsy as “very much a matter of trial and error”. He had no criticism of the care Gaia received from Professor Walker or the investigations that he ordered. Asked about his view on the fact some of those investigations that Professor Walker ordered, the neuropsychology assessment and the neuropsychiatry assessments, were not completed during Gaia’s admission in July 2017 he responded:
“It’s regrettable. I know from my own experience in running a surgical treatment programme that organising lots of disciplines to see a person in a specified period of time can be challenging…
Have to recognise sometimes administrative regimes in the health services are not as good as one would wish.
I think that’s unfortunate and regrettable, whether that omission would have made any difference is less certain”.
Asked if it were a gross failure he responded:
“It is clearly regrettable and upsetting. One would like the health service to be able to do these things faultlessly, but on occasions I’m afraid it doesn’t.”
Pushed further by counsel for the inquest, Sarah Clarke on whether gross failure was something he felt able to apply or exclude in relation to this matter, his response was:
“It wouldn’t be a term I’d embrace overwhelmingly. It’s an expression… very human frailties in a system where many different disciplines trying to achieve best ends for an individual and sometimes coordinating that causes problems”.
He conceded he would regard it as a serious failure. In her questioning the coroner asked him again whether he felt it was a gross failure, explaining the coronial definition of neglect as serious failure to provide basic medical care. He appeared somewhat evasive responding that they “should have happened during the course of the July admission”, asked if it were a serious failure he responded “it should have happened”. The Coroner sought to pin him down asking if he believed it was serious that it didn’t, to which he responded:
“It is regrettable, but having worked in the health service all my life I know these things happen, are not with any intent as such”.
He didn’t feel that the failure of the tests being done had a clear and direct causal link to Gaia’s death.
Prof Chadwick was similarly circumspect when asked about failures of communication between various teams managing Gaia’s epilepsy and mental health. At first suggesting he was impressed at the efforts made, although he rolled back on this a little under questioning:
SC: as far as you’re concerned communication and coordination between various disciplines in Gaia’s case, what’s your view of that?
DW: I think they were reasonable. I got the impression that Dr Page’s team were contactable and appeared reasonably responsive to families’ questions. I think there was a reasonable amount of shared information between neurology on one hand and psychiatric input on the other.
That is something that is difficult I think, because neurologists are always thought of as living in some sort of ivory tower and not being terribly approachable, very much hospital clinicians, that’s the environment they work in. Whereas psychiatry is much more community based specialism, something of a gulf to be bridged there.
I was reasonably impressed efforts were made in Gaia’s case to communicate effectively between the two.
SC: we’ve heard evidence about that in the course of the inquest from other witnesses. Taking for example, Gaia’s admission to hospital in February to 2017, the doctors and other mental health specialists that dealt with Gaia during that period have said there wasn’t actually any communication during that admission between them and neurology team dealing with her epilepsy, them and for example Dr Page. Certainly some of them felt on reflection there should have been, what’s your view about where there should have been?
DC: I’d agree with that
SC: If you were Gaia’s treating epilepsy doctor and she were sectioned for amongst other things psychosis, would you have wanted to know about it?
DC: I would yes
SC: Would it have been relevant to you to know two days before that admission she had a tonic clonic seizure?
DC: It would
Prof Chadwick went on to expand that he’s also wish to know about Gaia’s deterioration, and would want to ascertain whether her mental state at that time was attributable to her epilepsy of an independent and primary psychiatric disorder. He said he’d have wanted to perform a clinical assessment of her at the time, and to conduct clinical investigations, specifically an EEG.
Prof Chadwick also confirmed that he’d have wanted to be informed about Gaia’s admission to hospital under Section 2 of the Mental Health Act (and later as a voluntary admission) in February and March 2017. Within that he’d specifically have wanted to be told that she was having symptoms of psychosis. He confirmed he’d also have wanted to be told about the mental health act assessment of Gaia and admission to Poole General Hospital over the weekend in October 2017.
What is particularly tragic about this situation, not a term I use lightly, is that Gaia herself had gone to hospital in October wishing to receive help for her epilepsy. The court heard evidence last week that she became distressed when she realised that she was being treated by liaison psychiatry and not by neurology that weekend.
Asked about whether it made a difference that Gaia’s symptoms resolved relatively quickly he confirmed, as Prof Walker also suggested last week, that rapid resolution would push one towards believing Gaia was suffering from postictal psychosis.
On which note the coroner picked up on something that Dr Jeffery, the specialist registrar on call for liaison psychiatry during Gaia’s October to Poole General Hospital, had told the court in his evidence last week. He had conflated postictal confusion and postictal psychosis, claiming a general catch all postictal syndrome.
Coroner: the jury have been told about postictal syndrome, one witness said use general term rather than postictal confusion or psychosis. Have you ever come across postictal syndrome?
DC: To be honest no
Coroner: So that’s not a recognised medical term?
DC: I don’t recognise it as such
Coroner: Can you generalise postictal confusion and psychosis or are they very different?
DC: Features may be similar but time at which they occur and their duration are very different.
Professor Chadwick informed the court that postictal psychosis is likely to resolve in at most 5 to 7 days; whereas he’d anticipate postictal confusion to resolve within about 30-45mins following a seizure, much less time in localised seizures. Then another caveat:
Coroner: is it an exact science or not?
DC: there’s no exact science
Coroner: so although that’s usual, but no science that after two hours every postictal confusion will be resolved?
DC: the first thing medical students learn is never to say never.
The combination of caveat and circumspect and allowances for human frailties seemed to explain, or perhaps excuse, an awful lot. Asked about the failure for Gaia’s epilepsy specialists to be told about the deteriorations in her mental health he considered that it couldn’t be a gross failure as Gaia was still receiving her anti-epileptic drug treatment.
He indicated that he considered it to be a missed opportunity to review Gaia’s epilepsy care, however he wasn’t able to say whether that would have made a difference to her treatment.
Prof Chadwick confirmed to counsel to the inquest, Sarah Clarke, that he felt there were failures in communication; when asked how serious those were he responded:
It is a level certainly below optimal practice. Umm, again one of those areas where human frailties can mean that things don’t occur as one would like them to.
When clinicians are very busy and under stress I’m afraid it is almost universally the case that the thing that gets economised on is communication, particularly communication between doctor and patient.
On questioning from Sophy Miles, for Gaia’s maternal family, Prof Chadwick confirmed that Gaia’s behaviour of stripping her clothes could have possibly been as a result of seizure activity:
That kind of behaviour can certainly occur in confusional states after seizures. It’s unusual behaviour to be quite so organised, in terms of achieving a result like taking your clothes off. It is still possible.
Asked by the coroner whether it was probable he felt that it being a possibility was as far as he could go. He couldn’t confirm whether or not, on the balance of probabilities, Gaia’s epilepsy had contributed more than negligibly, trivially or minimally to her death.
There were no jury questions for Prof Chadwick, so the final question came from Gaia’s family themselves, I’ll finish it with it:
SM: this is my final question, one from the family, you’ve talked about the vital role of the epilepsy specialist nurses. We learned there are two nurses in the local team with 10,000 patients. In your opinion do they have sufficient resources to do the job they’re required to do?
DC: There are never sufficient resources.
Court returns tomorrow with the first of the family evidence, we’re due to hear from Gaia’s older sister Clara, and her twin sister Maya.