Yesterday morning the court’s third witness was Dr Christopher Williamson. He told the court that he was a GP Partner at Churchfields Surgery, Bromsgrove and Sally registered with the GP practice in 2010. He had only met Sally on one occasion, for her learning disability review (which I assume to be their terminology for her annual healthcheck) on 7 September 2016.
The coroner asked Dr Williamson to outline the medications that Sally was regularly prescribed, which he did. Sally attended the surgery every couple of weeks for an injection for her mental health, he said that appointment would be with one of their nursing team. She also attended the surgery as required for any other matters.
C: When is the first mention in her records that there may be issues with constipation?
DrW: Ms Lewis was registered in the surgery in September 2010. At this time she had a first review with one of my colleagues, it was noted she suffered with constipation. So from our first engagement with Ms Lewis we were aware … discussed several times, with myself at her learning disability review and with several of my colleagues
C: Ok, looking at your statement we can see couple visits in August 2015 specifically about the issue of constipation is that right?
C: And again in October of that year?
In response to questions from the coroner, Dr Williamson outlined the medication regime that Sally was on with regard to her constipation. He told the court that the main medication Sally was on was Laxido, but also Bisacodyl at night. He explained that Bisacodyl was mainly used for softening stools, and that Sally was on it when she joined their surgery .
C: Going back to October 2015 after the appointment with the GP on that occasion, any regular medications first of all for constipation?
DrW: Laxido I’d consider regular medication, in that we weren’t expecting her to stop, that was the instructions
C: What were instructions in relation to Laxido as at OCtober 2015?
DrW: Dr Sarkar prescribed it once daily as required to try to get at least one soft daily motion
C: How would you have expected those looking after Sally to know whether she needed Laxido or not?
DrW: I can’t speak for Dr Sarkar, but myself, when I speak to someone about constipation, I talk to them about number of different factors that affect everyone’s bowel movements day to day, week to week. Always emphasise outcome is most important, combination of two, can be consistency of motion, maybe being too hard, or problem with frequency, or combination of two. So it’s important we try to set a target for bowel motions when suffering constipation.
It’s usual we ask them to monitor, or ask a carer to document how regularly they’re going to the toilet and when they do what’s the consistency and size of motion, and to judge consistency with use of the Bristol Stool Chart.
The coroner discussed with Dr Williamson the type of laxatives that Sally was prescribed, he said that they were both osmotic laxatives (which draw water from the rest of your body to soften your stool) and that Bisacodyl also has a “weak stimulus effect”.
C: Alright, you then saw Sally just under a year later on 7 September 2016
C: Am I right in thinking she hadn’t been brought for a GP consultation or any sort of consultation at the surgery between October 2015 and September 2016?
DrW: Looking at my notes it looks like she’d been seen by one doctor about distress and a fall, and another colleague spoke to carers about a missed dose of medication. So seen on one occasion and spoke to carers on one occasion.
The coroner asked Dr Williamson to describe what his learning disability review with Sally would cover and he described the process as a wide reaching assessment. He explained that patients with learning disability would be on the surgery’s learning disability register and they would be invited to come in, with a family member or carer, to identify how they’re doing, physical state and general wellbeing. He remembered Sally attending with a female carer. Asked if the carer, or Sally, raised the issue of constipation at that review Dr Williamson told the coroner that he remembered bringing it up himself.
Asked if he remembered what was discussed he told the court that he asked how frequently Sally was going to the toilet, the consistency of her motions and how regularly she was being given the Laxido medication. He also remembered examining Sally on that occasion. He asked whether Sally “wasn’t herself” and explained that people with a learning disability sometimes present with less typical symptoms such as agitation or abdominal swelling.
C: What information were you given?
DrW: Seemed like things were improving… she’d appeared more settled, when I brought up constipation, they said they were using Laxido intermittently, they said she was having soft motions but only once a week, which was causing her some distress. I was concerned she was still suffering from constipation at that point.
C: Just pause there. So the information you were being given was she was receiving the Laxido regularly, but not every day?
C: And as a result, soft motions, but only once a week and that was causing her some distress?
C: You felt on the information you were being given that indicated Sally was still suffering from constipation?
C: Because of the lack of frequency of movements?
Dr Williamson explained that although frequency varies for everyone “pushing it to once a week is too far and it was also causing her distress”. Asked by the coroner if he gave any further advice he said that he did. He told the court when he talks to people about constipation he always reiterates the importance of non-medical factors, discusses diet and the importance of including fruit, fibre and fluids.
Dr Williamson told the court that seeing as Sally’s bowels weren’t opening frequently enough he wanted to add in a stimulant laxative. He said the previous year there had been an issue with Sally’s bowels stopping and starting and he wanted to avoid that “with a cautious dose of Senna”. He explained that the intention was that Sally would open her bowels “once a day with a soft motion” and if that wasn’t achieved they should come back.
C: What was dose you prescribed?
DrW: 7.5mg of Senna twice a week
C: In addition to the softener she was currently on? So Bisacodyl would continue, and also Laxido as required?
C: And the advice was if that didn’t result in one motion every day they should return to you to reconsider the dosage?
DrW: Yes, not just one motion, a good size, yes, they should return to us
C: When you gave this advice, clearly what you were saying was someone needed to monitor Sally’s bowels, take note of the stools she was passing and how often?
C: Was any surprise suggested to you this was being requested?
DrW: Not that I remember
C: Did anyone suggest it was difficult to monitor Sally’s bowel movements because of her privacy?
Asked by the coroner what he’d had advised if the carer had suggested that they didn’t like to monitor Sally’s visits to the toilet because she likes her privacy and can get upset and agitated, he said that he’d have checked if that was always the case or had been a new behavioural change.
I’d very strongly have said we need to know she’s opening her bowels or we’re never going to know whether the treatment we were prescribing was successful.
He said that it would have surprised him as in his experience monitoring of bowels was a “universally done thing” in most supportive care or hospital settings.
C: Doctor would it surprise you to hear there’s no record after December 2016 of any Laxido being given to Sally at all?
C: And would you agree doctor, in monitoring a person’s bowel movements, it is as important to record there’s no bowel movement as it is to record the nature of any stools that are passed?
DrW: Yes, the documentation [fuller answer – can’t hear]
C: Those instructions you had given, there’s nothing particularly complex about those instructions would you say?
C: No reason to think the carer who was with Sally wouldn’t be able to understand that was what was required?
DrW: No. And I always make sure when I discuss a treatment regime, either the patient or carers understand.
C: Would you describe that regime, and advice given, as a basic level of medical care?
The coroner thanked Dr Williamson and said that he’d ask Mr Clarke for Sally’s family if he had any questions he’d like to ask him.
SC: Just in terms of Dr Sarkar’s review, is it right it was documented that the carers had stopped the Laxido? In October 2015?
DrW: Yes, she was informed they’d stopped giving the Laxido
SC: That was because they were concerned about stool’s being loose?
SC: The outcome was that Sally was constipated with faecal overloading?
DrW: That’s correct
Mr Clarke asked if he’d have expected the carers to have known about constipation and faecal overloading and he said he would. Asked if it was something he’d brought up at Sally’s learning disability review a year later he said he didn’t recall specifically talking about it. Mr Clarke asked him how the surgery communicated what had happened, besides speaking with the carer attending and Dr Williamson explained that there was variability. He said that certain supporting living services or care homes would ask the surgery to write down what was agreed but he wasn’t asked on this occasion. He added that he was “always happy to write it down for clarification”. Asked if he knew whether the request for it to be written down varied by provider or home to home, depending on their policies, he said he didn’t know.
Mr Clarke asked if the surgery had reviewed their practices since Sally’s death and considered whether they needed to change how they communicate when carers attend. Dr Williamson said that since Sally’s death there had been significant change in how patients with learning disabilities were managed across the area, and that in addition to learning disability reviews they now had a specific doctor employed who is lead for learning disability and who provides consistency of access for all carers of someone with a learning disability. Asked what their practice was in communicating back to care homes or supported living placements, Dr Williamson said he’d not asked them specifically.
No more questions from Mr Clarke.
Mr Hassall KC for Dimensions had a number of questions for Dr Williamson. He asked about the advice given on the four consultations recorded in the notes that specifically reference constipation. Dr Williamson said that he could not speak for his colleague Dr Sarkar’s practice. Mr Hassall said that there was no reference in the doctor’s notes to the Bristol Stool Chart. He said what was recorded seemed to be Dr Sarkar’s assessment.
CH: You said in your evidence in relation to what is important in relation to constipation, that monitoring is very important?
CH: And also it’s important to set a target for motions?
CH: And you said if it’s a carer we ask them to monitor whoever they are caring for?
CH: How regularly, consistency and size. You said to judge consistency we’d recommend a Bristol Stool Chart?
Dr Williamson nodded.
CH: Again in records of those consultations is there any reference at all to the Bristol Stool Chart?
DrW: No, as I say, the notes I make on a visit are not verbatim, and certainly for myself I can say in practice I’ll always talk about the Bristol Stool Chart, but again I don’t document every word.
CH: There was I understand it yesterday reference to ‘if it’s not recorded it didn’t happen’
DrW: That’s not what a doctor would say about their records
CH: That doesn’t apply to medical records?
DrW: No medical records vary from person to person admittedly but are to act as evidence of what happened, provide for yourself if you need to look back at notes, and as I’m sure you can see, there is variability in what people write
CH: That’s why can’t comment on your colleagues?
DrW: I can interpret with confidence what was written but I can’t give a full account of what happened in that conversation
CH: Is it your evidence you can specifically remember saying as part of that learning disability review they should be completing Bristol Stool Charts?
DrW: Bristol Stool Chart is a reference chart that describes through numbering and pictures what different consistency of stools are. I’d advise the easiest way to do it, which isn’t up for interpretation, is to use the Bristol Stool Chart for reference
CH: You said in your evidence what you think you would have advised, my question is did you advise that?
CH: During this learning disability review?
DrW: Yes. Its 6 years ago, but I want to make sure I’m being as clear as possible
Mr Hassall then discussed agitation as a sign of possible constipation with Dr Williamson.
CH: You said one of the possible signs of constipation is agitation?
CH: Of course you’d be aware Sally could, at any time, display signs of agitation?
CH: So she being largely non verbal, it might be difficult for someone supporting her to distinguish what agitation would be?
DrW: It could be, and that’s why they should present to a doctor if they’re unsure
Mr Hassall then asked about who would be responsible for Sally’s anti psychotic medication, whether that would fall under Dr Williamson’s review. He said that he’d asked how Sally had been on the injection but decisions over adjusting or monitoring that medication would be had with the consultant psychiatrist.
Mr Hassall said that Sally was coming to the surgery to receive that injection every two weeks or on a weekly basis, possibly 4 weeks at different times. Dr Williamson said that he couldn’t give exact dates and he knew there had been a dose adjustment earlier in the year. Mr Hassall asked if there had been an appointment on 18 October 2017 with one of the nursing staff for Sally to receive her injection and Dr Williamson confirmed that was what he’d recorded in his statement.
CH: So she’d be seen at the practice by someone with formal nursing qualification, sometimes as often as every two weeks?
DrW: That’s correct
No questions from counsel for Julie Campbell, Worcestershire County Council, or the CQC.
Finally Mr Mumford, his own counsel asked him questions about the learning disability review process. Dr Wiliamson described the requirement was for each patient to have a review at some stage between 1 April and 31 March the following year. He told the court that the learning disability reviews form part of the Quality Outcome Frameworks, a set of targets for GP surgeries. He said one target was to have a learning disability register, and the other was to provide patients on that register with an annual review. He explained that the practice were trying to move to a practice of reviewing patients in their birth year, but that was in progress. Mr Mumford clarified that Sally’s last review had been in September 2016 and she’d not yet been seen for a review in the April 2017-March 2018 year at the time of her death.
No further questions for Dr Williamson, the coroner thanked him and released him shortly before 1pm.
The coroner then read onto the record the statements from Natalka Greenwood and Ellen McNiece, a paramedic and trainee paramedic who attended Sally on the day of her death. He also summarised the log.
The evidence was that the crew had been tasked to an unconscious, not breathing, category one call and that The Dock was very close to their station and they’d arrived within six minutes. They described how they worked on Sally, and the fact they were attended by a second crew.
It was recorded in the log record that the patient had collapsed, last seen alive by at 07:50, discovered by care staff at 07:58. It was also noted that Sally had been found supine on the floor by Sonia Parchment who recognised the patient wasn’t breathing and commenced CPR while the other carer called 999.
The call was received at 07:57, paramedics arrived on scene at 08:03 and were at Sally’s side y 08:04. All attempts at resuscitation were unsuccessful and Sally was recorded as life extinct at 08:32.