Sally Lewis Inquest: Prof Sir Ian Gilmore

The first witness on Day 3 of Sally’s inquest was the court appointed expert, Professor Sir Ian Gilmore. He gave an affirmation and started by explaining that more evidence had come to light since he’d submitted his report and that’s why he’d shared two medical journal articles.

Professor Gilmore gave his name, affiliation and an overview of his qualifications and experience. He told the court that he’s a Consultant Physician at the Royal Liverpool Hospital and a Professor at the University of Liverpool. His area of expertise is gastroenterology.

The coroner said that Professor Gilmore had been asked to consider a number of reports and documents in this case including a bundle of statements and reports, witness evidence including the post mortem examination report. He said that there was also a large bundle of documents, over 3000 pages, from Dimensions UK, an Adult Safeguarding Report from Worcestershire County Council, and Sally’s GP records and other medical records.

Professor Gilmore was asked to outline his understanding of the issues that Sally had with constipation and her bowels, and he was asked to tell the court, as far as he could, how far back those issues went. He said that her medical records dated back to 2010 and that there was previous reference to enemas, Senna and Movicol [Laxido] in the earliest records in 2010.

Professor Gilmore told the court that he didn’t think there was sufficient information in the records to get a view of how much Sally’s constipation troubled her. He said that in Dr Williamson’s report it said that his colleague Dr Sarkar had arranged a disimpaction in 2015 but the report didn’t detail what that involved. He said that it would normally mean giving enemas and rectal examination to ease the stool out of the rectum. Professor Gilmore said that disimpaction implies that there was a blockage at that time.

C: Thank you, by the date of the events we’re concerned with in October 2017 were you able to discern what the medication regime for Sally’s bowels was at that time?

ProfG: Yes I was. It was Senokot liquid and Bisacodyl given regularly, these are similar medications, and Laxido is to be given as required. Senna was twice weekly added in October 2016. Laxido changed at some point, couldn’t work out when changed from one regularly to one as required, certainly by 2016 it was as required. In October 2016 Senna liquid twice weekly was added to the Bisacodyl.

C: Deal with each please. Bisacodyl what sort of medication is that?

ProfG: That and Senna are stimulants… they stimulate the bowel to move things along, whereas Laxido or Movicol is an osmotic laxative, draws fluid into the bowel to make stool softer and more liquid. They are, in a sense, complementing.

C: This regime seems to be in place since October 16, have I understood that correctly?

ProfG: Yes

C: Can I ask you then in your view, given everything you were able to ascertain about Sally’s situation, actually before I ask you that question, in light of what we’ve received this morning, you’re aware now Sally was on a number of other medications relating to other issues including anti-psychotic medication as she was a diagnosed schizophrenic.

ProfG: My understanding is these are given to address behavioural issues, I don’t know if I saw reference to schizophrenia.

The coroner said he thought that he’d seen reference to schizophrenia in the records.

ProfG: They are anti-psychotic drugs.

C: Given the two research papers you’ve given to us this morning, do I take it, there is some thinking that certain types of anti-psychotic medication can affect bowel motility?

ProfG: Yes

C: Are you able to say, from what you know about this case, that Sally’s case would fit that profile? Part of the reason for the bowel issues mentioned may have been down to anti-psychotic medication?

ProfG: I think more likely than not that was a contributory factor. We do know people with learning disabilities are more prone to constipation any way, it’s multi-factorial, including diet, fluid intake, exercise and the like, but I think [can’t hear]. Anti-psychotic drugs do seem to have an anti-colon [can’t hear] pathway… tend to slow down the motility of the colon. I think it’s more likely than not anti-psychotic therapy was a significant factor in her constipation.

C: Next question, how widely known is it that anti-psychotic medication can contribute to constipation?

ProfG: It is fairly widely known, it’s been general knowledge summaries of NICE, reference to British National Formulary, I haven’t checked back, you can get online most recent version, think likely they’d have referred to constipation going back a decade or so.

Professor Gilmore discussed the papers he’d shared with the court more. The coroner then asked him to what extent it was well known that people with a learning disability were prone to constipation.

C: Fact people with a learning disability are more prone to constipation, is that something which is widely known?

ProfG: It’s widely known by those involved in their care. Not sure a general surgeon or someone would know that, but a psychiatrist specialising in that are, they would be aware.

C: I don’t know if you can assist with this or not. This inquest has focused quite a lot on care provided to Sally in the residential placement in which she was living, by those supporting her, and arrangements which may or may not have been made to monitor her bowels. l will ask you about that later on. In terms of guidance to those working in care settings, guidance to GPs, that sort of thing, are both these factors likely to be widely known within those sort of areas?

Professor Gilmore said that was beyond his area of expertise, but some regime with appropriate monitoring is required, and some system of finding out. The coroner said he was likely to return to that later before asking more about the medication regime in place for Sally. Professor Gilmore told the court that he thought the medication regime in place for Sally, since September 2016, was appropriate, and that the addition of Laxido was reasonable.

C: In terms of the dosages of the Senakot and Bisacodyl, did they appear to be appropriate for the sort of issues Sally was experiencing?

ProfG: Yes

C: And the Laxido was appropriate to make it PRN, as opposed to be given regularly?

ProfG: I think so [can’t hear] there may be problems fed back to the GP, they might have come back to make it regular, but an as required regime is reasonable.

C: So next question, from your examination of the records, did it appear, were you able to tell, whether that regime was being followed within the care setting?

ProfG: I wasn’t able to find that out.

C: For what reason?

ProfG: Really because I couldn’t find a regular record of [can’t hear] and needed to be added.

C: I think in your report you established that the Laxido was given a total of 11 times, up until December 2016 is that right?

ProfG: I think that’s correct, I made it my best, you mentioned over 3 thousand sheets of records, some bits appeared randomly shuffled, it wasn’t easy.

C: I’m looking at line 230 of your report.

ProfG: Yes

C: Can I indicate, don’t know if you can assist or not, my own looking through those records I think I found 15 times, don’t know if anyone is going to disagree with that? 4 occasions in June 2016, 7 in August, 2 in September and 2 in December. That’s going to be a matter in the end for me to decide. If it was 15 times as opposed to the 11 times you found up until December 2016, would that make any difference to the conclusions that you drew?

ProfG: No

C: It wouldn’t, alright. From your reading of the records, how should Sally’s constipation have been treated and monitored in the time she was living at this particular setting, with this regime in place?

ProfG: Stool charts would have been, of bowel function daily, would have been most helpful. Frequency and consistency documented.

C: Why would that have been important, why would it be important to monitor the frequency and consistency of her stools?

ProfG: First of all as a general, [can’t hear] but also you can’t really judge an ‘as required’ unless you have some index of whether its required or not.

Asked by the coroner if he could find any evidence in the paper that Sally’s bowel movements were monitored and recorded as they should have been, Professor Gilmore said that there was some records. The coroner asked whether the entries were of sufficient clarity and content to assist with the decision about whether to give PRN medication or not, and Professor Gilmore explained some of the difficulties with constipation.

C: Did you have an impression at all, whether those completing the care records had a consistent idea of what they were looking for, and what they were meant to be monitoring?

ProfG: I didn’t [fuller answer – can’t hear]

The coroner asked about common symptoms of constipation and Professor Gilmore outlined some, also commenting that he didn’t know what Sally’s communication skills were like and said he could imagine that there might be some difficulty in getting a clear picture of whether or not Sally was constipated from listening to her. The coroner then asked what symptoms the support workers might be looking for in Sally to identify she was constipated.

C: We heard the suggestion constipation can lead to a distended stomach?

ProfG: Yes

C: So, abdominal pain, distended stomach, I’m trying to get a picture of what those in a care setting might be looking out for besides scrutinising Sally’s behaviour in the toilet, outside the toilet for example, abdominal pain, distended stomach, any other things looking for, given what we know that might be a symptom of constipation

ProfG: One symptom of severe constipation is of course impaction, would be vomiting, in Sally’s case it did not appear to be some obstruction although colon was not [can’t hear].

The coroner then asked if Professor Gilmore remembered the chart of electronic entries documenting Sally’s bowel movements in 2017.

C: We’re led to believe I think that this is a print out which shows the entries made in an electronic bowel chart between 1 January 2017 and the date of Sally’s death on 27 October that year, period of about 10 months, if look next page two further entries. I think its 21 entries in all, most of those record the fact there’s been no bowel movements, couple of entries that refer to large movements of type 1 and we’ve heard evidence that would be type 1 on the Bristol Stool Chart.

ProfG: Yes, I do recall.

C: If these proved to be the only entries that were made over that 10 month period, in your view is that a sufficient account and sufficient to allow those caring for Sally to make an informed decision about giving her the PRN Laxido?

ProfG: No

C: And why not?

ProfG: [can’t hear] Have no evidence, would be some bowel movements between those dates, but was no entry made.

C: Just thinking about that for a moment, we’ve a couple periods between dates of 14 days [lists] how likely in your view would it be for someone to go for such a long period without passing a bowel motion?

ProfG: It’s certainly possible.

Professor Gilmore said that there were clinical reports of people going a year without having any bowel action and not coming to harm from it. He said he suspected that although there was no firm evidence, that there were periods in the previous 7 years where Sally would have gone for periods without having a bowel movement.

The coroner asked whether, given the post mortem findings, Professor Gilmore could say how long it was likely Sally had been suffering from the severe constipation that led to her death on 27 October 2017. He said that he couldn’t. He told the court Sally had suffered from constipation for several years, that she had a suspected faecal impaction two years previously. He said in the weeks prior to Sally’s death the records hadn’t necessarily shown a difference in her symptoms, although he did note that the observations of Sally’s family was that she suffered some distension and some behavioural change, which he thought was certainly quite possible.

The coroner then asked whether Professor Gilmore was able to say if Sally had been demonstrating signs of pain or discomfort in the days leading up to her death. I didn’t hear the start of Professor Gilmore’s answer but he ended it:

With that degree of distention one would expect to experience symptoms of pain or discomfort but has to be taken in context of someone who may have been in that state for a long period of time and become more attuned to it.

The coroner described how Sally presented the evening before her death, including being out of her routine, tired, and wobbly on her feet and asked whether those symptoms were consistent with severe constipation leading to gross faecal impaction and Professor Gilmore replied:

They’re likely related, the fact she had faecal impaction… lining of the colon was beginning to become necrotic, that had allowed bacteria and toxins to get into the blood stream. We have early signs of sepsis.

In response to follow up questions from the coroner, Professor Gilmore told the court that the distension Sally suffered would compromise the blood supply to her bowel and that was what allowed the lining of the bowel to become necrotic.

C: Do I take it in your view the inevitable consequence of toxins entering the blood stream is that Sally became septic?

ProfG: Yes

The coroner then asked Professor Gilmore if, on the balance of probability, Sally had been given Laxido as required she wouldn’t have died when she did, and the Professor said yes. When the coroner asked if it was fair to describe monitoring, recording and provision of laxative medication, as being at the level of basic medical care, Professor Gilmore said he didn’t really feel in a position to judge about practice in a care home, but it certainly would not satisfy him if a patient was in a hospital bed. He added that the person prescribing the medication should be in a position to say.

Next Mr Clarke for Sally’s family asked questions. First of all he asked questions about why some people get constipation, and attempts to prevent it by diet and exercise.

SC: So if carers were relying on the fact Sally had a good diet, she was going for walks, to address constipation, would that take you by surprise?

ProfG: What would take me by surprise, is not knowing whether or not she had constipation.

Next Mr Clarke asked how long it was likely to take from Sally becoming ill to her death.

SC: Are you able to assist us, once she starts to show her symptoms do you know how long it would normally take to death?

ProfG: This is quite an unusual cause of death so I don’t think there’s a great deal to go on to answer your question, but do think it’s highly likely the malaise that evening was the result of the beginning of septicaemia… death within 12 hours is more rapid than usual, but not beyond the balance of probability.

No questions from Mr Kay for Julie Campbell or Mr Cox for Worcestershire County Council.

Mr Mumford for Dr Williamson had a point of accuracy relating to the number of times Laxido was given to Sally in 2016. His review of the records, specifically the August 2016 MAR charts, appeared to show Laxido being given 8 times, not the 7 times that the Coroner had suggested. He asked Professor Gilmore if that would change the answer he’d given to the coroner earlier, he said it would not and he added that there was “insufficient monitoring” of Sally’s bowels.

No further questions from Mr Mumford, and none from Ms Wilks for the CQC.

Mr Hassall KC for Dimensions started by asking whether it was important that Support Workers had clear documentation or information, that was not open to interpretation, about whether Laxido was going to be required. Professor Gilmore said that would depend on the expertise and experience of the staff. Mr Hassall said that advice was being given by qualified doctors to people with no medical qualifications, and Professor Gilmore said that he wasn’t aware of the training or qualifications of care staff.

Mr Hassall asked Professor Gilmore what PRN meant, and he said that he’d forgotten the latin (pro re nata if you’re interested) but the translation is as necessary, or as required. Mr Hassall then suggested to Professor Gilmore that the instructions given to staff about the use of Laxido, one as required to try and get at least one soft bowel action daily, were open to interpretation. The coroner clarified the question for Professor Gilmore.

C: The question is whether that could be interpreted as not sufficiently clear as an instruction, would you agree with that?

ProfG: I’m not a general practitioner and I’m not aware of the experience or expertise of those working in the care home, it does seem fairly easy to follow to me, as a qualified person. If one was having 6 liquid stools a day I would not give them Laxido, would leave as not required, whether interpreted as such by a care worker, I’d have thought so, but I’m not in a position to reassure you.

In response to a question from Mr Hassall, Professor Gilmore confirmed that he did not find the time when Laxido was changed to PRN in the records. Mr Hassall then asked Professor Gilmore whether he agreed with his suggestion that once Senna was prescribed to Sally in September 2016, Laxido was only given twice more in December 2016.

CH: After Dr WIlliamson has added in the Senna, Laxido falls off after the Senna has being introduced. Would you agree then, there’s support within the MAR charts for what we might expect to see, once Senna added in is less need for the as necessary Laxido?

ProfG: I don’t think I can answer that without going back to the charts, but I suspect the charts are missing some information.

C: Mr Hassall, the MAR charts simply show what was given and what wasn’t given. Whether that can be interpreted as staff felt Laxido wasn’t required as Senna was working or not is really speculation. If you’re asking this witness to form conclusions on MAR charts alone, that really is speculation isn’t it?

CH: MAR charts are a record, am taking through that because comment is being made no Laxido post 2016, then it’s not speculation to identify that the administration of Laxido dropped off after the Senna, another laxative was added in.

C: As a simple matter of fact its clear there’s a coincidence in time, but I think you were asking the witness to draw more of a conclusion than simply that, weren’t you? Because staff thought Laxido was no longer required. I don’t think that’s a proper conclusion this witness can draw from that information.

CH: Laxido was prescribed.

C: Yes. Can I put it this way, I’m not going to allow the witness to answer that question.

Mr Hassall then took Professor Gilmore to bundle 3, tab 6.

CH: So what I think the agreed summary of the administration of Laxido is that it was administered 4 times in June 2016, was administered 8 times in August 2016, Senna was added in in September 2016, and then Laxido was not administered again until 27 and 28 December 2016, which you can see the record is on page 2588?

ProfG: Yes

CH: Thank you, then there’s a hand written note on 5 January 2017 which is on our page 2589. About a week or so after the Laxido was being administered for first time in several months, note is reference to Senna and [can’t hear]. Not given due to loose [can’t hear]. So here is a situation where Laxido is not being given for some time, the as required medication, then it is given at the end of December and a week or so later, it’s the Senna not given rather than Laxido, reference there to one of laxatives not being given because stools at that time were too loose.

ProfG: [can’t hear]

CH: Yes, I can’t comment on the grammatical skills of the person writing the record but reference to too loose in relation to prescribed laxative, my suggestion, might be to do with Sally’s stools at that time?

ProfG: I agree that may, or may not, be correct.

CH: Laxido not given some time, given end of December, comment few days later about loose stools.

ProfG: About two weeks, I’ll just work it out.

CH: About a week.

C: 8 days I think.

ProfG: It’s possible, it’s all speculative. You have to remember sometimes with faecal impaction patients get loose coming around the solid stool.

CH: Yes, I’ll ask a little about that. Do you agree with the evidence from Dr Williamson yesterday in treatment of constipation that monitoring of bowel movements is vital?

ProfG: Yes

CH: As we’ve already identified there is no reference, in many of the consultation notes with the general practitioner, to monitoring, bowel charts or the Bristol Stool Chart. Do you agree?

ProfG: I do. I didn’t see the advice given to the staff, but I assume the carer would have accompanied Sally?

CH: Oh yes.

ProfG: And would have been given the instruction.

Mr Hassall asked if Professor Gilmore had found any such note in the record

ProfG: I thought that would be normal practice.

C: To be fair Dr Williamson’s evidence yesterday was that he did make reference, in review, to the Bristol Stool Chart.

CH: Yes my question was in the records. Is no reference to type of stool with reference to the Bristol Stool Chart the carers should be looking for?

ProfG: I’m afraid I did not examine the records with those points in mind, that was not in the brief.

Mr Hassall then discussed the contents of the Bristol Stool Chart with Professor Gilmore and asked him whether he’d expect a bowel monitoring chart to have a date, time and type from the Bristol Stool Chart, and some estimation of size, Professor Gilmore agreed.

Mr Hassall then told the court that when someone has a large impacted stool internally, which is solid, outwardly it can look like things are going in the other direction and the person is suffering from diarrhoea. Professor Gilmore agreed. Mr Hassall then moved on to ask about Sally going long periods without bowel movements.

CH: Looking at Sally’s case, one period was 2 weeks, or might have been much longer than that. It’s clear that all records were not [can’t hear] and that’s accepted. What’s your view of whether Sally was having movement of her bowel during that period of time? Given other evidence was she was eating normally, she was not vomiting and support workers were saying she’d take herself off to the toilet at times and we didn’t know whether she’d been or not. Looking at all evidence in relation to Sally, do you think she probably was passing stools intermittently during that period of time?

ProfG: I’d really find it impossible to answer that speculative question. It’s certainly quite possible she did pass stools unsupervised, it’s possible she may not have done.

CH: No, no. If you just can’t, say. You were asked as well about whether behavioural changes might be a symptom of constipation, um [can’t hear] behaviour problems would be consistent with long term constipation?

ProfG: I said there could be changes in behaviour, yes… [can’t hear]

CH: But of course its important in this case to identify that it’s also consistent, the behavioural challenge with someone who’s behaviour was clearly being complex … learning disability… schizophrenia…other external factors that did not include severe constipation, would you agree?

ProfG: I would agree in someone with behavioural issues, in one episode or any pattern, it would be very difficult to identify what the cause was [fuller answer – can’t hear].

CH: You said it would be normal for someone with those symptoms to experience pain, but might be lightened by their body adapting over time to faecal impaction, is that right?

ProfG: Adapting to constipation yes, but individuals vary greatly [can’t hear] there is huge individual variation.

CH: Even without factoring in the psychiatric and learning disabilities. As you say quite clearly in your report, any symptoms of pain and distress there might have been would be in the context of Sally Lewis’s condition. You say in your report you’re not an expert in psychiatry… you conclude that the evidence available from staff at The Dock I believe is unlikely Ms Lewis suffered significant pain or distress prior to death?

ProfG: Yes

A discussion then followed about what bowel monitoring should look like. Professor Gilmore was clear that it was beyond his expertise to comment on how bowel monitoring was, or should be, interpreted in a care home setting, but he outlined the minimum he’d expect (which I couldn’t hear).

CH: No. What I’m interested in is, as a gastroenterologist, if you tell someone with chronic constipation, that is the type of information you’d be looking for?

ProfG: [can’t hear] sometimes in a clinical setting we’re reliant on patient’s story or their carer

CH: Yes assuming you have a patient who is capacitous and consenting… presumably in your experience they might be a little embarrassed by the intrusion, but they will understand it is for their own good and will comply with your direction to record the timing, frequency, consistency, size of their bowel movements?

ProfG: It would be unusual to have that degree of detail in an outpatient role… but the majority of patients would cooperate and let me know what was happening in terms of differences.

CH: What I’m asking about really Professor is this, in the case of a patient who is consenting, capacitous, able to make decision in their own best interest, it is a relatively straight forward matter to say, between me seeing you now and when I next see you would you please keep a record of what is happening when you go to the toilet?

ProfG nods

CH: The practicalities of bowel monitoring are likely to be very different in the case of a learning disabled patient with challenging behaviour, who is able to use the toilet independently and for whom use of the toilet is a trigger for their challenging behaviour. Would you agree bowel monitoring is going to be a very different prospect in that latter context to previous?

ProfG: [can’t hear]

CH: So what you would have to do in order to monitor bowel movements properly and fully, would stop her using the toilet independently, because if they did go to the toilet independently they might open their bowels and flush away physical evidence you’d want support workers to compare to the Bristol Stool Chart?

ProfG: There are so many variables. The lavatory, behaviours and so on. I’d rely on the carer to inform me if responsible, if it was not possible and we’d discuss what would be the better compromise.

CH: If you want to achieve a full picture of every bowel movement would you need to ensure, practically… that each time the toilet was used, at whatever time of the day or night, that whoever was looking after the patient would be there at the toilet, between them opening their bowels and the toilet being flushed?

ProfG: [can’t hear] could use a bed pan, might be a situation where could override the flush so it wasn’t operated by patients, there are lots of possibilities but that is beyond my expertise.

CH: No, but you accept those are all factors which would have to be considered in relation to bowel monitoring of a patient in Sally’s position?

ProfG: I accept that bowel monitoring is always in the context of the patient and their needs.

Mr Hassall then moved to ask Professor Gilmore about the additional journal articles he’d supplied to the court. Mr Hassall summarised their contents as learning within the medical professional about “another potentially complicating factor in treating constipation in patients prescribed anti-psychotic medication”. Adding that the medication Sally was on appeared to give the strongest constipating effect. Professor Gilmore agreed, although he caveated that was just one paper from China, but he had ever reason to believe Sally’s medication would have side effects on the patient.

A discussion followed about whether there is greater interest in these possible connections recently and Professor Gilmore said he thought perhaps there was but he had no objective basis for that. Mr Hassall then listed what he called “the different factors that may well have had an impact on Sally’s care” and asked Professor Gilmore whether he agreed with them. They were:

  • general gastroenterological, that Sally suffered from constipation, that was widely known and managed over the years by different combinations of medication – yes
  • that was managed by her GP, different combinations of laxatives at different times and earlier references to enemas, faecal impaction, monitored and treated – yes in the context of every patient in themselves [can’t hear]
  • there is then the learning disability factor, you told us people with a learning disability are simply more susceptible to constipation than the general population – yes
  • then psychiatric medication as a potential trigger for constipation – yes
  • also within potential practical ramifications of the efficacy or possibility of the bowel action – yes.

ProfG: Yes, these are issues.

CH: You’d expect psychiatrists specialising in the area of learning disability to be aware of general tendency of patients to suffer from constipation?

ProfG: Yes, that’s to say they should. I’m not a psychiatrist but I’d be generally surprised if they weren’t aware.

CH: Yes, and so in managing Sally’s constipation we have those different factors that we know in Sally’s case were ordinarily managed by different physicians. Then of courae there were the Support Workers, who were the ones who would, are actually doing the monitoring, to pass on the information to [can’t hear]?

ProfG: Yes

CH: So with all of those factors, what’s your opinion of who should be coordinating all of those doctors? Deciding how all those factors are interacting in providing appropriate care to Sally?

ProfG: I don’t think I’m in a position to answer that… series of factors in managing constipation in people with learning disability and some mental illness.

CH: Your answer would be it’s complex?

ProfG: It’s a complex picture.

CH: That all feeds into the issues of Sally’s constipation?

ProfG: [can’t hear]

CH: So can I ask you who should be coordinating the response… who’s the overarching expertise to say, you’re not saying it ought to be one of the unqualified Support Workers who were supposed to be going to the toilet to see what happened, to coordinate the response?

C interjects: Mr Hassall, you say they’re unqualified I don’t think that’s entirely fair is it?

CH: They do not have a nursing qualification.

C: Agreed.

CH: Or degrees in subjects close to having expertise to co-ordinate [can’t hear].

C: Agreed

CH: That’s my point.

ProfG: I agree. I don’t think the care worker on the ground, who’s looking after the patient every day, should be coordinating the care, but I do think they’re the persons who have responsibility for filling in the chart.

CH: Yes of course.

Mr Hassall’s final question was about Professor Gilmore’s earlier answer about whether Sally would have died when she did, on the balance of probabilities, if she’d been given the Laxido medication.

CH: Your evidence to the learned coroner was, you said on the balance of probabilities, if the Laxido laxative was given as required then Sally would not have died when she did. Do you agree then, it goes back to the central importance of the question of as required?

ProfG: It requires a conversation of whether or not a bowel has been opened or not.

Professor Gilmore then agree that he’d said that the GP who prescribed the medication [Dr Williamson] should be able to say whether what happened in terms of monitoring satisfied his requirements.

Professor Gilmore was thanked by the coroner for his report and attendance and released.

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