After a mid morning break court returned shortly before midday and the coroner called Dr Yaqoob Ghumro to the stand. He swore an oath.

[Dr Ghumro was relatively quietly spoken and at times I could not hear his answers from the back of the court. As with all my reporting its as accurate as I can possibly be, and where I am uncertain or can not hear I will indicate as such. If I am indicating that I missed information within an answer I will use the convention of …].

Coroner Crispin Oliver started by stating Dr Ghumro had two statements, his first and an addendum statement. He asked him to confirm who he is, what he does and where he works.

Dr Ghumro answered but all I could catch was that he had been a consultant at Calderdale and Huddersfield NHS FT since 2015.

The coroner observed he had a loose copy of his statement with him, but suggested he referenced the one in the court bundle.

C: You’ve got a loose copy in front of you. On the table are 2 files, one is the court bundle, have you got that?

YG: Yes

C: Probably best to go to page 14 in that bundle do you recognise that document? Is that your statement with the addendum?

Dr Ghumro was reading documents

Mr Birch: Sir, is he looking at the medical records bundle?

C: I think he probably is

The coroner got to his feet and walked over to the witness stand, and sorted the files out so that Dr Ghumro had the correct bundle.

C: I’ll take you through your statements and I’ll basically go through getting much of what is that statement on to the court record. Everything has to go onto evidence and get recorded, but then there will be more focused evidence about what happened during the admission you describe, alright. So, right you recognise that document first off?

Dr Ghumro nodded

C: I see that it carries a signature I’m assuming is yours is that right?

YG: Yes

The coroner confirmed there were two statements, Dr Ghumro’s original statement and then a second addendum statement dated 5 December 2024 that was provided after a court direction by the coroner.

C: You say you are one of the acute medicine consultants, Clinical Director of Acute Medicine, working at the Trust for 8 years. You said you never actually met the patient?

YG: In that episode in August when the patient came

C: You never met the patient in August?

YG: I was on the on-call consultant

C: You did meet in his subsequent admission?

YG: In October

C: Right, you give an outline of the admission, you say Myles presented in Medical [missed] Unit when you were on-call consultant, referred by his GP with query DVT in left lower leg. Seen by junior doctor examined patient, asked for relevant tests … blood results, she’s asked for an ultrasound scan left leg same day, showed thrombosis in mid femoral vein… on basis of ultrasound diagnosed with DVT

Dr Ghumro nodded

C: Patient reviewed by doctor, all guidelines and protocols followed, started on blood thinning medication that’s rivaroxaban?

YG: Yes

C: Follow up clinic in [missed] time… Given appropriate advice on taking medication… [missed] essentially patient discharged same day on anti coagulation treatment with an appointment for the DVT clinic. Right, now reading that this all looks fairly unfortunate, it’s a dangerous condition but correctly diagnosed, correct medication, I don’t think Professor Hunt subsequently says. Have you read Professor Hunt’s report?

YG: No

C: Well Professor Hunt did note that aspect of the review is not of itself, no direct criticism suggested, looks fairly straight forward.

YG: Yeh

C: I suppose the only difficulty is the one we’ve now heard described this morning. You’ve got someone who has difficultly, faces challenges in appreciating detail and sequential information which if not followed might have consequences. Can you recall on that occasion, during that admission, I know you didn’t meet Myles, your junior colleague did, was there any comment about his capacity or ability to process information?

YG: No was documented in notes he was told about treatment, and education about treatment, but no concerns raised.

C: That sort of discussion would happen with any patient?

Dr Ghumro nodded

C: Was anyone alive to the possibility, the probability that Myles wouldn’t process it?

YG: There was nothing like that

C: No thought given to that?

YG: Nothing mentioned like that, normally if you suspect [can’t hear]

C: So I understand during the September admission nothing was flagged or acted upon with regard to Myles’s capacity, or ability, or otherwise to process advice and information?

Dr Ghumro nodded

C: Am I right in inferring had you gone through that process it would have gone onto the note?

YG: Yes

C: Is it right therefore for me to infer it didn’t happen?

YG: Yes, according to the medical notes it doesn’t show

C: OK, if we move on to your addendum, 5 December you add you did see the patient on 20^th in the VTE Clinic along with your registrar, Dr [missed], he was accompanied by his step father, previously said number of left leg DVT, on anti-coagulation, did not have any history of clots before last DVT … lists medication … recent travel to Greece end September and back 2 October … shortness of breath, background history of ADHD and depression, you don’t mention anything else there, learning disabilities or autism?

YG: I didn’t mention this specifically but I did mention he had ADHD and depression

C: Yes in terms of autism and learning disability, the ability to process information, understand advice, that was not recognised by you at that stage is that right?

YG: No, we didn’t find any issue at that time

C: At that time you didn’t notice anything?

YG: No

C: OK where did you get the information about ADHD and depression from?

YG: From Myles and his stepfather, they were both at the same time in the clinic, the stepfather was telling the story and we were asking

C: So that came directly from them, there’s nothing previously in the notes about that, about his mental health or learning disability and capacity, there’s nothing connected with that was there?

Dr Ghumro shook his head

C: So you relied entirely on that verbal report from Myles and his father?

YG: Yes, as far as I remember

C: How did he present to you, can you recall?

YG: He came to VTE Clinic as a follow up. When he came they mentioned he was feeling breathless and having a cough, when we inquired he said he had a trip to Greece. Normally in VTE Clinic, it is just to assess anti-coagulation, everything is going right, leg is getting better, but when they came they told us the story of feeling unwell, breathless and productive cough, that was concerning for me

C: A cough against Myles’s background of DVT is actually quite concerning isn’t it?

YG: Yes

C: That gives the impression his condition is worsening?

YG: It was difficult, I thought it likely he was having a chest infection as a productive cough, or recurrence of the clot, these were two things in my mind when I saw him. Normally in clinic we assess leg is improving, because of his condition we thought we need to treat this.

C: Alright, you say on examination chest clear, heart sounds normal, mild oedema in ankle …. Check x-ray, bloods, d-dimer …. Suggested need for lifelong anti-coagulation. These tests?

YG: Yes, to show whether infection or recurrence of the clot

C: [missed] CT scan organised for the next day, patient sent home, next day CT angiogram in the morning, showed bilateral pulmonary emboli with right heart strain, that’s the diagnosis confirmed?

YG: Yes

C: Also changes …. Seen Dr Beatrix Langara after CT Pulmonary Angiogram, who advised start [missed]… advised stop rivaroxaban. She asked for Inpatient Echocardiogram, suggested go onto warfarin after 2 or 3 days as some concerns about compliance raised. Let’s just break that down.

YG: Sure

C: 20^th he comes in, preliminary assessment made, he’s sent home. CT scan and then sent home. Next day 21 October CT Pulmonary Angiogram in morning, so he goes home and comes back. Shows bilateral pulmonary emboli and right heart strain, right? Then he ends up by that stage you’ve got on morning 21^st positive diagnosis, then you have Dr Langara says apart from anything else stop the rivaroxaban?

Dr Ghumro nods

C: It is available to infer, is it not, at that point, as she probably did, that this is a PE which has occurred despite previous medication, which is reasonable to infer it’s just not working?

YG: Yes

C: She asks for inpatient echocardiogram, then suggestion warfarin after 2 or 3 days or an alternative

YG: Anti coagulation

C: Yes, so number of things going on here, once is diagnosis, quite clear advice Dr Langara that rivaroxaban is not working, PE despite the rivaroxaban, we need to go onto warfarin after 2 or 3 days, yes?

YG: Or an alternative

C: Yes the critical thing is rivaroxaban is not working, that’s clear advice at the time. Then it says this, “some concerns of compliance from patient being raised”. Where did that come from?

YG: Was documented in the notes later on

C: Can you help me out, that bundle you looked at, blue one, can you show me where it is in the notes that’s documented?

Dr Ghumro flicked through the bundle for a couple of minutes

C: I could be wrong here, and I’m willing to strand corrected, I’m struggling

Paul: Sir can I be helpful? Page 35 of the medical notes it says rivaroxaban compliance needs to be assured

C: Alright, that states patient has some learning disability and is on the spectrum, that is dated 21^st, right OK. Now, is that what you’re referring to in the statement?

YG: That’s right

C: It does say compliance needs to be assured, as opposed to positive evidence not being complied with?

YG: You do suspect if someone is on treatment and having a clot, suspicion will be either medication is not working or patient is not compliant, these are the two things we’ll be looking at

C: OK, by that stage, that comes from Dr Langara, by that stage

YG: Patient was already on blood thinning injections

C: Yes, by that stage its evident that by the afternoon of the 21^st we have conversation between David and Amanda Mckie which are on the notes, the hospital notes. If you look page 10 you will see you’ve got Matron for Learning Disabilities, phone call from David Black, Uncle of Myles, Medical Director Sheffield Teaching Hospital, explained Myles has autism and mild learning disabilities too, often advocates for Myles and his mum Jane, would like to speak to medical team concerning care… can he see CT scan and medical review, can medical team ask permission of Myles and Jane and update David. Then addendum no learning disability flag on the EPR [Electronic Patient Record]. Checked with duty worker in learning disability mental health team, under psychiatry, known learning disability, flag initiated … p[ease ensure passport … ensure make necessary reasonable adjustments to meet his needs of learning disability, autism, likely prefer quiet environment, Uncle explained would struggle with understanding, may need Easy Read leaflets, broken down into chunks with no jargon… [missed] did any of that filter its way through to you?

YG: Later on. This was 22^nd, I saw him on the 20^th

C: You saw him on the 20^th, this came in afterwards is that right?

YG: I saw him 20^th in VT Clinic and referred him to medical estate for bloods, and so on…

C: Did you see him at all after that?

YG: No … system works different acute consultant on different days

C: So you never saw him afterwards?

YG: No

C: Alright just wait there, Mr Chawatama

SC: No questions sir

C: Ms Hayton do you want to ask anything at this stage?

VH: No thank you

C: Paul, David?

DB: I’d like to ask, he was seen in your clinic on the 20^th but he wasn’t admitted and treated for his PE until the 21^st is that right?

YG: Now protocol is suspect if chest infection or clot, he had chest x-ray … blood … his d-dimer was raised, this suggested likely clot, majority of times in patient we expect clot we give injection and send home and do assessment the next day

DB: So he had an injection before he went, that’s helpful. In the pack of medical records is a letter from Dr Yousab, it reflects clinic in part, interested it says discharging him from VE Clinic to your care, would you like to comment on that?

YG: Normally how it works is we seen him in VT Clinic, we sent to medical …

DB: Your registrar did discharge, having seen him in clinic, following admission, he was in clinic and saw Myles who fortuitously presented with symptoms of DVT, but he was discharged from clinic? I am struggling to understand why that happened, why was that the appropriate step to take?

YG: Later on clinic, just summarised episode of admission in hospital, did not show… in real world at DVT clinic if we see someone like that, who comes with DVT and everything applies, we will discharge them home with long term medical [missed] in Myles’s he came different, came for DVT clinic, signs and symptoms showing likely had another clot, we just wanted to treat him, so he went for acute treatment, we would never have discharged him from the clinic like it says. We used to do DVT clinics twice in week … now at moment have specialist on both sites, so patient not discharged

DB: So for clarity which consultant was responsible for his discharge on 20^th?

C: You said he was discharged on the 20^th

YG: We refer to same day medical assessment, they have seen him, they’ve done bloods and all those things, practically not possible to do CT Scan the same day, so send home and bring him back next day. This is process we follow for majority of patients, when he came next day…

C: He was kept in after that?

YG: Yes, because it was confirmed big clot

DB: That’s very helpful, but the letter says discharged from VT Clinic and letter covers his clinic and admission, it’s important to understand what consultant was responsible for that decision

YG: It wasn’t a discharge… we referred him for acute treatment

PS: Let me ask slightly differently, when Myles was sent home was he still under the care of a consultant, and if so whom?

YG: It should have been me, because I was consultant of the day

C: At the time did you know he had gone home?

Dr Ghumro nods

C: And you’re content that happened?

Dr Ghumro nods

DB: Letter Dr Yousab wrote followed the clinic, scan and admission… point I’m making is as it covered both elements of his care and says we’re discharging him from DVT Clinic to your care, this wasn’t to hospital this was letter to GP. It seems pretty critical.

YG: I’m going back on my statement, the registrar summarises everything, didn’t give true reflection. I’ve seen Myles in my clinic, acute symptoms, because of those I’ve referred to medical estate

C: Point is this letter goes to the GP, its totally inaccurate

YG: There’s inadequacies in the letter. I should have done the letter but I was out of the country at that time. He was with me in the clinic, he has reflected on that, he shouldn’t have done the letter like that.

C: We’ve agreed Dr Yousab isn’t coming, but you agree that’s inaccurate?

YG: Yes

C: And its unhelpful, and would have gone to the GP with inaccurate information?

YG: I agree

PS: Although inaccurate, we’re trying to work out letter on 26^th, was total package, on 26^th Myles was discharged back to the care of his GP and there was no other responsibility at that point that the hospital took for his care?

DB: Yes, it was accurate representation of what said… he was being discharged and says follow up none?

Mr Birch: Sir I don’t know if it will assist, Dr Desai will give evidence in due course and can talk about the process

C: I don’t think, well, I think that’s probably right, I think I’ve got the point. Alright, anything else?

DB: One more question, my concern the Trust has not learnt lessons it needs to, refer to page 62 of evidence pack in which statement is made Myles should have had telephone appointment in DVT Clinic 3-6 months after discharge. I want to ask what you think the appropriateness of a telephone consultation would be for someone with learning disabilities and autism?

Coroner checked the reference…

C: Should have had telephone call between 3 and 6 months after discharge

DB: Something the Trust produced in response to all of this, I’m concerned telephone review, despite the fact it didn’t happen, wasn’t the best approach

C: Did it occur to you when dealing with Myles that this chap needs a little attention, were you talking to him or his father?

YG: Difficult to remember, we were talking to both of them, were talking to stepfather …. didn’t have any issue in finding out the history that I’d documented at time, recent visit to Greece, was breathless, green phlegm, these were all from both of them

PS: Could I ask a question sir?

C: Hold on, that was coming from both of them?

YG: Yes, stepfather was talking and Myles was nodding

C: So who was doing the talking, Myles or his father?

YG: His father

C: Leading onto next question, is it standard procedure to offer phone consultation?

YG: That was old system but now have regular clinics both sites… majority of clinics are done on phone but some we identify to see them

C: I don’t want to apply hindsight overly in any inquest but would you agree with me, the information you had available on the 21 October was really insufficient to establish, to communicate with Myles directly, adequately?

Dr Ghumro nods

C: Yes, that’s a yes, we don’t do non-verbal stuff in court

YG: Yes

C: That’s yes, the information you had was insufficient, and therefore your assessment of what he needed and how you manged his care after discharge was insufficient. Would you agree with that?

YG: I was not involved with care after that, but as a clinician it was accurate information we got, we treated him appropriately, we did right tests and treated him accordingly. If I didn’t get the right information I wouldn’t have referred him. The information on [missed] was helpful, but it didn’t influence my decision to diagnose and treat him

C: From what I’m getting about Myles and how he was presenting, difficulty in processing information, a telephone consultation would not have been a very good way…

YG: I agree with you

C: Wouldn’t be good way of addressing things

YG: I agree, why clinic now, specialists see them directly face to face, Myles would have been one of those

The coroner asked Paul if he wanted to ask any questions.

Paul started by thanking Dr Ghumro for his care of Myles.

PS: How usual is it for a 31 year old male to attend a clinic with his stepfather? How usual is that?

YG: We do have a number of patients who do

PS: How usual?

YG: 5% 10%

PS: So it’s unusual. In terms of ascertaining detailed information about what is happening with Myles, was it him providing information or his stepfather stepping in?

YG: Difficult to remember at time, whenever patient coming, would ask for story

PS: Can you remember who did tell you the story?

YG: I would say it was his stepfather telling the story and Myles was nodding. I remember I did make a joke about Greece, built up a rapport.

PS: That’s really helpful. Can I come onto your addendum statement then with regards to Dr Beatrix Langara, also a Lead in Learning Disabilities in the Trust according to her witness statement and the website of the Trust. You seem to suggest here something quite significant. You seem to suggest her understanding was Myles would have to go onto warfarin, because of concerns of compliance, is that correct?

YG: That wasn’t my understanding, got to be honestly speaking. Myles when he came, he had clot despite rivaroxaban, you have to look both elements, whether drug is not working or issue with non-compliance

PS: So you think Dr Langara’s medical view, based on understanding of learning disability, is non-compliance in Myles’s case might be a reason to go onto warfarin?

YG: I don’t think so

PS: But your statement says, “she suggested he may need to go onto warfarin after 2 to 3 days or alternative anticoagulant as some concern regarding compliance”. So, you’re linking compliance to potential change?

YG: No these were, I was not directly involved, so I looked at her statement, she said she needed reassurance regarding compliance. If you see the same page where saw earlier, haematology statement regarding that

C: You do say, because, you use the word because. How would you express non-compliance and different medication, why express it like that? I just want to know why, it’s not a cross examination, you’ve got two different concepts overlapping there.

YG: I could have expressed it differently to be honest, I never meant to say it was because of non-compliance. There were concerns raised, thought I’d mention concerns raised, was not definite decision why wanted to go and [missed]

C: 35 says compliance needs to be assured

YG: There was a discussion about haematology registrar also on same page

PS: but on page 35 the plan with Dr Langara is very clear. Two elements, she’s aware potential non-compliance needs to be assured, at same time she may need to switch to warfarin after 2 days. In your mind what are you trying to say there? I don’t understand why it’s there for the because element

C: One is in your own mind you were thinking we need to consider change of medication because non-compliance, the other is two separate consideration, non-compliant and change in medication, you’ve simply drafter statement badly, which is it?

YG: If you ask me in both conditions, if someone has non-compliance or medication is not working, we do think need to change medications

C: So if not non-compliance then change medication is that what you said?

YG: No

C: So a) are you saying change medication because of non-compliance, or b) you’re changing medication and there’s some concerns about non-compliance?

YG: B

C: OK

PS: That’s helpful, going back to first time Myles was seen, no concerns raised by your junior regards to learning disability and autism, do you know whether that member of staff had been trained about patients with learning disability and autism or they hadn’t had any training?

YG: Is difficult to say. Junior doctor who seen patient Myles was GP trainee, majority of time they do have this part of training. How to manage that.

DB: Can I ask one question?

C: Yes go on

DB: Just reasons, as someone who runs DT clinic, if you’re concerned someone was not compliant was that reason to change to warfarin due to ability to monitor through tests?

YG: Have both options, sometimes change to warfarin, have to think about how to monitor warfarin… [missed chunk, apologies] injection is difficult but we have in some cases also

DB: So warfarin could be used where concerned about compliance because you can check the INR?

YG: Majority of patients don’t inject themselves, sometimes District Nurses inject and we have reassurance injected, anyone on warfarin have INR check

PS: Think question is more simple, if you the consultant running clinic have concerns, is it medically appropriate to change person from rivaroxaban from potential non-compliance issues onto warfarin so can check INR and monitor whether compliance is taking place?

C: Is warfarin more easily checked?

YG: It’s not more easily checked but have to go for blood tests every second week, pharmacy team monitor, at same time have difficulty whether patient can manage warfarin

PS: Have to say as rivaroxaban isn’t routinely measured in blood so no way can monitor and check anti-coagulation effect, as warfarin is used across the country… you would use warfarin to check if someone is being anti-coagulated, because you can monitor INR … ?

YG: We have significant number of patients who prefer not to go on warfarin because of monitoring

PS: That’s not the question, the question is, is it clinically appropriate to put someone on warfarin to check compliance with medication?

YG: I would say yes

PS: Thank you

C: Alright, Mr Birch

MrB: If I pick up last question first, you said clinically appropriate to put someone on warfarin to check compliance?

C: Yes, the answer was yes

MrB: Does it therefore follow when have concerns about compliance warfarin is always the option?

YG: No, if compliance is issue you have other options, if sure someone is non-compliant you can give same medication but reassure compliance is done

Mr B: So that was the options, parking that… to be strictly correct, did you have any discussions about compliance with Myles or his stepfather?

YG: No

Mr B: When would you have discussions about compliance?

YG: When he was diagnosed with a clot, I didn’t see him when he was diagnosed with the clot … my suspicion was he might have chest infection and a clot…. If clot confirmed would discuss with him or family how was his compliance

Mr B: Again we’re asking you about things that come later that you’re not involved with.. compliance and treatment options… if someone is very clear that they’re non-compliant, whatever medication you use will be an issue. Even same medication, you need to reassure compliance is maintained. Would you use warfarin to provide assurance about compliance?

YG: Is difficult, depends person to person, if I have reassurance from family that someone will take responsibility to take him for blood tests routinely and INR will be monitored, yes is doable

Mr B: Comes with reassurance of compliance with warfarin treatment?

YG: Yes, and compliance with monitoring

Mr B: So a level of monitoring that some patients consider to be more onerous, is that correct doctor?

YG: Yes

C: So I understand this, you’re saying rivaroxaban wasn’t working, so the point of changing medication was as alternative, so most common one is warfarin?

YG: Or another …

C: Whatever, one of benefits of warfarin is enhances checkability of compliance, can more easily check because of the blood testing?

YG: Majority of patients we have on warfarin take responsibility to go for blood tests

C: None of this denigrates from issue of whether or not he was compliant in the first place. Alright.

PS: One more question, what weight would you put on change of anti-coagulant if haematology had told you, were preferred choice of drug?

Mr Birch said something [missed]

C: We’ve got to be careful we ask right witness the right question, and be careful don’t overplay hindsight card, not court of negligence, whether or not that occurred is another matter, am looking at how Myles came by his death and what information had at the time… Mr Birch?

Mr B: Thank you sir, one more question in relation to other people’s care then come back to your own. Learned coroner took you to page 35 Dr Langara’s plan. Could you find in medical records bundle?

YG: Yes

Mr B: Page 34 seen with mum, referring diagnosis, background ADHD and depression, at that stage advise echo, TCI? Middle of page 34

YG: Sorry

Mr B: Just clarifying, middle page, on examination, ECG changes noted, discussion Dr Langara, after that advise echo and patient TCI

YG: TCI means you admit patient on different ward, transfer of care … seen in medical estate, decided need admitting on ward, transfer of care. Spoken to Uncle David and updated with plan, then refer [missed] …may need to switch to warfarin after 2 days or alternative … is that switch from [injection]

YG: From [missed name – a drug given whilst in hospital]

Mr B: Talks about… compliance needs to be assured, Uncle on phone states patient has some learning difficulties and is on the spectrum… on page 35 you sought to articulate earlier how you’ve interpreted that when providing your statement

YG: Yes

Mr B: Now in relation to your time meeting Myles, you met Myles with his stepfather, endeavoured assist court with what you recalled, did anyone mention learning difficulties as part of that discussion?

YG: I don’t remember, the documentation is what I have to rely on basically

C: It’s not mentioned

Mr B: So in your notes depression is recorded, ADHD is noted but learning disability isn’t. Maybe not mentioned, maybe not recorded

YG: Yes

Mr B: Did you feel you had sufficient communication with Myles and his stepfather?

YG: Enough to get sufficient information of what is really going on, which is why I made provisional diagnosis might be chest infection or might be clot

Mr B: You’ve heard Myles’s Uncle’s indication of Myles [think he said] but that’s different to how you found Myles?

YG: Personally didn’t find any difficulty with what we needed to learn

C: You say you got information you needed, no reference to anything other than ADHD and depression, all you can say, you obviously met him once, had no deep knowledge of him, all you can say is you got the information you need in terms of assessing him. You’re not claiming to have a full complete knowledge of his issues are you?

YG: I’m definitely not claiming that, as far as I’m claiming, I need all the information I got, I referred him appropriately, my conscience is clear. He got diagnosed and he got treated, if had been any issue with communication I’d not have reached conclusion

C: Well it would have gone in notes, if so memorable at the time would have been sufficiently important to write in notes…

YG: Sometimes we don’t write everything in the notes

C: No its an aide memoire but there’s no mention of autism or of learning disabilities

YG: No

Mr B: Capacity being assumed… your interaction you thought you had sufficient clarity, you’re not having discussions about compliance with medication?

Dr Ghumro nods

Mr B: Discharge point, decision when keep someone in hospital versus … is there scoring system, some way of assessing situation, help making decisions?

YG: Protocol, if someone comes and suspect clot, you follow score card, if score is low, give injection, send them home and bring them back for scan next day

Mr B: SE score, do you know what that stands for?

YG: Blood pressure, oxygen requirement, stability, and when he was seen in medical estate his BP was fine, he was not requiring oxygen, was right decision to send him home, give injection and do scan in morning. When he had scan because … clot, was decided he needed to be admitted

Mr B: Thank you doctor, so is tool to help decision whether need to stay in or come back in morning?

YG: Yes, we have significant number of patients who go home and have scan next day, if patients quite unstable would do scan

Mr B: For your interaction with Myles was sufficient indication… if had concerns was challenge of understanding, what would you have done?

YG: I would have had concerns about information, I’d try to speak to the family

Mr B: Would you seek any assistance from within the trust?

YG: First point of contact is always Amanda, Amanda Mckie, she told me next day about communication with his uncle

Mr B: So you don’t have any personal involvement the next day, but you discuss with Amanda Mckie?

YG: Yes, she knew I’d seen patient so she contacted me and explained had discussion with Uncle and patient, I reassured her patient started on treatment and admitted.

Mr B: You have no further direct involvement in relation to Myles treatment?

YG: No even next day he was seen by my colleague, she did contact me because I’d seen patient.

Mr B: Oversight, built now in care of other colleagues and treating team?

YG: Yes

Mr B: Nothing further sir.

C: Thank you very much indeed, thank you for your help.

The coroner told Dr Ghumro he was welcome to stay if he wished before adjourning for a lunch break.

[After lunch the court heard from Dr Hardy, another consultant at Calderdale and Huddersfield NHS FT. I will write Dr Hardy’s evidence up as soon as I can. I was unable to attend court yesterday when a physician associate and two GPs gave their evidence. In court today I heard further evidence from one of the GPs and the evidence of two court appointed experts. The first part of the inquest ended today, it reconvenes in June, with an outcome anticipated in July. I will report on the evidence from this week as and when I can around other work commitments]