The afternoon of Day 1 of Myles’s inquest started with the coroner calling Dr Hardy to the stand. He gave an affirmation.

C: Start with who you are, what your professional discipline is, and where you work?

AH: I’m Dr Andrew Hardy, Consultant in Respiratory Medicine and I work at Calderdale and Huddersfield NHS Foundation Trust.

The coroner checks he has the bundles in front of him. He does. The coroner takes him to page 17, his first statement, and a further statement at page 19 before asking him to confirm that they are his statements. He does.

C: I’ll go through your statement to fix you within the timeline of events and take you mainly to your second document and talk about some things raised there. Along the way will take you to certain medical documents. I do stress this isn’t a court where people have places or positions, not trying to prove negligence or anything like that, I need to know what happened. How it is Myles came to his death, and what contributing factors to that might be, and I need to make findings about that.

AH: Ok

C: You’re a Consultant in Respiratory Medicine. [At this point the coroner apologised for calling him Mr not Dr earlier]

You describe how Myles was admitted to Calderdale Royal Hospital on 21 October and discharged on 25^th, you describe previous admission in September under care of Dr Ghumro … he was diagnosed with DVT with plan follow up in 6 weeks, seen on 20 October. Noticed recently travelled to Greece, clot and breathlessness, plan CT scan and d-dimer… CT Pulmonary angiogram showed large bilateral pulmonary emboli with right heart strain…. Then recount what we’ve heard already that Myles attending [missed] emergency care unit on 21 October. Noted he had a history of autism and learning disability. he was then admitted to respiratory unit, saw Dr Thomas, Consultant in Respiratory Medicine. Noted EWS was 0.. Mr Scriven reported taking his rivaroxaban at home and on holiday. Plan was [missed] discuss haematology … and arrange echocardiogram.

So far you agree with all of that, I’m just putting onto court record what you said on your statement.

AH: Yes, I agree with that.

C: Discussion with haematology. You reviewed 11:09 on 25 October, noted EWS still 0, didn’t need oxygen, prior discussion with haematology, you say was noted difficulty confirming compliance with treatment, mother confirmed Myles did tablets himself… Myles notes his compliance, if compliance is issue …. Felt compliance more likely with rivaroxaban as once daily treatment, therapeutic dose after one … does not require monitoring with blood tests….

Urgent echocardiogram request 21 October, plan further outpatient follow up based on …. no follow up prior to Mr Scriven readmission with fatal cardiac arrest on 16 April the following year.

Going to your next statement you clarify a number of points don’t you

AH: Yes

C: You say you’d been informed Myles had echocardiogram on 4 November and you reported there under, you also had the chance to review and reflect on independent expert witness within this inquest provided by Professor Hunt. You’ve noted some factual errors, we’ll come back to those.

I just want to check with you at this stage, you can help me out with this, the Trust itself through its report, case study and MDT review accepts the report of Professor Hunt with exception of one point, which is in relation to compliance. Trust says it just defers to the NICE Guidance which does not recommend monitoring blood levels of rivaroxaban.

I just wanted to know from you, you’re represented separately from the Trust, you’re a separate Interested Person in the inquest, do you accept Professor Hunt’s outcome or not?

AH: I accept the outcome of Professor Hunt

C: You do?

AH: Yes, I mention that in my statement.

C: You say … agree best cause of action would have been to change to warfarin in October 2022. That’s a specific, very important concession to make, which is helpful in terms of clarifying issues.

Do you as an extension of that concession, accept the same way you made comment in second statement, the generality of what Professor Hunt has asserted?

AH: I accept the generality of her statement, yes

C: Thank you for that. We’ll go through your second statement and then look at medical notes.

AH: OK

C: You have picked up on Professor Hunt where you say she states no echocardiogram was undertaken, you say its subsequently come to light, in light of echocardiogram was done on 2 November, that wasn’t relayed to yourself or medical record, hence your statement

AH: At the time echo reports were coming on paper, even though bulk of medical records were electronic. Process was it should have been sent to my secretary who’d scanned it and make me aware, that didn’t happen.

C: OK, that’s an explanation obviously and thank you for that, but obviously the fact remains the treatment plan was done without reference to the results of the echocardiogram?

AH: Yes, the plan would be to review once results were made available to me

C: Was that ever done?

AH: No, because the echocardiogram results weren’t made aware to me. The point of the echo is to check strain on right ventricle… if ongoing strain is further evidence the treatment isn’t working, in that case we’d arrange a further urgent appointment within a week, with view to change treatment. The result here is that it was normal, and…

C: To summarise you’re saying what echocardiogram demonstrated was reassuring?

AH: At that point, as clot burden had decreased and was no ongoing clot burden

C: On page 13 is stated by Professor Hunt “is no note Dr Hardy spoke directly to Mr Scriven, that’s Myles”… you say I did undertake a direct conversation with Mr Scriven [coroner reading statement, too fast for me to catch, missed chunk] Can you remember how long that discussion took?

AH: I don’t recall no

C: We’ll go through some of Dr Hunt’s report points, you say she has said you didn’t recognise patient condition had progressed …. treatment had seriously failed, your view is in fact that the ultrasound compression venogram on 31 August 2022 and CT pulmonary angiogram on 31 October were sufficiently separated to be considered separate events?

AH: Yes, that’s correct I’d consider a separate event 4-6 weeks after

C: Your view is it wasn’t related to the first one?

AH: On the balance of probability, it’s possible that part of the clot could have broken off and gone to the lung, but we’d say if there are two events 4 to 6 weeks apart there is evidence there that position has progressed (my paraphrase at end)

C: Second point of Professor Hunt … didn’t explore… you said [can’t hear] you say, correct me if I’m wrong, we already knew what the position was?

AH: Yes, we wouldn’t do repeat leg ultrasound when we’ve already seen that position has progressed as demonstrated by clot on [missed]

The coroner then asked a question which I missed entirely, apologies.

C: You say, is note saying recommending investigations done in few weeks… you’re saying then wasn’t the right time?

AH: At the time that was my opinion, yes

C: You say that was your opinion at the time. Do you think that’s a reasonable opinion?

AH: Have had opportunity to reflect on my management, and review evidence by Professor Hunt and do further reading on this matter, I think I should have done testing at the time, if we’d diagnosed [missed] it would have significantly altered the future treatment

C: It would have been different?

AH: Had Myles tested positive on [missed] yes …. My understanding was you have to give a period of time to do the testing, on reflection it would have been better to do the test at the time. If it came back negative could be repeated when the patient came back to clinic, but would have had material impact on treatment at the time if I’d done it. We don’t always get results back immediately, but I should have done it at the time, yes.

C: It’s unclear on what basis you’ve concluded non-compliance was an issue, despite assurances from the patient and his mother. You agree is insufficient information in the medical record to make this judgement. At this point I’d like to divert to the medical records if you don’t mind. Can you go to page 10 to start with.

AH: Yes

C: You’re obviously directly involved in the care, the person involved with Myles from before 11:09 on 25 October, yes?

AH: A short period of time before yes, that was time entry was made in the record, yes

C: If you look at page 10 you’ll see two entries from Amanda Mckie which you’ve heard reference to this morning in the evidence, for completeness [coroner reads the entry, which we’ve heard in earlier evidence too].… telephone call from David Black… Medical Director Sheffield Teaching Hospitals, explained Myles has autism, will struggle to understand everything, his mum has learning disabilities too…. [missed] the addendum is no LD flag, EPR checked… known learning disability autism flag added, ensure hospital passport filled out with family, make sure necessary reasonable adjustments to meet his needs of his learning disability and autism. Notice in side room, likely prefer quiet environment. Uncles explained will struggle with understanding, may need Easy Read and information broken down into chunks… triggers assessment under the Mental Capacity Act … By the time you were involved with Myles you had this available to you?

AH: It would have been available to me, yes

C: Did you actually read it?

AH: I can’t recall, but usually I’d read through relevant medical information before I see a person, so I’m confident it would be available to me

C: It’s a pretty pinpoint heads up, isn’t it?

AH: There’s always nuance, we’ve heard more information from the family but yes, if provided written information in Easy Read format, and in small chunks and avoid use of medical jargon

C: Also it triggers assessment under the Mental Capacity Act, it triggers understanding?

AH: My understanding is a full MCA assessment is required if he doesn’t have capacity

C: It says here, triggers for assessment, does that not say?

AH: We don’t do a full assessment unless we think he doesn’t have capacity, on that basis when I spoke to Myles I would have believed he had capacity, otherwise I’d have acted differently

C: When you’re speaking to him, we’ve had the advantage now of hearing how challenging it was to communicate with him in a way he understood. When you’re speaking to him did any of these pointers conveyed in these referenced make you stop and think I need to be careful about the information I’m conveying to him?

AH: I don’t recall the conversation, but based on the record I’d have been aware of need to give in small chunks … and so on … my subsequent entry suggests it didn’t cause me any concern, because I make record in note and don’t reference need for full capacity assessment at the time, but I don’t recall the conversation.

C: OK, well I don’t want you to start guessing. Can we go to page 45, actually go onto page 51

AH: The assessment by Dr Thomas?

C: This was on 22^nd, so again, available to you on the 25^th?

AH: It would have been, yes

C: And it’s got an entry, says today, entry 4 lines down, says taking his rivaroxaban at home and on holiday, never missed a dose, just had symptoms since he came back from Greece in October.

AH: Yes, and there’s no entry in Dr Thomas’s note of any concerns about capacity

C: No, I was just wondering then, if no concerns about capacity then why not act on that and take it he was compliant? He clearly wasn’t believed was he?

AH: I think that’s a strong statement, but yes

C: In essence that’s what it comes down to, if he’s saying he’s taking it, and you’re saying he has capacity, then presumably you’re not taking his statement as entirely accurate?

AH: You’re basing it on what you’re hearing at the time, and clinical judgement

C: I’ll come onto that

AH: Did you want me to go into that more detail now?

C: No… we’ll go onto that

AH: You’re correct, the information in the record I’m relying on states a number of times he was fully compliant with treatment, so I should have based decision making on the assumption he was fully compliant.

C: Go to page 49, there’s a plan here from Samuel Crickmore, your colleague?

AH: Sam would have been documenting the ward round records

C: Says “restart rivaroxaban, warfarin would be difficult given non-compliance” [he reads more, didn’t catch].

In light of him saying he’s compliant, that would suggest he’s not being believed, wouldn’t it?

AH: Yes, it would

C: Go onto page 48 your 11:09 note, “difficulty confirming compliance, mother says does tablets himself apart from ADHD, if compliance is issue then more likely”…. [reads more, didn’t catch] Again, that’s you saying he’s saying one thing but I can’t really rely on it?

AH: That’s correct

C: Go on to page 45, which again is in notes that would have been available to you, dated 24 October. This is again Sam Crickmore, who I think we’ll hear from tomorrow, “spoke to Jane, next of kin… Jane says Myles usually quite good at taking his medication, they help him take ADHD medications but everything else he does himself, she’s unaware of him missing his medication”. Again, another person, his mother, is saying as far as we’re concerned, he’s taking his medication. You’d have to agree with that, wouldn’t you?

AH: I do agree with that

C: We get at page 44 I think, background to that this is issues, advise long term warfarin rather than alternative … still needs check patient fully compliant with medications.

At the point you see him, his mother is saying he’s compliant, he’s saying he’s compliant, but you still think there’s an element of material doubt to that information, is that right?

AH: Based on my subsequent actions, yes

C: Right if we go back as well to the entries made on the 21^st by Amanda Mckie

AH: On page 10 again?

C: Yeh. The upshot of both those entries is look, there are people here who are connected with the family, they are extended family members who will be able to provide an insight into Myles, his communication issues, and they’re asking medical team to get permission from Jane and Myles to update David Black. He’s here in court.

Did it ever occur to you when dealing with Myles, look I’m speaking to Myles, speaking to his mother, still have some niggling doubts here, to see if you could get permission to speak to David, did that occur to you?

AH: Obviously it didn’t, because I didn’t speak to him

C: I’m just wondering first of all, why you therefore persisted in your view that the treatment plan, medication provided, should be based on uncertainty about compliance and why you didn’t look for more information from an available third source?

Why did you act, basically on the assumption, the basis that he wasn’t compliant? Why didn’t you check it with a third source?

AH: Just to say firstly, it’s quite an unusual scenario, treatment failure on modern anti-coagulants is relatively infrequent occurrence, perhaps 1-2% of the time. The number of individuals I’d personally see with treatment failures is incredibly small numbers, one every couple years.

With infrequent occurring conditions part of decision making is based on previous experience in these situations. My experience to date is treatment, and non-compliance with treatment, is a common factor in previous individuals who’ve failed treatment. So I’d partly be basing my decision making on my previous experience in this aera.

Therefore, we are told to consider non-compliance as a factor. I think on reflection, I made an incorrect decision here, and partly that is based on my previous experience of situations where people have been non-compliant with treatment and it’s been difficult to establish that.

We know people often have an incorrect recollection of their compliance, for example therapies for asthma, people will often say they’re compliant, relatives say they’re compliant, but we know from research people aren’t always as compliant as they think they are.

We’ve heard additional information from family today that they were keen to ensure he was compliant, by going in and counting tablets which suggests to me it wasn’t unreasonable to consider non-compliance as an issue. I agree I have over relied on that as a factor and not considered other issues of treatment failure, and that has led to failure of decisions [last sentence is paraphrased]

C: That’s very candid of you

AH: The way it has been explained to me in the past, is if compliance is an issue you’re better off on DOACs (direct oral anti-coagulants), as you’re more likely to stay in treatment range. Statement of Professor Hunt doesn’t agree with that, I agree going forward I’d make different decisions as the points Professor Hunt has made is important, as is ability to consider compliance through blood testing …. also other side effects… prefer to use DOACs where we can. Less restriction on diet, generally preferred over warfarin.

As I say, I think I’ve made a bad decision here, partly based on previous experience with previous cases, and discussions over treatment options, particularly for young people.

C: That is very candid of you, and I appreciate that.

Just help me with this, at the time, you were treating, at the time you were treating Myles and he was under your care. Given what I’ve taken you through in terms of available information, was it, firstly, was it available to you at that point, firstly, to have sought out further evidence or information about his compliance, and secondly to put him onto warfarin?

AH: Yes, it would have been possible to gather more information, as I say I can’t recall my exact decision making process at the time. I think at the time, it is likely I’d have still come to the same decision if I had more information available. If I had further information about compliance is probable I would have made the same decision … Yes, it would have been possible to switch to warfarin quite quickly, had I wished to.

C: To be clear, you accept you made a bad decision. Yes, you could have got more information, had you, you’re saying you would have come to the same decision about the medication. Is that right?

AH: Yes, all the information in the record suggests he was compliant, it was in the records at the time, getting someone else to say he was compliant, I’m not sure how I’d have made a different decision at the time

C: You were making a decision based on doubt as to compliance, weren’t you?

AH: Yes

C: That was the principle reason you stuck to rivaroxaban wasn’t it?

AH: Yes, and based on my previous experience, where involved with treatment failure where more often than not people stay on the same treatment

C: So, yes you’d have got more information, the information would been from increasing number of sources, not just Myles but his mother, potentially David and potentially Paul. You’re saying despite of that, you’d have stuck with rivaroxaban?

AH: I don’t know, its hypothetical isn’t it. In retrospect, obviously not

C: This isn’t a classic hindsight scenario, this is actually a counter factual. Had you acted on the information you had available to you, including possible result from David who is a medical professional, Paul who has insight into the dynamics of this family. If you had that, and as good evidence as could that he was compliant, are you telling me you’d still have stuck on rivaroxaban?

AH: I’m saying having reviewed notes it’s difficult to know why I didn’t switch him to warfarin. I can’t remember the detail, I can’t remember why we didn’t switch him to warfarin. All I can say is getting further information without knowing why I made the decision to continue rivaroxaban …

C: Do you agree you had enough information, or potentially available had it been sourced, to put him onto warfarin?

AH: I believe there’s enough information available in the records as I read them now, to believe I should have switched him to warfarin, definitely.

C: I need to be clear, one way or other. You in October 2022, you look at notes as existed at that time. Are you telling me you had enough information at that point, to come to the conclusion he should have been on warfarin?

AH: Well, I don’t disagree it would have been helpful to get further information, but his mother said he’s fully compliant

C: He’s said he’s fully compliant

AH: He said he’s fully compliant. I clearly didn’t have any concerns at time about his capacity, I didn’t speak directly to his mother, Sam did, and he was on the ward round with me.

So, I should have made a decision based on the fact he was compliant with treatment. I don’t think anyone can dispute that really.

C: Had he had, had you made a decision based on that basis, would he have gone onto warfarin at that point?

AH: Yes, he would have gone onto warfarin. The other option is higher dose of rivaroxaban, but yes, I think he’d have been switched to warfarin.

There were no questions for Dr Hardy from Mr Chawatama for Dalton Surgery GP Practice, and none from Mr Birch for Calderdale and Huddersfield NHS FT [who are still Dr Hardy’s employer despite him being separately represented at the inquest].

C: Paul? David?

DB: I just want to pick up how you determined the choice of rivaroxaban to continue. The bit that’s not clear to me, you say you’ve got fairly limited experience of treatment for pulmonary embolism, accept not that common, what expert advice did you take to guide your decision? There was expert advice available to you?

The haematologist hadn’t seen Myles themselves but is expert advice from haematology team regarding treatment options. They’re experts, they advise he should go on warfarin, you say limited experience, you’re making your decision regardless of issue of compliance, what stopped you having conversation with haematology about warfarin. Do you know why they recommended it?

AH: I’m assuming because his treatment on rivaroxaban isn’t working, so reasonable in that situation to try an alternative treatment, but I didn’t speak to them directly myself

DB: I raise that because Professor Hunt highlights warfarin is easily monitored thru IRN testing. He says he’s compliant so rivaroxaban is not working … that that conversation is not taking place, that expert advice is available to you and despite your limited experience, is unfortunate.

AH: There’s more to it than monitoring, we consider other things like bleeding risk. More difficult to take from lifestyle point of view, diet and if your IRN is consistently sub-therapeutic then you need heparin alongside treatment.

So I completely agree with you, is possible to monitor warfarin more easily, we don’t monitor rivaroxaban. In terms of decision making process would argue is more to it than just considering how easy it is to monitor the treatment.

I agree with you, I’m struggling myself to understand why I didn’t switch him, I’ve thought about it a lot.

At this point Dr Hardy got upset and the coroner asked if he’d like a break. Before he had a chance to answer, the coroner made the decision that court would be adjourned for 5 minutes and reminded Dr Hardy not to speak to anyone.

We returned to court shortly after 3pm.

DB: I know these questions are difficult Dr Hardy. This is a question about follow up. In all the notes there’s no mention of follow up. All we have is your note that if you’d seen the echo you’d have arranged follow up.

There’s nothing for the GP. Is even more painful for me, galling, that when I spoke to Ms Mckie in January 2023 (?) I knew, and she knew, that the echo was normal.

I never knew you’d not seen that echo, it seems strange. Was there a plan to follow up Myles, particularly as he presented to the VT Clinic, at a routine appointment with symptoms picked up at that clinic? I’d have been quite alarmed, needing to keep a close eye on Myles?

AH: Well yes, he’d had recurrent VT, so we should be following up. The plan for follow up wasn’t made at discharge, because I was waiting for the results of the echo, we would have wanted to follow up through clinic.

DB: Would it not have been safer to make the follow up appointment at the time of discharge?

AH: It’s unusual for us not to get the results by the time of discharge. Yes, in terms of safety it would have been.

At this point Paul asked Dr Hardy if Dr R Knight, the registrar, is part of his team and Dr Hardy confirmed that she was on the respiratory floor at the time.

PS: I just want to go through, there is a plan to see Myles at outpatients. It reads “needs to clarify with mum if Myles is fully compliant with meds, continue until above known. Then if not compliant, refer to DOAC. If it has been”, therefore I assume it has been confirmed he is compliant on rivaroxaban, “then to change to warfarin and then to investigate as an outpatient”.

What is the difference in your view at the time, someone who was going to be discharged on the DOACs he wasn’t compliant on, would go and be checked at outpatients, but someone who was put on warfarin would have been checked up on outpatients?

AH: The way its written isn’t helpful, if not compliant return to DOACs

C: Well, its “if not” query?

AH: Yes, then refer to outpatients, at that point we’d not done bloods, the coag screen.

PS: Can I ask you, at the time you discharged Myles were you of the view he was compliant or not compliant at that time?

AH: I’ve acted as though I believed he was not compliant

PS: Why would you discharge a patient, knowing there had been a failure of treatment?

AH: We’re getting an echo aren’t we, so if echo is normal, it implies clot burden is reduced so whatever treatment he’s on at that time would appear effective. If echo is not normal, we need to see him back more urgently and consider treatment and therapies. It’s dependent on the echo report.

DB: I just want ask about the echocardiogram. Was performed 10 days after he was discharged, during which time he’d received dalteparin as inpatient?

AH: For a short period, yes

DB: So, I’m wondering whether it is the correct interpretation?

AH: It’s possible and he was reloaded with rivaroxaban as well. One of the other options is treat at higher dose, at time of echo he would have been on higher dose because he was on loading dose, so it’s possible if he was on higher dose of rivaroxaban that would have, is possible.

The important thing for me is do we need to see this urgently, if ongoing evidence of ventricular strain might refer to Sheffield … if gone back to normal, whatever decision doesn’t need to be made urgently is way I’d have interpreted, at the time

PS: Can I go back and ask questions about the consultation you had with Myles on 25^th, you saw my evidence this morning, area I knew Myles very well. Can I ask roughly how long face to face did you see Myles?

AH: I don’t recall, would probably have been about 10 minutes to do assessment, physical examination and further consultation as well.

PS: Did Myles ask you any question, do you recall, regarding his treatment or what you were doing?

AH: I don’t recall, sorry

PS: When you saw Myles and you decided Myles could give you informed consent, what criteria where you using and how did you assess that?

AH: I can’t recall the specific conversation, generally I’d ask what happened during hospital stay to date, what told so far about what going on, have you got any questions. If he’d said I don’t know, that would be a concern as we have evidence people were telling him results of tests. I’d assume he was able to give reasonable coherent story of what happened during his hospital stay.

PS: but you can’t recall the conversation?

AH: I cant, no

PS: Quite rightly you say the Mental Capacity Act means that you have to assume capacity, there are 5 key principles, are you aware of the core principles?

AH: We receive training on core principles, yes

PS: I appreciate you have training, were you aware at the time of treating Myles of the 5 key principles of the Mental Capacity Act?

AH: I believe I would have been, That’s assume capacity and so on

PS: Are you aware of the core key principles?

Paul asks Dr Hardy if he is aware of principle two, and he responds that he cannot recall off the top of his head.

PS: Principle 2 is about functionality

AH: Is this can they retain information, can they recall?

PS: That’s part of the functionality test but not principle two. Principle two says in doing those things you have to make judgement about whether things are required for Myles to make fully informed consent. Principle 2 says they should have support required.

Did you assess whether Myles had the right support before asking him to make a decision of what medication he was discharged on?

AH: Two things, I don’t think I was asking him to make the decision, the decision making was mine. Clearly, I gave information about two options, but I’d have taken him to a preferred option if you like, to stay on the same treatment.

Although we discuss treatment options, usually people ask us to give a preferred option. If two treatments are equally effective, 50/50 fair enough, but most of the time there’s a preferred treatment.

I don’t think I likely asked him to make a decision. I think I would have presented two options, then told him my preferred treatment and asked if he was happy to go with that.

There was information available to me in Amanda’s entry about not using jargon … [missed]

PS: Did you ask if he required written information?

AH: No, I didn’t give written information, is entry from Amanda saying written might not be best

PS: It might not be, did you ask how he’d prefer to receive the information?

AH: I didn’t, no.

PS: What period of time did you give for Myles to have recall, to remember and retain information for the decision he had taken?

AH: Would have been the time available in that consult, I didn’t go back to check later. So, 5 or 10 minutes.

PS: So at the beginning of the consultation, you’ve have said?

AH: Yes, I’d have said 2 options for treatment, option 1 stay on current treatment, option 2 is move onto other treatment, would need blood test and things like that. I’d check understanding as conversation was evolving, but you’re correct I didn’t give the option to retain and go back and check later.

PS: Based on notes from Amanda, a full capacity assessment would be required?

Mr Birch interjects: Sir?

PS: Triggered, and significant notes had to be taken. Given you knew Myles had a learning disability and autism, and potentially issues with communication, what was your thinking in not making documentation that indicates Myles had made an informed decision and had capacity?

AH: As I said, I don’t recall the details. I suspect had he indicated he didn’t want to take the advice I was giving, or if he had a clear lack of understanding about rivaroxaban treatment, it would have triggered me.

Had I been offering warfarin, and he said he wanted to stay on rivaroxaban, at that point it might trigger a more detailed conversation.

He appears to understand the treatment he’s already on, he’s not disagreeing with my recommendation, so I thought a fuller capacity assessment wasn’t required

PS: Moving away from the capacity test then, to GMC Guidance and NICE guidance on consent. It says it must be specific. You knew Myles had a learning disability?

AH: Yes

PS: You knew he had autism from the records. Good guidance suggests people should be asked whether they wanted someone to help them make a decision at that time. Did you ask that questions of Myles at the time, given you knew he had learning disabilities and autism?

AH: No, I didn’t or I’d have recorded that on the records. As you know yourself learning disabilities is a very wide spectrum there, just because an individual has a learning disability doesn’t mean they always needs someone with them, as you describe is good practice to offer that, there’s no evidence I did offer that.

PS: Capacity isn’t for everything, it is time specific and for that decision. For that treatment decision, what was going through your mind about other options to support Myles potentially on understanding what was happening? Anything ruled out at that point?

AH: Based on the information in the record, nothing else was offered.

As I say, had I had a concern that he either didn’t understand the treatment he was currently on or was any suggestion he didn’t agree with my decision making would have triggered a more holistic assessment. Given there wasn’t any disagreement about what to do between myself and him, I didn’t take it any further.

As I say, I’ve seen the expert’s statement, and done further reading on it outside Trust requirements, you’re right that should have been offered as routine, rather than the exception.

C: Correct me if I’m wrong, you’re building up to, in your own way, I have to say that 10 minutes contact with Myles, it really wasn’t very good?

AH: Well, I clearly didn’t have a concern about the information, if I had, it’s quite common that we support people with meetings with families and give people more time. At the time I didn’t see it as an issue, on reflection I should have done and I should have done more.

PS: Just moving focus away from you personally, clearly is provision in the Trust to support and help people with learning disabilities. Would you know how to contact them? What support would you expect if you contacted them, with someone in Myles’s position, with learning disabilities and autism. Is that widely available? Are you able to access that?

AH: Is more widely available now than it was at the time. At the time was Amanda, but she wasn’t actually available, because she was away. We see a lot of Amanda, she is very proactive and gets flagged when patients with these sorts of issues come in. At the time there wasn’t a back up, but now there is because Beatrix is in a supporting role as well.

PS: So at the time of Myles’s admission and your care, there was one person or two people?

AH: Think there was just Amanda at that time

PS: Amanda was away, you wouldn’t know was there other provision or where to turn if you did require help?

AH: There are other ways, yes. I could have escalated to my manager and said I’ve got this concern about this person with learning difficulties, Amanda is away, I could have asked that

PS: Thank you very much

DB: I just wanted to ask one more question, in the expert report in evidence pack, page 137 Dr Herrieven’s report, page 137

C: The bullet point summary list?

DB: What Dr Herrieven says is no reasonable adjustments were made to allow Myles to properly understand … regarding his anti-coagulation treatment, looking to supporting patients decision making related to decision making consent, talks about does patient want anyone else to be involved, a relative to help them make that decision.

It sounds an awful lot like you decide rivaroxaban was the preferred treatment, you told Myles that was the treatment you thought he should have … was there any discussion, we don’t think you could tolerate blood tests, we’ll not give you warfarin? There were lots of assumptions made, don’t see any reasonable adjustments made. Was that what happened?

AH: There were some adjustments made, he was in a side room. I believe I would have given information in small chunks and avoided jargon, but as you described the reasonable adjustments were insufficient.

The coroner then moved on to Dr Hardy’s own legal representative to ask him questions.

C: Ms Hayton?

VH: Couple points please in clarification. Your addendum statement, second one, deals with Professor Hunt. Page 20, question 3 you didn’t enquire about family history of clots. You’ve given some evidence, could you expand a little bit about that. Your response is entry in notes on 22 October, you saw Myles on 25^th, did you read that entry?

AH: From the haematologist? Yes

VH: In your mind at the time you saw Myles, were you under the impression in a few weeks would be a further test, a blood test?

AH: Yes, usually don’t do test at the time as the presence of clot can affect the result, so yes, my belief is would have done it when did follow up when he came to clinic.

VH: Would that have been at the same time as the outpatient echocardiogram?

AH: No. Do echo, get result, then do bloods at time when came to clinic, whenever that was. With this situation with echo being normal would be 3 or 4 months away

VH: So, when you see him on 25^th and you continue rivaroxaban, in your mind once discharged to the GP, what was the plan from the hospital point of view?  What did you expect to happen for Myles?

Dr Hardy asked her to clarify her question as he didn’t understand. When she did Dr Hardy said he believed Myles’s follow up appointment at clinic would have been months away. Ms Hayton then asked if the echocardiogram was done during Myles’s admission. Dr Hardy said that he would not have done an echo then as he had seen the heart strain on the CT so there was no need. He would have done the echo in 3 or 4 weeks.

VH: So as far as you were concerned, when he was discharged from hospital he would return in 3 or 4 weeks for an outpatient echocardiogram. Is that right?

AH: Yes

VH: We know that did happen, but you weren’t made aware as you never got the report of the echocardiogram?

AH: That’s correct, yes

VH: Unfortunately, I assume you have a number of patients, unless a report was presented to you, you wouldn’t go back and check has Myles had his echo report? AH: There isn’t a process, we don’t keep a ledger of outstanding reports. If they don’t attend for the test we get a letter to say not attended. If don’t attend we know, if they do 99 times out of a 100 we’d get the result. These days we get results through on electronic record now.

Ms Hayton then asked Dr Hardy if the echo was normal what the follow-up would be.

AH: Usually 12 weeks, if request for 12 weeks don’t always get seen, standard is 3 months

C: To be clear, he has echocardiogram 4 November, you don’t get to see that, which explains why it didn’t appear in your statement. Absent you seeing that, was he ever given any follow up appointment?

AH: No, he wasn’t. We probably should have requested a follow up appointment at the time of discharge. In my experience is very unusual we don’t get test results back. Won’t be able to say why, we usually get results through.

C: Given, to be clear in my own mind, given the echocardiogram appeared to you to be normal, he’d not be given a rapid review of that?

AH: No

C: But he would have been scheduled for one in a few months time?

AH: Yes, 3 months

C: But in the event, that didn’t happen?

AH: Well, no

C: OK

VH: So your view of the echocardiogram being normal, would have given you some assurance the rivaroxaban was working?

AH: It would have at the time, but that would have been false assurance given subsequent event

VH: So even if you had the report, he’d have potentially been followed up 3 months from November, about February time?

AH: Yes, 3 months from November

VH: What would that have entailed? He’d come in face to face for an appointment with you?

AH: Yes, option to refer to VT Clinic but given he was admitted to respiratory, would have followed up in respiratory clinic

Ms Hayton asked what that follow up clinic visit would have entailed.

AH: Results of the echo, checking compliance, bloods, further investigation … at that stage you’d expect ongoing respiratory symptoms, if breathless at that point was a red flag need to do something different, but obviously we don’t know what the outcome would have been.

VH: Back in your statement, question 3 says in a few weeks. Would you expect the clinician put that in, say come back in a few weeks?

AH: We’d usually do it when they come back to clinic. My practice has changed going forward, as Prof Hunt comments on the Antiphospholipid Syndrome … if they are positive then failure rate is quite high, 15-20%, something like that. At that time I wasn’t aware of that information, only found that out through doing additional reading and reading Professor Hunt’s statement

Ms Hayton had no further questions for Dr Hardy but there were a few matters arising for David and the coroner.

DB: No follow up is really bad. Nothing in the GP note, if you’d fallen under a bus what would indicate follow-up needs to occur? Nothing was put in the notes about follow-up, just the echo. If anything had happened to you, how would anyone else know a follow-up appointment would be planned?

AH: 11 November, there wouldn’t have been any information, but at the time I got the result I’d have written to the GP and said this is the plan.

DB: Myles presented to a routine clinic with a pulmonary embolism, talk of follow up in 2 or 3 months. I’m struggling to understand what adjustment is in your mind as someone who presented at routine clinic with PE?

AH: You’re saying because he had a learning disability, we should arrange follow-up more quickly, is that right?

DB: Yes, I am saying that. That would be a reasonable adjustment. What do you think?

AH: I think you’d have to take it on individual requirements

C: Can I just ask you this, had there been a follow-up, sometime in February, would the follow-up have involved investigations which could have diagnosed the worsening of the DVT?

AH: There’s two things, one is yes we’d have done blood test at that point may have highlighted … secondly would have done clinical assessment, sounds likely he had ongoing breathlessness, which would have triggered review of further investigations or review of medication, or both. Think likely he’d have had symptoms at that point, given quite soon after he presented to the GP.

C: So he could have had an earlier diagnosis?

AH: Yes. I think it’s very likely if he came back to clinic in February he’d have said he had a cough or ongoing breathlessness or something that would have trigged assessment, or change in treatment, or likely both.

The coroner thanked Dr Hardy for his evidence, adding “I realise this has been a difficult experience for you, appreciate you’ve been straight forward and candid which is all can ask for”.

Dr Hardy ended by passing on his sincere and deep condolences and apologies to the family.

[The coroner then read a statement of Dr Raafat Yousab onto the record. He was a speciality doctor in the acute medicine department, working under Dr Ghumro during Myles’s visit to the VT Clinic on 20 October 2022. Dr Yousab’s statement recapped what happened in the clinic, as per Dr Ghumro (I’ll not repeat) and said that on the 26 October he’d drafted a retrospective letter that “incorporated the whole episode” of Myles’s visit to the clinic and immediate admission to hospital. His statement stated “this summary was not a true reflection of the VT Clinic on 20 October” and that his own involvement had been reviewing under the supervision of the consultant, and arranging blood tests. He ended his statement by passing on his condolences to Myles’s family

I wasn’t able to be at court on the Tuesday but there were three live witnesses, Mr Samuel Crickmore, a Physician Associate at Calderdale and Huddersfield NHS FT and two GPs, Dr Sajad Khokhar and Dr Chris Martland. I was granted a remote access link on Wednesday and will write that evidence up separately].