[I was unable to attend on Day 2 and am very grateful to the coroner who granted me remote access to attend on Day 3]

Day three of Myles’s inquest started at 10:55 with a discussion about late disclosure from the Dalton Surgery, that had been made overnight.

C: Mr Chawatama?

SC: Yes, good morning sir. Sir, can I start by saying my apologies for the delay, the other hearing went on until about 10:15

C: You shouldn’t have told me that, I wasn’t aware of it.  We were busy with the disclosure, thank you for your candour but your lateness made no difference to events this morning. Obviously, people at the surgery have been working very hard, I’ve counted 111 documents, including summary of 97 pages

Obviously, they cover several decades … I’ve looked at most recent years and skimmed a select number of them over the last 10 years, alright, will just address this to everybody at this stage.

I do not propose this is all disclosed at this stage for 2 reasons, firstly given the amount of time to do that would require be checked for redaction purposes, circulated and digested, that would necessarily mean the inquest would need to stop now and be rescheduled going forward.

Whist that’s always a possibility I then sit back and think what actually is the probative value of this, what will it prove? It tends to the evidence of Dr Martland yesterday that there is more documentation, evidently there is.  I will ask questions about this, I will ask him to revisit whether any of the disclosure provided causes him to change any of his evidence thus far regarding personal interaction with Myles.

Then the documents extracted individually, I propose he gives evidence on those, those have been circulated, do you agree with that?

SC: Yes, also another document 3 July 2020

C: Yes, if that comes through I’d be grateful to see that

SC: Also paper documents archived

C: I read that, would take 5 days to produce, again same point … existence might go to general point, lot of documentation there, more extensive than provided at outset of inquest, which is in the disclosure bundle.

Tends to be general point, is more documentation and involvement with Myles than superficially indicated by the slim Dalton Surgery records that were provided at the outset of these proceedings.  I’m absolutely not going to adjourn the inquest for production of all that, not audit of entire life’s work medical treatment of Myles, we’re dealing with last few months in relation to PE and his particular conditions. So, I think that’s the constructive way to deal with this.

SC: I agree

C: How quickly can that single document, is that coming to us now?

SC: Yes, I’ll double check

C: I will check with other Interested Persons whether they concur with that approach

VG: Yes

MrB: Yes sir, and the GP expert will have heard your observations

C: These have been sent now. Paul, David?

[I didn’t note who spoke but family]: Two things we think relevant to courts presentation, don’t want go back through long history but speaking to family after yesterday, first referral to paediatrician with interest in learning disability was when he was 6 or 7. That was an important recollection, to Dr Sills in Huddersfield

Second one, are we going to get the EMIS statement provided yesterday? Significant point hit overnight that Dr Martland couldn’t recall whether the x-ray request had gone to Huddersfield. We need to be clear whether that request went or not, or if it is in any record, normally goes electronically and we couldn’t find it.

C: That last point is discrete forensic point, first matter of general observation, we can get Dr Martland to agree or disagree, am sure he’ll agree in evidence that is the case. The second one is a matter of forensic inquiry, um, I wonder is there in the time available this morning, would it be possible to establish, that Mr Chawatama?

About the letter for the x-ray, correspondence in relation to the x-ray, if necessary I’ll allow you to take instructions before Dr Martland gives his evidence, he’s got that point nailed, so even if on screen to look at, otherwise content to proceed on that basis.

SC: Yes

C: In that instance, can you make that inquiry now about the x-ray, can you get copy and circulate. We’ll resume with Dr Martland in 10 minutes, thank you very much.

Court was adjourned at 11:03 for 10 minutes

When everyone returned to court the coroner checked that all the Interested Person’s had everything and the coroner asked Dr Chris Martland GP to return to the stand and take the affirmation again.

C: Right, you’re obviously Dr Martland of Dalton Surgery, you gave evidence yesterday. First of all, can I thank you and your staff at the surgery very much indeed for the considerable efforts they put in overnight. Obviously, documentation is bulky and needed some processing to get here.

Just wanted to check with you about the documentation, and the general points arising from it, and then talk about particular items from it.

Firstly, you made the point yesterday in evidence that the documentation we have so far hitherto disclosed into the inquest, are not representative of the totality of the available documentation in relation to Myles, yes.

So, simple show and tell exercise you’ve produced 111 documents, first one I read is 97 pages long, you’d say that’s the point, yes?

CM: [couldn’t hear]

C: Secondly, you’d say it goes back over many, many years, I can’t recall the first year?

CM: I think would go back to his primary immunisations at a few months old

C: As a baby

CM: Yes

C: Then digitisation

CM: We became digitised in 2003/4, prior to that would be paper form… old fashioned records, which are the ones we could obtain for you, they’re archived off site

C: The covering email to me is these are archived, they take 5 days to obtain, am I right the paper documentation relates to before things started to get digital?

CM: Yes, 2004

C: So first 14 or so years of Myles’s life, and there are records there. Alright, if I start to get a little more specific, yesterday you said your recollection is that you knew Myles well, you’d seen him a few times over the years, that he was registered at birth, you said your estimate was you’d seen him about 10 times?

CM: That’s an estimate yes

C: Anything from your more recent perusal of documentation that would cause you to change your evidence about that?

CM: I’ve not counted them but I stand by what I said yesterday [I think he said – hard to hear]

C: Right now, do you have these documents in front of you, what I’ll do for ease of reference is go through in chronological order

First one is dated 3 July 2020?

CM: Yes sir

C: It’s from Kirklees Learning Disability Service and Dr Laycock, yes?

CM: Yes

C: Who’s a psychiatrist, includes diagnosis of moderate learning disability, IQ assessment shows IQ to be 59, autism spectrum disorder, ADHD, psoriasis currently experiencing flare ups

Right, description of some of the family dynamics, lifestyle, Myles’s lifestyle, advice about getting some support, little change in his presentation, he’s low risk to himself and others, review again in 6 months

Is there anything more significant than that I’ve highlighted in that document?

CM: I think this was mentioned yesterday because this was when he was coded as having learning disabilities on the LD Register

C: That was July 2020, your evidence yesterday?

CM: Yes, don’t think anything specific about this letter other than that. The coding and the register.

C: That’s him going on the register July 2020

CM: It’s an administrative action, doesn’t involve us as doctors, would be done at senior administration level in the practice

C: OK, next one 24 November 2021, we’ve got same diagnosis, got his medications, it’s a telephone consultation, in line with Trust Covid-19 guidelines, so options for face to face consultations are greatly restricted at that time.

Says last reviewed Dr Dan July 2021, spoke Ashley Myles’s stepfather, again Myles’s presentation stable, relatively stable, there’s description there of his presentation, described as again reference to social support, reference to physical health.

There is an interesting entry here. Capacity, Myles does not have capacity to consent to treatment and psychotropic medications prescribed in his best interest in consultation with his family…. family… blood test monitoring, Ashley agreed make self-referral to social services and follow up in 3 months time, yes?

Capacity, Myles does not have capacity to consent to treatment and psychotropic medications prescribed in his best interests. Capacity is something that is never fixed, needs to be assessed on ongoing basis, but were you aware of that particular assessment in that letter?

CM: At the time I saw him in March?

C: Yes

CM: I probably didn’t trawl back through all these records when I saw him

C: No. Were you ever aware of that assessment?

CM: I’m not sure

C: I’m not going to ask you to guess, but you’re saying you’re not sure, what do you mean by that, without guessing?

CM: I’m not sure I’ve seen the documents, but I don’t remember doing

C: Now it is fair to say, I think you’d agree with me on this, all evidence we’ve heard so far, clinicians, whether primary or secondary, working with Myles in 2022, 2023 all worked on the basis he had capacity to consent, yes?

Dr Martland asked the coroner to repeat his question, he does. Dr Martland responds that was the case with “the issues dealing with at the time, specific situations”. The coroner then asked how that relates to the statement that Myles doesn’t have capacity to consent.

CM: Is related to decision being made and complexities thereof, so Learning Disability Team when looking at Myles‘s medication and issues around that, may have felt he didn’t have capacity to understand all the nuances of that. When dealing with the issue of his chest pain in consultation, and the safety netting around that, I certainly felt he had capacity to understand that. Depends on the decision in front of us, simple things he may well have had capacity for, complex things he may not have.

C: Alright, I want to summarise what you’re saying. You can’t recall, you’re not sure if you were ever aware of that particular part of that correspondence in November 2021, that would apply at the time and through to the current time?

CM: Well, I’ve looked at these in the preparation for this

C: Until you looked at it for today’s purposes you weren’t aware of that, not sure were ever aware of that?

CM: No

C: Secondly you’re saying it does say Myles does not have capacity to consent to treatment, you’re saying might be case in relation to medication but in relation to his describing symptoms, he had capacity to describe symptoms to you?

CM: Capacity to do with decisions really, and understanding choices about say a management plan, in the context of his learning disability and his autism, his ADHD management plan, the clinician here seemed to feel his capacity was diminished.

C: Alright so you’d say look in terms of capacity to agree to treatment and a management plan, that does seem to say he didn’t have capacity, diminished capacity, he’d lacked capacity?

Silence

C: Right, do you think that was correct, are you challenging that assessment? Sorry, are you?

CM: By the specialist?

C: Yes

CM: No.

C: Right, ok. Let’s move on, um, the next one is correspondence 27 June 2022 Kirklees Learning Disability Service, from Dr Zaha/Saha [sp?]. This is another review of Myles and again diagnosis remains the same, slightly filled out … IQ 59, autistic spectrum disorder, ADHD and psoriasis

Myles attends with Ashley and Jane, first time Dr Zaha has met with Myles. Description there of his presentation, how he gets angry, how he can be anxious about change to plans, sleeping all day, lifestyle, taking medication regularly, reported no side effects, advice about lifestyle. Mental state examination, casually dressed, well kempt, wearing mask and hoodie …. eye contact… rapport difficult establish, answering short sentences, almost monosyllabic… depressed, slightly agitated at times…. he has some insight into his mental health

That engagement with the psychiatrist, answering short sentences almost monosyllabic. Is that something you recognise?

CM: Yes

C: Right, now the last correspondence you’ve got is 8 November 2022, this is the correspondence referred to yesterday, from Dalton Surgery to Myles with regards to review of his medication, anti-coagulant medication, your interpretation was at this stage it was likely he was preoccupied with his hospital admissions?

CM: At the same time, yes [think he said, very softly spoken] the second paragraph infers that weight check and review by the nurse would have been part of his learning disability review

C: Oh right. How are you progressing with regards to the correspondence on the x-ray Mr Chawatama?

SC: He can answer that

C: Can you give specifics about the correspondence?

Silence

C: From that do I conclude, it’s there and you can’t find it, or its simply not there?

CM: Being honest and candid about this, it’s not there

C: Do I conclude from that it’s not there because it’s been lost, or because it was never created?

CM: Could have been either, but being honest with you I feel it’s probably omitted as an action

C: Probably not created and omitted as an action, alright. Well thank you for your candour which is always appreciated, and all I can ask for. What I’ll do is tender you to firstly Ms Hayton, any questions?

VH: No

C: Mr Birch?

MrB: Just one on that x-ray point, is that a point when requests are done electronically not in paper form?

CM: Would be done electronically

MrB: So, you’d expect to see something on the system saying one had been requested?

CM: Until yesterday I can’t find it wasn’t there, can’t find record or on the radiology portal, I can’t see it

MrB: Just one further point on that in relation to your evidence yesterday, you said can take some weeks, is it right you could have arranged an urgent x-ray if you thought that was appropriate?

CM: Yes, you can, still likely to be weeks plus, even for urgent GP requests

MrB: And other option is refer to xx to be seen the same day?

CM: Yes, or to A&E

MrB: Thank you, nothing further

C: Alright, Paul, David?

PS: I’ll start sir. Yesterday in evidence Dr Martland, you did say that you spoke to Myles in general terms and would listen to his answers, and you did say sentences actually.

In light of what’s in here, and what you said this morning, do you recall at that consultation Myles was speaking in short sentences and monosyllabic, or what you said yesterday in sentences?

C: Are you modifying your evidence?

CM: My recollections of what was said are hazy I’ll admit. From my knowledge of Myles in previous encounters I’d expect his articulation and his language to be monosyllabic or short sentences

PS: What reasonable adjustments did you make in that consultation to gain his understanding? Not that he’s aware of what said by you but his understanding of the significance of what was being said, in particular the safety netting you said you gave to him?

CM: Discussed yesterday, I think I would have had an approach that would be sensitive to his knowledge of learning disability, his ADHD and autism. I would have explained things, would have listened to him with appropriate open questions and closed questions, safety netting in small simple chunks for him to understand

PS: In light of evidence being presented today which was in your practice, did you make any reasonable adjustments [can’t hear] anyone in your practice particularly regarding … and appropriate steps for them to take your understanding of Myles?

CM: No, I didn’t

PS: Could I ask, do you feel knowing Myles as you did, that that might have been a step which would have helped Myles take the appropriate steps required before you got the x-ray which you were waiting for to review Myles with?

C: Can I put that slightly differently. At the time, I think at the time you were operating on the basis he had capacity, at the time you didn’t make adjustments for his autism or his learning disabilities to the extent of contacting his family with regards to the treatment plan, yes?

CM: Yes

C: Right, that’s quite evident, there’s no note of you doing that?

CM: No

C: Now knowing what you now know, do you think that was an appropriate approach to take with him? Element of hindsight I’ll allow.

CM: With retrospect?

C: With retrospect on this occasion, primarily interested in what you did at time on what basis and what happened. You’re looking back, Dr Martland now, looking back to the Dr Martland in March 2023, do you remain satisfied that was the correct course of action?

CM: With retrospect, obviously knowing how this has unfolded, I think any clinician will look back at decision and judgements made and reflect were other choices appropriate. With how things turned out of course you’d think I should have done a, b, c instead of what done. At time I thought was safe management based on clinical decision made, and safety netting I gave him, in the manner I gave it to him

C: OK this is problem with hindsight, I’m sitting here, Myles died, I’m answering questions what was I doing in week before he died… so exercise is naturally coloured by what has happened, which is why we’re always a little wary of this sort of exercise, but if I can just ask you look at this if you can in strict isolation. Looking back at your decision making process and actions in last consultation on 20 March, do you remain satisfied that was a reasonable course of action?

CM: That’s difficult to answer

C: It is a yes or no and that’s why I’m asking it

CM: With hindsight factored in, no. I felt at the time I managed him appropriately

C: OK. Go on Paul

PS: Yesterday your colleague Dr Khokhar in his evidence stated there was a practice review of Myles’s death and learning,. Were you involved with that?

CM: Yes

PS: Did you review the whole of Myles’s previous records with regards to his learning disability since 2010 to inform your management of future learning disabled patients? Because clearly today it’s raised some issues, were they involved in your learning? If not, why did you think as a practice …

The coroner interjected to ask Paul if he could break it down and ask one question at a time.

PS: If you used notes from 2020, from that point on it was identified Myles had a learning disability?

CM: Yes

PS: So, you’d have seen the document then, that we have today, as part of that review?

C: Put another way, can you remember seeing these documents before?

CM: Honestly, in itemised detail like this, specific document, no. But we’d have read through the notes and shared the information we knew about Myles as collective documentation, rather than specific documents.

PS: So can I ask what specific changes have been made in policy which are potentially available to patients, or your staff, with regards to communication and Reasonable Adjustments?

CM: I think primary purpose of the review was management of the physical side of presentation like Myles had, the pulmonary embolism, to have a lower threshold for taking things very seriously and actioning so events like this are much less likely to happen. In terms of the learning disability side of things I think the team were just made aware to be more sensitive to patients with these problems, give them more time, more adjustments

PS: You used that term yesterday Dr Martland, can you be more specific about sensitive? Requirements for people with learning disabilities are very clear about Reasonable Adjustments and taking into account their needs. Has any review at your practice since Myles’s death, as part of practice learning, identified issue and made systemic changes to policy at your practice?

CM: No

PS: Thank you, I have no further questions sir

C: ok, ok. David, did you want to ask anything?

DB: [can’t hear]

C: No alternative diagnosis to PE was made, Dr Martland noted past history of DVT and PE commenting that Myles was on rivaroxaban. In my opinion all GPs should be aware anti-coagulant treatment does not necessarily prevent PE, especially in a patient who already had a PE on that treatment…. [didn’t catch]…. failing to call the medic on-call falls below the standard of a reasonably competent GP. Go on

CM: I mean I think my assessment at the time, I didn’t make a firm diagnosis as we discussed before, felt other possible diagnoses apart from a PE, I did consider PE, but chest wall tenderness and the fact he was on the rivaroxaban, I probably took more reassurance from that than in retrospect than I should have done

DB: [can’t hear] … in response a comment made, I’d like to know the difference between a medication review and an annual review?

CM: Got to be absolutely honest I don’t know the minutiae of details as a GP, we wouldn’t actually be doing these in practice, would be Practice Nurse. Would be template to follow with information about if they’re functioning, family set up, issues struggling with, medication problems and other things including physical health… don’t know minute details

DB: Do you think a review of that sort might highlight what Reasonable Adjustments and family support would be needed?

CM: Yes probably

DB: Was there any note in the record Myles was invited for any annual learning disability review?

CM: I didn’t see one, but he was under the care of the other teams.

DB: What teams?

CM: Learning Disability Psychiatry care

David asked how that would help.

CM: We were aware of the diagnoses and the fact he was under their care

DB: That’s good, so his psychiatric mental health care was taken care of, he didn’t die from that, he died from a PE. This relates to his physical health care, I’m struggling to understand how psychiatric assessment helps [missed]

CM: Not what I meant… I think from the mental health side of things we feel things would be covered by their input, the physical side of things still needs doing

PS: Can I ask another question for clarity?

C: Yes

PS: The letter 8 November, with regards to Myles’s anti-coagulant medication check in the notes, page 5 medical notes page 5

CM: Ok

PS: It says 14 November 2022, an anti-coagulant medication review took place at the practice. Is that correct Dr Martland?

C: It says anti-coagulant, have you got page 5 doctor?

CM: What day was it again sir?

PS: It’s the 5^th, at the top 14 November 2022

CM: Different page over here, but yes got it

PS: So an anti-coagulation check did take place on 14 November, did it?

CM: Yes

PS: Does that refer to the letter of 8 November 2022?

CM: Yes

PS: So that did take place?

CM: Yes

PS: Also page 6, 14 November, 12 o’clock is record of that anti-coagulant medication review, correct?

CM: Yes

PS: So there was nothing there to do with a learning disability assessment within that annual review, is that correct?

CM: Yes PS: Thank you, no further questions sir

The coroner then went to Mr Chawatama, counsel for the GP practice and Dr Martland, and asked if he had any questions. He did not.

The coroner thanked Dr Chris Martland for his evidence and his candour and released him at 11:52. He said he was welcome to stay if he wished, but he said he needed to get back to work.

The coroner thanked him for returning on a second day and again asked him to convey his thanks to the people in the practice for their work with the disclosure.

[The rest of Day 3 was spent hearing the evidence of two independent court experts, Dr Elizabeth Herrieven an expert in learning disability and autism, and Dr Lynnette Hykin, an expert in General Practice. I will report their evidence tomorrow/over the weekend].