The third witness to give evidence on Day 3 was Dr Lynnette Hykin, she gave an affirmation shortly after 14:30. I could only remain for a further hour so that is reported below but unfortunately I was not able to stay to the end of her evidence.

LH: First, I’d like to say how sorry I am to hear about the death of Myles and extend my compassion to the family. My specialist field is general practice, I’ve been a doctor since 1991 and a GP since 1997, partner since [missed]… as well as usual GP day job have worked for CQC … training doctors … sit on various Medical Defence Union Committees and on the MDU Board … I think I’d be described now as a portfolio GP.

C: Right OK, I don’t think you gave your name, its Dr Hykin and you’re a General Practitioner and you’re based in Cornwall?

LH: Yes, yes

C: Your report you’ve provided, you have bundle prepared for this inquest?

LH: Yes

C: That includes material not available at the time of drafting your report, is that right?

LH: Yes sir

C: Also bundle of medical records, am I right?

LH: Yes

C: Also, documentation during hearing itself, statement from Dr Khokhar?

LH: Yes

C: And correspondence we’ve been referring to today, and I think you’ve been online for the duration of the day?

LH: Yes

C: So, you know what we’re talking to is correspondence from Dr Zaha/Saha [sp?], psychiatrist. Will start at the beginning. Dr Laycock dated 3 July 2020, psychiatrist, Dr Zaha, another psychiatrist 27 June 2022, not forgetting psychiatrist Dr Tan November 2021, and finally from clinical support Paula Fisher at Dalton Surgery 8 November 2022. Yes?

LH: Yes

C: You’ve had advantage of hearing some evidence from Dr Martland this morning and you’ve heard all of the evidence of Dr Herrieven this afternoon

LH: Yes

C: So that’s it, what I’m going to do, as with Dr Herrieven. I’m not going to take you through line by line your report, just highlight features of it I think are material, then I’m going to take you to your conclusions and ask you whether there’s anything you’ve seen, or read, or heard subsequent to this report that causes you to alter any conclusions. Alright?

LH: Yes

C: So you start your introduction with a summary and say you’re concerned with Myles, give circumstances you’re focusing on his contacts. His stepfather contacting the surgery on 16 March, resulting in telephone consult with Dr Khokhar on 17 March, following that face-to-face with Dr Martland on 20 March. You’ve been asked to answer questions about care provided by GP staff, you say whilst given preliminary opinion, don’t have access to full records, which will be my final question, given all you have does your opinion change.

Put a pin in that for now. Over the page, questions I put to you, were put by Dr Bell, formerly the coroner here. What he asks you to consider is:

1. are you able to identify any deviation from anticipated standards of care on 16 and 20 March 2023 in relation to progression of previously diagnosed thromboembolic disease
2. if so, likely impact for Myles
3. any deviation between 16 and 20 March in relation to associated problem of autism and learning disabilities
4. if yes, likely impact for Myles
5. if identified deficiencies in management what required changes to prevent further adverse outcomes [paraphrased]
6. any aspects could be improved in primary care [paraphrase].

That’s the brief, then look at facts which you outline in detail, then go onto internal page 10 section 4, your opinion. On that first question are you able to identify any deviation from anticipated standards and if the answer to that is yes can you set out what the likely impact was for Myles.

I think you say 4.2.5 to say this on 16 March Dr Khokhar neither saw Myles face-to-face, nor referred to A&E, hadn’t recorded any [missed] for breathlessness… in failing to arrange same day face-to-face assessment of Mr Scriven fell below that expected of a reasonably competent GP

4.2.9 on page 13 you say my opinion therefore unless GP had considered PE, because of his past history and was sufficiently convinced was alternative diagnosis, and did not expect PE at all, should have spoken to medic on call for advice for how PE excluded. Effectively given Well Score was low and doubt about d-dimer and Myles is already on rivaroxaban, and had already failed to prevent a PE.

You say in relation 17 March I did not consider lack of audible breathlessness on telephone was sufficient reassurance Myles did not have a PE on 16 March.

My opinion standard care of Dr Khokhar on 17 March, failing arrange face-to-face assessment, fell below that expected of a reasonable competent GP.

In relation to 20 March you say in my opinion, these are essential component of an assessment, I’ll go and read the whole paragraph out 4.2.13:

On 20 March Mr Scriven was seen by GP, Dr Martland who examined his chest commenting tender on left anterior axillary line, no abnormality of lungs, no note on temperature, blood pressure, respiratory rate [other observations – missed] … if Dr Martland failed to undertake this assessment would be my opinion the standard of care fell below that expected of a reasonably competent GP

In evidence yesterday Dr Martland said he would have done but unaccountably failed to note it up. So, it is available to one explanation is he did it but didn’t note it, as much as there is possible explanation he didn’t do it. His preferred explanation was he would have done it and unaccountably failed to note it up, we’ll come back to that. Ask you to bear in mind.

You say no alternative diagnosis of PE was made, Dr Martland had noted past history of DVT and PE commenting Mr Scriven was on rivaroxaban. In my opinion all GPs should be aware anti-coagulation does not necessarily prevent PE especially in patient who already sustained a PE on that treatment… failing to call the medic on call for advice of how to proceed fell below that expected from reasonably competent GP

You also go on to consider whether there were any identifiable deviation from anticipated standards of care with contact on GP Surgery regarding autism and learning disability and if yes, likely impact would be for Myles.

You do have caveat, we don’t have evidence of how learning disability and autism impacted on him, may have difficulty communicating symptoms and concerns over telephone and may benefit from face-to-face assessment … sometimes may need longer time and utilise non-verbal cues to assist, should have been lower threshold for face-to-face assessment on 16 and 17 March. This does not alter my opinion, even without learning disability and autism, is my opinion should have been a face-to-face assessment on 16 March, failing that 17 March.

My understanding, for sake of clarity, is at time of writing you had no particular insight into how Myles affected precisely, his communication, ability to communicate symptoms and concerns but generally someone with those conditions would need more time and help in communicating their conditions, but in any event, there should have been a face-to-face assessment on 16, 17 March in order to have a complete appropriate assessment diagnostic exercise. Is that right?

LH: Yes that’s right, either needed to be GP seeing Myles or if they really couldn’t do that could advise him to go directly to the Emergency Department that would have been acceptable.

C: OK, you say 20 March, no note made of Myles’s breathlessness, what induced it or impacted it in day to day life… possibly learning disability meant less likely to volunteer spontaneously at appointment if Dr Martland didn’t ask, instead of relying on Myles to give history unprompted… would be in my opinion this standard fell below that expected from reasonably competent GP.

Whilst GP should ask history of any patient presenting, my opinion should have ensured Mr Scriven understood what he was asking, and given time convey his feelings during the appointment.

C: Was it, was a 13 minute appointment?

LH: We don’t know was 13 minute appointment. All we know is record was open for 13 minutes, with some systems can have another record open and consult another patient with overlap of time.

C: So you could shave off, it could have been shorter than 13 minutes?

LH: Indeed, it could have been longer as well, but the GP would be working blind without record open, which is unusual and quite uncomfortable

C: Just for the sake I understand what you’re telling me, are you telling me, it is available for you to say no that’s not right, are you telling me the most likely scenario is it was up to 13 minutes but unlikely to be longer than 13 minutes

LH: Correct, yes

C: Right. Right now I’ve covered at a canter your report in so far as your analysis as to what happened and deviations in what should have happened, what it says, that’s on court record, everyone has read the report.

Now, can you help me with this, you’ve had all this extra material last week, extra material this week and heard some evidence today. Is there anything in any of that which causes you to amend your opinion and conclusions?

LH: Um I was thinking about the letter, let me just find the letter that says Myles doesn’t have capacity to consent to treatment and psychotropic medication prescribed in his best interests in consultation with his family 24 November

C: Yes

LH: That’s quite a big thing to be said, hadn’t realised from the records as they stood, that Myles was so incapacitated by his disability. The implication though, it’s not said in this letter is that these decisions should be made in collaboration with his family, that’s second part of that sentence.

I think it would have been helpful for GPs to have that sentence made more obvious to them, not open letters look at page 2 of 3 of one letter in the past. I know now reasonable adjustment flags are much more in place, computer software is up and running which it wasn’t in 2021.

Now should happen when you receive a letter like that, you might have discussion, would certainly make note to reflect that sentence, to understand degree of disability and how it impacted on Myles. The phonecall from stepfather on 16th suggests were different contact numbers, manifest on 17^th where Dr Khokhar made a couple of phonecalls, so he obviously had different contact numbers for Myles on his computer record. Sometimes little notes on record that says things like mum, dad or stepdad next to phone numbers, sometimes also have consent speak to, ore prefers to speak to can be put on front of record and that would have been really helpful.

C: Will pause you now, moved away from area looking at. Your opinion in 2 broad areas, what happened and how service can be improved in light of what happened, got onto that 2^nd function of report, want to stick at the moment with first part.

What happened and you’ve summarised everything at paragraph 5 internal page 18, you say in your opinion the standard of care of Dr Khokhar 16 and 17 March, failing to arrange face-to-face assessment with Mr Scriven or alternatively advise go directly to A&E fell below the standard of a reasonably competent GP

Dr Martland’s failure to record examinations… blood pressure, pulse, temperature… fell below the standard of a reasonably competent GP. He says he probably did check it but didn’t note it.

You say Dr Martland’s failure to call medic 20 March for advice how to proceed, and advise Mr Scriven to go directly to A&E fell below the standard of a reasonably competent GP

Is those I want to focus on, the three, not how might improve. Is anything you’ve heard or read in this case since you produced this report which causes you to change your overall opinion?

LH: No

C: No. I suppose you’d say subject to view I might take whether Dr Martland did the numeric observations. He says he probably did but definitely didn’t record them, which is a lapse in its own right. Subject to that, nothing to cause you to change your mind about these various deficiencies?

LH: That’s right

C: Right, want to lead onto something else which is this, the follow up question to that want to address now. Is, given these lapses, to what extent did they ultimately contribute to the death? Can have lapse, deficiency in standards applied to patient and it’s not very good but doesn’t necessarily mean someone dies when overwise they should live. In this instance, is there anything in those 3 conclusions you’ve come to that you could say actually contributed to the death?

LH: Yes, all three

C: Right. Now again I’ll put point in different way as I did with Dr Hartland. Same point expressed rather differently, are you saying but for these deficiencies in care Myles would not have died?

LH: I can’t say exactly what would have happened in the hospital, but on the basis of the note made by Linda Whitbread, that note saying he was breathless, took him 5 to 10 minutes to get his breath back.

That note, and his past history meant PE was a possible diagnosis and we don’t easily have a way of diagnosing or excluding that in Primary Care. So the outcome would have been he would have needed to go to Secondary Care.

I can’t say what secondary care definitely would have done, but can speculate on basis what they usually do. Would have made an assessment include Well Score, d -dimer, don’t know if would be elevated, depends whether due to further PE, on basis what happened to Myles and what previously happened to Myles I think it’s likely but outside my area of expertise

C: On basis Linda Whitbread … breathlessness, PE was possible diagnosis, that should have been referred to secondary care?

LH: Yes

C: Think you’re saying had there been a PE at that point, at that time, it is likely to have been diagnosed?

LH: Yes, and it would have represented as well, even if it had not been PE, outside my area of expertise, but would have presented a further opportunity for secondary care to review his anti-coagulation

C: OK. If go onto second task you were instructed to undertake in your report, you’ve provided at 4.4 and 4.46 some advice as to how to address these deficiencies. Say don’t consider management of triaging … appropriate … to be outside usual scope of primary care. In my opinion, all reasonably competent GPs would have undertaken this, as set out above, so do not think further changes are needed to avoid… is more the care provided fell below reasonable standards [paraphrase]

So, basically on this occasion was collective error, systems in place should deal with this but they weren’t adhered to, is that right?

LH: That’s right. I noticed note from Dr Khokhar saying surgery was full on the Friday when he was made aware of the situation on the Thursday, subsequently made got more staff on Friday, things like that.

I think any GP you’d ask would you say no emergency on a Friday, is not correct. Any GP would know could capacity on any day, and you must see them if it’s an emergency. You can’t say we’re full, we’ll see you after the weekend.

C: Right you’re saying that’s just not good enough, just doesn’t cut it?

LH: Yes that’s right. Not a new thing GPs need to know about, GPs do know emergencies need to be seen on the same day.

C: You then go on to address this question, absence any deviation…. categories could be improved in primary care. Although Mr Scriven coded as having a learning disability on 3 July 2020, unclear whether he was added to the learning disability register.

In fact, seems he was. May be helpful to ensure all patients on learning disability register are flagged, may be case, such that when records loaded, aware need additional requirements of care and information [paraphrase].

Think that’s what broadly you were alluding to before, you had buried in the weight of documentation that I’ve now seen on block in relation to Myles for his entire life, had buried in it nuggets of extremely important information which the witness confirmed they really hadn’t got in front of them, when dealing with him between 16 and 20 March.

You’re saying should be flagged so they know what documents may be relevant to assessing his capacity, as well as his physical condition, is that what you’re telling me?

LH: Yes. I think the development of the Reasonable Adjustments flag which I knew about when writing report, but wasn’t available at time of events, if that works that system hopefully will take care of this.

C: Then you venture outsight your field of expertise, you very properly say, and speculate whether anti-coagulants after PE diagnosis October 2022 were influenced by Mr Scriven’s learning disability and whether those decisions were made appropriately. Given those caveats you’ve quite properly raised I won’t ask you to elaborate further on that.

You then in your conclusion refer to this flagging exercise, all patients on the LD Register are flagged such when records loaded is clear to clinicians and receptionist… additional communication and explanation, you’ve covered that.

Right, will pass you over to the advocates present and I will see if they’ve got any questions for you.

C: Mr Birch?

MrB: No

C: Ms Hayton?

VH: No

C: Mr Chawatama?

SC: Can I go last?

C: If you like

SC: Something may emerge

C: I’m not against that

The coroner explained usual practice that person whose witness it is goes last with questions, expert witness ordinarily would ask family to go last, given witness touches on Dalton Practice the coroner is prepared to allow Mr Chawatama to go last. Then it was over to Paul Scriven to ask questions.

PS: 3 times through discussion, statement was made we’ve seen evidence Myles was on the learning disability register at the practice. We haven’t, we’ve had statement from Dr Martland.

C: Who says he was

PS: Yes. There’s no evidence Myles was flagged on that practice’s learning disability register

LH: Can I offer clarification?

C: No pause for a minute, let’s go back to what the evidence was, I want to get this straightened up

SC: One place sir is paragraph 12 of Dr Khokhar’s statement

C: I want to go back to the original records as well, marker indicating a learning disability

SC: Evidence given about a pop- up which came up on the screen which listed a variety of conditions

C: Dr Martland was, his evidence was he was on the register, he was registered in Summer 2020. I’ve taken as accurate your point, is no evidence.

PS: Until this morning, yesterday Dr Martland said he couldn’t recall but thought he had sent x-ray, on further investigation he hadn’t. Think it’s important to establish if Myles was on the Learning Disability Register

C: If I understand your point it’s this, you’re saying I know Dr Martland said that, gave month and year when it happened, we have not seen any corroborative evidence that was done in documentation, and Dr Martland’s recall has otherwise, let’s say, been patchy

PS: But also on learning disability, he seemed to think learning disability assessment was sub-contracted out to psychiatry department, or parts of it, which makes me think not full understanding of what the Learning Disability Register is, the marker or its exact format

C: Alright ok, you think possibly is available to entertain that Dr Martland simply doesn’t know what it is. If we work on basis two possibilities here Dr Hykin, firstly I’ve been told by Dr Martland and in Dr Khokar’s report, Myles was on the learning disability register from 2020, July 2020. Firstly that that is actually accurate, that’s possibility number 1. The other possibility being raised by Paul Scriven, he’s unclear and David Black, his husband, is look, it’s equally plausible that given there’s no documentary corroboration of that, that frankly Dr Martland may have just got that wrong, he doesn’t realise that, no documentary corroboration of that, therefore he may not have been on the register, right.

LH: Well

C: Hold on, I’ve not asked the question yet. That’s the situation, first of all can you just tell me what documentation would arise for someone on the register?

LH: A register isn’t an entity it’s a search run for a code, the code says the person is on the register. Could be the code was entered on 3 July 2020, LD, if that’s the code the practice used to search for the register, could be code date put onto register. What the practice chooses to do with their register is another matter.

C: So it’s a code, if I use inappropriate terminology or conceptualising wrong, by all means tell me, so someone coded being on register, is signpost to say this person is on this register, yes?

LH: Correct

C: What practice then do is entirely a matter for them, their processes and discretion, is that right?

LH: They’re supposed to do annual learning disability reviews with everyone on the register

C: Uh hum

LH: They would often delegate that to a nurse practitioner or a GP with a special interest

C: Right. Now if I go back to Dr Khokhar’s evidence, his evidence was that was delegated to a nurse in the practice, now as of yesterday he said he couldn’t see any record of reviews in the records, right. Now, would those reviews, would they necessarily be reflected in the medical notes, in the documentation in relation to Myles?

LH: Yes, they would

C: Alright, so if they’re not there, the conclusion would be on the balance of probabilities, he’s not on the register, or the nurse hasn’t been doing the reviews?

LH: Well

C: Is that accurate?

LH: I think it’s a bit more nuanced, there are lots of registers, a hypertension register, a diabetes register, a learning disability register. Lots of people are on these registers, that code entered on that date, I take to indicate he is on the register but somehow practice has not taken appropriate measure to issue the invitation, or having done that chase up his non-attendance. Usually issuing invitation would give mark on record, in the set I’ve reviewed I can’t see any mark to indicate he was ever invited for a learning disability review as he should have been.

C: OK right, that’s helpful. Alright have you finished, anything else?

Paul had no more questions, so then it was over to David Black to ask his.

DB: Thank you very much, I’m Paul’s husband and Myles’s uncle. In Dr Khokhar’s statement, paragraph 8 or 9 he says, I’ll wait for you to find it

C: Are you there Dr Hykin?

LH: I’ve got them, yes

DB: Thank you, I just want to check Dr Khokhar says Linda Whitbread was, he sort of suggests, she didn’t see situation as immediate threat to life, call came 9am didn’t tell him till 2pm. He said he had a lot of calls, he was busy, decision influenced by need to begin his afternoon surgery promptly. Was that a good reason not to take any action with regards to Myles on that day?

LH: No, it’s not

DB: Thank you. The next day he completed a telephone consultation, how easy is it to conduct an assessment of someone presenting with breathlessness over the telephone?

LH: So if somebody is breathless when you’re speaking to them on the telephone, usually they’re sat down at rest when taking phonecall, so breathless at rest, in young person that’s extremely serious. That’s not what was described, was breathlessness on exertion. You wouldn’t expect phonecall to be taken whilst someone is exerting themselves, so in no way reassuring, because it doesn’t negate the symptom reported.

DB: Thank you, you mentioned Wells Score, is that something most GPs are able to do?

LH: Yes

DB: There’s nothing esoteric or odd or weird about a Wells Score?

LH: No there isn’t and its freely available from getting NICE Guidelines up, or template used in clinics have the Wells Score available

DB: Thank you, and just want to go to Dr Martland’s consultation. There’s nothing to reflect on, the note is short and there isn’t any record of a Wells Score or any observations being recorded.

How serious is that in terms of reasonably acceptable medical practice? Dr Martland said he thought he must have done it, he doesn’t recall doing it and there’s nothing written down. What do you make of that and its seriousness?

LH: Two things here, firstly didn’t record any physical examination, the temperature, pulse [etc – missed others] he had to record those, that’s examination.

As for Wells Score we only do when considering PE, even slight possibility, when start consider might be PE that’s when we apply the Wells Score. If see it in someone else not Myles, patient gets short of breath when doing lots of running, happens every time, think normal we all do that, so you wouldn’t apply the Wells Score. As soon as you apply Wells Score there are further actions you must take, it’s a gestalt, have to have feeling, thought they have a PE, but of course he’d already had a PE so you must have that thought.

DB: That’s really helpful, just wanted to ask, would it be reasonable to expect Dr Martland to look at discharge letter from Myles’s previous admission when he suffered PE whilst taking rivaroxaban, would it be reasonable to expect him to look at that?

LH: I think I’d describe that as best practice to look at record, nonetheless would be aware from summary Myles had DVT followed shortly later by PE. Simple questioning would have established Myles was on rivaroxaban at time he had the PE and was now on rivaroxaban

DB: We heard from Dr Martland, although he’d written down chest x-ray requested, but we heard no referral was made. What’s the seriousness of that?

LH: Firstly, I’d say chest x-ray is inappropriate investigation in this situation, only thing that should have been done was referral to secondary care.

Chest x-ray not given a lot of thought to, as it wasn’t the right test. With computer system have to make request electronically, leaves a mark on the record, sometimes patient also has to call to book x-ray, varies locally. You make a request and it would leave an audit trail.

DB: Thank you

PS: Can I ask a supplementary to that particular question?

C: By all means, I’ve got a question

PS: If the x-ray request had of gone to the Trust, the advice to Myles and his family were to review Myles once the x-ray came back. That’s in the notes and advice the family understood. Would that have been chance if x-ray come back in 4 weeks for Dr Martland to potentially refer Myles back to secondary care?

LH: Yes

C: You said earlier actually you’re quite clear your view is by 20th at least, at the latest, he should have been referred to secondary care?

LH: Yes

C: Do you agree, your opinion by 20th at least should have been referred to secondary care?

LH: That’s correct

C: Now second point arising Paul putting, x-ray you said I don’t think was ideal investigation in any event, should have had battery of things done in secondary care not available in primary care. Not withstanding that point, how would an x-ray have informed someone in primary care as to possibility of a PE?

LH: So I suspect that the x-ray would have been reported as normal, showing no pathology and so in the same way the examination of lungs was normal this gave no explanation for symptoms experienced by Myles

C: Right, ok.

[Unfortunately, that was the moment I had to leave court on Wednesday. That was the end of Part 1 of Myles’s final inquest hearing. I will try to report from Part 2 next month and the coroner’s conclusion in July if I am able].