I was back in court in Bradford today for the second part of Myles Scriven’s inquest. The coroner was hearing from Prevention of Future Deaths witnesses and his final expert.

The coroner’s final witness of fact was Professor Beverley Hunt, who gave evidence from overseas, as she is out of the country at present. She gave her evidence after lunch on Day 4.

There was a slight echo in the line so there was some discussion at the start about clarity of the sound but matters continued. At places I missed content due to sound or speed and have indicated with … or [missed]. A reminder that this is not a transcript but contemporaneous reporting as accurately as I am able to manage.

Professor Hunt gave an affirmation and confirmed in response to questions from the coroner that she works at Guys and St Thomas’ and as part of Kings Health Partners. She is a Consultant in Thrombosis and Haemostasis and a Strategic Lead for Haematology.

The coroner thanked Professor Hunt for her report dated July 2024, and she confirmed that she was originally instructed by his colleague Dr Bell. Prof Hunt confirmed that she had her report with her and had had a chance to refresh her memory as to the report.

The coroner said that he would highlight certain parts of Prof Hunt’s report, relay certain things that had happened and evidence heard in the inquest so far and then Interested Persons may have questions for her.

The coroner introduced the IPs in the room and Prof Hunt asked if the clerk were able to change the camera views to that she would see the whole court.

BH: Thank you. Could I please ask that the clerk change my view, I can only see you and there’s another view where I can see the whole court

C: Who do you want to watch, the court or me? I’ll not be offended.

BH: I just want to see everyone.

C: When I ask questions it will be on me, and when IPs are asking questions it will be on them, does that suit?

BH: That sounds splendid, thank you

C: Can I have the view on me. Right, you have provided your summary earlier on in your report, then asked particular questions, won’t trawl through your whole report, everyone has got that. You express a view on the investigations and care following the diagnosis of VTE, you say 6 week review, 21 October 2022 was good practice and fortuitous for Myles because consultant recognised he was suffering from multiple pulmonary emboli… he was admitted and switched to heparin because the use of rivaroxaban had failed, failed to prevent a further clot. Seriously failed because Myles developed further pulmonary emboli… am going to skip ahead, you then say page 11 having failed rivaroxaban you would have expected a patient to have had the aetiology of his venous thromboembolism explored, then start new long term anticoagulant, most likely Vitamin K and Warfarin… [missed a lot, coroner is reading at speed]

You say you’re concerned Myles was not offered the best care.

And if I just pause there, if I then go to Dr Hardy who was the one who reverted back to the rivaroxaban, which he did on the 25 October and he says this in his response.

I should say as well he now accepts that was a bad decision and he has put on record in the context of everything in this investigation, he’s put on record having had time to consider Professor Hunt’s argument and combination of knowledge of event and tragic outcome, he agrees best course of action would have been to change Myles’s treatment in October 2022, so he accepts he got it wrong.

I believe thrombosis progressed…. August 2022 deep vein thrombosis and October pulmonary embolism sufficiently separate in time to be considered separate events.

Am I right in inferring from that you look on the aetiology of the VTE and PE between August and October as being one single event, as opposed to two separate ones?

BH: So he originally presented with a deep vein thrombosis, passage of time on rivaroxaban in order to develop multiple small pulmonary emboli, could either of had one major event, or continued to produced small amounts of clots breaking off from the deep vein thrombosis and gradually making him more breathless. Suspect was combination, and a few large ones with continued small ones.

C: OK, but in that scenario you’re saying is demonstrated the rivaroxaban was ineffective as a medication?

BH: It failed its job, ongoing thrombotic events, whole point of ongoing anticoagulation isn’t to resolve the clot but to keep it stable, and prevent further deep vein thrombosis, and that clearly failed.

C: Clearly failed, and that was a reasonably available conclusion by the admission in October, is that correct?

BH: Yes

C: Was any other possible conclusion reasonably available, or was the only one that was reasonable available?

BH: The rivaroxaban has failed. It has not prevented ongoing venous thromboembolism.

C: I think the answer to question was there was no other reasonable conclusion?

BH: No

C: And therefore, the necessary conclusion following from that is he should have been put on warfarin?

BH: He needed investigation as to why rivaroxaban had failed ideally, but in that situation, we should switch someone to warfarin. Warfarin I know it has a poor reputation, is the most fantastic anticoagulation, has much better depth of action than rivaroxaban, that was really the only oral option left available to him, to go to warfarin tablet.

C: Now I’m just going to move on, you said your final sentence of paragraph 13: What I find unforgivable on this admission is to discharge Myles from hospital on same medication on which he’d already had a major pulmonary embolism on, not knowing whether he was compliant or not, and not arranging any investigations of aetiology and no follow up at all to check he was compliant. Furthermore, to compound problem, no mention to GP of conversations in hospital about Myles being non-compliant so GP could help Myles… when he presented with shortness of breath in March 2023 the GP would have suspected PE [possible paraphrase towards the end, apologies]. That’s your firmly held opinion, if you can confirm that?

BH: Yes

C: Come back to something not available to you originally, in your opinion final illness and Myles’s death would have been avoided if Myles’s venous thromboembolism was managed better in October admission, if Myles had started warfarin because rivaroxaban had failed was high certainty Myles [missed] led to failed rivaroxaban therapy, thus discharging him home on same medication meant he was high risk of VTE and death. If he was non-compliant GP and family should have been [alerted?] to discuss way forward. [missed question] Your opinion is had he been discharged on warfarin, you’ve said high certainty, highly probably or beyond reasonable doubt or neither?

BH: I think beyond reasonable doubt, because warfarin is such a better anticoagulant, he’d have to go to the clinic regularly and be monitored, would be supervisions as well, if there were any issues with compliance they would have discussions with him, he could have had a dosset box, his mother could have given the medication, I remember she was giving the ADHD medication, but other medication he was looking after himself

C: I specifically asked you not to go into compliance because the evidence I’ve heard is he was compliant

BH: Oh sorry

C: You’ve not had the benefit of evidence. The evidence we’ve heard is he was compliant and that was simply not apprehended by the hospital clinicians as it should have been, if park that for a minute, look physical condition, the VTE and medication.

Assuming he was compliant, assuming he was on warfarin would he have survived if he was put on warfarin in October?

BH: It is s my belief he would have survived, because he would not have had another clot.

C: And that is beyond reasonable doubt?

BH: On the evidence given to me, and my knowledge of medicine, I think beyond reasonable doubt, yes.

C: Right OK. One thing in your initial report, you didn’t appreciate there had been an echocardiogram, but Dr Hardy didn’t see it. You’ve been informed of that, and said made no difference to your report in terms of your conclusions?

BH: Yes

C: Right what Dr Hardy said, he’s given very candid evidence, he said look, the echocardiogram gave some reassurance because it appeared to be normal.

Your evidence is, as far as I think is that’s simply because he was recovering from the previous PE but in fact Dr Hardy said was false reassurance, although he didn’t see it. What he did say which is quite material is this, had he seen the echocardiogram there would have been a review, in 3 months, and on the follow up review would been blood tests, clinical assessment, at that stage showing symptoms of breathlessness, that would have triggered a review of the medication.

So, it’s available to infer had he seen the echocardiogram there would have been a follow up assessment done in late February, which would have had blood tests, clinical assessment, possibly a review of medication at that stage. Now if there had been a review in February, late February, and that had led to a review of medication, would that have saved his life, Myles’s life?

BH: Um so it would depend on what the review showed wouldn’t it, I don’t know what tests Dr Hardy would have done. If he had been seen in late February he may already have been starting to get a little bit breathless, so possibly.

C: So you’re saying possibly would have saved his life?

BH: It’s very vague when you say would have been blood tests done and a clinical review, so it’s difficult to know, but when you do blood tests, especially when you look for factors which are risk factors for thromboembolism, always take couple of weeks to come back, so might have been a delay.

C: Of course, all we can say is we don’t know because he wasn’t assessed?

BH: Yes

C: Now, I’m now going to go on to where you talk in your third question answer, page 14 you talk about the presentation of Myles presenting with shortness of breath in March 2023.

And you talk about the interaction, contact there with GP services, comment on the nature of the examination, you talk about the GP Practice only having cursory notes from October 2022 admission, were not cognisant of lack of investigations, failure of medication and suggestion of Myles being non-compliant.

Number of provisos, you say should he been referred at that time should have had… would have shown another clot and chance anticoagulation that would have saved his life. Am I right inferring was opportunity there, given Myles was in front of clinicians, GPs, that was lost to save his life?

BH: Sadly yes

C: In your opinion when was the last chance, the last time his life could have been saved?

BH: It is that point, his last contact with a medical team, so unfortunately it was that point.

C: If you absent that, when was it physically in terms of nature of his condition, when did it become irreversible? Is it possible to say when it became irreversible?

BH: So if I think through what happened, after that GP appointment, he clearly already had new pulmonary emboli and he continued to have further pulmonary emboli, which eventually led to overwhelming burden of clot in his lungs, which led to his cardiac arrest. We know from the literature it is very difficult to bring people back from overwhelming clots in the lungs.

C: sorry I lost you there, extremely difficult to bring people back from?

BH: An overwhelming burden of clots that leads to cardiac arrest. There’s a lot of data out there showing if you have a heart attack and get defibrillated you can resuscitate people, but people who have had, young people who have had overwhelming burden of clots, it’s very difficult to resuscitate them.

Last few years my centre, had people arrive with cardiac arrest able to put them on [something, didn’t catch, apologies] but we are a unique centre with ability to do that, that is not available in Bradford, so sadly he died from overwhelming clot.

C: What you’re saying is to all practical intents and purposes

BH: Yes, if we look back on his history, when he had the pulmonary emboli in October and echocardiogram in November, he’d clearly got the ability to clear clots, he had normal echocardiogram.

When look at people and how well they clear clot is very variable, 6 months after pulmonary embolism 40% clear clot totally, 40% can’t do any clearance of the clot, and people in between. He actually had very good [missed] system, by which h I mean his ability to break down clots clearly wasn’t bad, so he could still come back from that recurrent episode of breathlessness I think in February 2023

C: He was at the GPs

BH: March 2023

C: He was at the GPs in March, saw Dr Khokar on the 20 March, do you think he could have, I think I’m inferring from what you’re saying, need you to confirm this or contradict this, on 20 March, had he been admitted on that occasion and received appropriate treatment do you think he would have survived?

BH: Oh yes, oh yes

C: And you’re saying that with confidence, I detect from your tone of voice, is that something you’re sure about, probable or possible?

BH: It’s highly probable. He needed a drug to stop him developing further clots.

C: Alright thank you for that, ok I’ll go around the interested persons and see if there’s anything they want to ask about. I think probably it’s you Mr Birch first, isn’t it?

DB: I’m in your hands sir. Good afternoon Professor, my name is Mr Birch I’m asking questions on behalf of the hospital trust. Can you hear me ok?

BH: I can hear you very well, thank you

DB: Just a couple questions from me if I may, noting evidence you just gave to the coroner there about the echo having cleared the clot. Are you able to say whether its natural processes in Myles’s body, or impact of rivaroxaban he’s on at that time, or combination, able to assist us at all to understand that?

BH: Of course. Point of giving an anticoagulant is to stop the clot growing and stop the deep vein thrombosis fully growing up the veins, it’s the new bits of clot that tend to be a little bit fragile, which break off and cause pulmonary emboli. That’s what anticoagulant is meant to do, when look at how one heals from pulmonary emboli, you are very dependent on your [missed] to break down a clot. Some people have quite good ability, others don’t. Fact Myles had normal echocardiogram suggests he had a reasonable ability to break down the clot that had gone to his lungs.

DB: Thank you, that’s very helpful Professor, so not about not growing it, the rivaroxaban is about growing it, the body is about breaking it down

BH: Yes

DB: Thank you. In relation to your evidence, seeking to assist the learned coroner about, you talk about the system being overwhelmed, just trying to find the turn of phrase, in terms of timing again. You explained about March, when hearing you explain matters with reference to the cardiac arrest at that point being very challenging for reasons you explain absent specialist equipment and mechanisms you have in your trust, does it still continue for some period after March if he’d had contact with services his death wouldn’t have occurred at time with correct medication, warfarin or otherwise?

BH: Understand question if he had further contact with medical services after March, he still had potential to be admitted to hospital, to be put on better anticoagulant to stop any further clot forming, that would mean he would probably survive.

C: Can I just ask a question again, is me, Mr Oliver, the coroner. When was the tipping point, when he could have survived, could have recovered from the clot, when was the tipping point where it became irrecoverable?

BH: That’s very difficult, so I can’t say with any certainty. It depends on his emboli and the size of them, I don’t think I can help you here.

C: Just need to be clear what you’re saying, you can’t say with any certainty, are you saying you can’t on balance of probabilities pin down any point?

BH: On balance of probability I cannot pin down a particular point, it would be helpful to know how breathless he was between that March appointment and his death

C: hmmm, ok fine. Right go on Mr Birch

DB: Thank you sir, but on my understanding of your evidence, in terms of you sounding very confident with the point of contact with the GP surgery

C: Was highly probable, not just probable

DB: Thank you sir, yes oh yes highly probable needed drugs to prevent the clot was my shorthand. Sorry Professor, perhaps you nodded there, was that a yes?

BH: Could you ask me the question again?

C: I think you’ve already been asked actually, we’ve got your evidence, don’t get distracted by that

DB: Slightly altered point, same matter, can one say when warfarin is administered, the time for it to take effect…. Is this something you could assist with time after administration of warfarin when it becomes effective to a case of this nature?

BH: If he had been admitted to hospital, NICE Guidance say he has to have a shot of low molecular weight heparin, if pulmonary embolism is suspected, then have a scan, another scan which would show one presumes further clot, so he’d be switched from rivaroxaban to low molecular weight heparin, daily injections. They work immediately, and under cover of the injections he’d be started on warfarin, the low molecular weight heparin would be stopped once he reached therapeutic level with the warfarin. That’s age old practice, we’ve been doing for 30 to 40 years in the national health service, so patient is covered [missed]

C: I’m inferring from that Professor, had he been admitted on 20 March he’d have had effective coagulants administered immediately and that would have probably have saved his life?

BH: Yes

C: Right

DB: Thanks sir. In relation to the rivaroxaban he was on, this was your evidence about the treatment having failed, I assume you have available to you, in your knowledge statistics around the failure rate of rivaroxaban?

BH: It’s very low, I’d say probably less than 1%, but it’s partly low because we, not everyone uses it, they’d only use it when they felt sure wasn’t going to be too much [can’t hear] but definitely I think less than 1%

DB: Struggled with line then, others used it only when

BH: Some conditions where if you suspect for example that the patient might have Antiphospholipid Syndrome, you wouldn’t use it, for this young man when he first presented, with his pulmonary embolism, his deep vein thrombosis, it was appropriate

DB: Thank you, so failure rate less than 1%, noting what you say about patient use it with, those who it is appropriate for such as Myles, failure rate is less than 1% have I understood correctly?

BH: Yes

DB: Within your report, was looking at page 11, within there you reference having seen many patients failing rivaroxaban treatment, stating this is the type of patient I get contacted about, my interpretation being your area of expertise you’re seeing patients because the rivaroxaban has failed, so they’re coming to you for your expertise?

BH: Yes, I see patients who don’t fail rivaroxaban, because I practice medicine, and see patients who do very well, but because of my expertise I get phoned or emailed about patients who fail on rivaroxaban

DB: So haematology support about failure of rivaroxaban, you find yourself in similar role

BH: Yes

DB: I’m mindful of evidence the coroner and court heard, Dr Hardy acknowledging making bad decision but in terms of moment when making decision having haematology advice, despite, with knowledge of discussion with Myles and his mother about compliance, he still had concerns about compliance. In terms of less than 1%, one assumes compliance might be a feature in some of those failing cases?

BH: Yes, it could be

DB: Just finally doctor, is it fair to make observation, acknowledging in this case evidence was Myles was compliant but Dr Hardy having exception otherwise at time, giving reference, won’t have heard evidence in court, he drew parallel to inhalers and patients thinking compliant with medication but not being so, and asking further questions about compliance. Also, your experience Professor in needing to explore with patients the importance of compliance?

BH: Yes, but there were several conversations discussing that. One of things with rivaroxaban is has to be taken with food, get poor absorption if not taken at meal time, other thing one can do is measure the level of rivaroxaban in blood to see if patient obtaining adequate levels, helpful thing to do if have problem and think patient may be non-compliant

DB: Nothing further, thank you sir.

C: Right, think at this stage given nature of evidence appropriate for Paul and David to ask questions

David Black introduces himself

DB: Just wanted to ask about role of whether reasonable expectation of the hospital, with advice of haematology in the record, to have made it consider treatment failure as possibility and administered warfarin with all benefits of monitoring warfarin has, might be useful to reiterate that for us?

BH: Myles had rivaroxaban failure. We have very little evidence from the notes to know why, and the haematology registrar came along and gave a very good opinion, said he’s failed rivaroxaban, he needs some more investigation might have underlying cause, and he ought to be switched to warfarin which is a much better anticoagulant.

DB: Thank you. Trust guidelines at time didn’t have reference to suspected treatment failure, since amended to be consistent with NICE Guidance. Your view on absence at time, whether you’d expect trust to talk about treatment failure or significant failure on trust governance process?

BH: To be fair when look at guidance on managing pulmonary embolism and deep vein thrombosis they heavily concentrate on diagnosis and initial treatment, and they don’t go on to look at what to do if treatment failure, I don’t consider not having advice on treatment failure in guidelines to be a failure of the trust. The management of DVT and PE has got more and more complex over time, so really important the diagnostic strategy is there. And patients are offered follow up with an expert.

We saw very good practice here, respiratory consultant noted short of breath when he came back 6 weeks after his deep vein thrombosis and got him admitted to see if he’d had a pulmonary embolism

DB: Thank you, just wanted to ask about the care of the GP Dr Khokar, was given telephone message Myles was breathless on Thursday, arranged telephone follow up with Myles and his mum Jane involved on Friday. What your view of appropriateness of telephone assessment of Myles given his breathlessness and history?

BH: First of all I have to say I’m not a general practitioner and standard of care needs judged by another GP fully, however if someone has had a PE, gets breathless again, already recognised as having treatment failure, has to be high on diagnosis that having another pulmonary embolism. This GP hampered because he didn’t have adequate information in hospital discharge about questions of compliance, so if that was said to him he would have sent to hospital

DB: When he was seen by Dr Martland, no recorded evidence of physical examination [lists what not done and asks about appropriateness – missed precise wording, apologies]

BH: One of issues nationally about pulmonary embolism is it always gets forgotten by medical practitioners. Thrombosis UK are trying to do a lot of work around raising awareness, anyone with chest symptoms can’t explain must think pulmonary embolism, if you have someone who’s already had one and is then breathless again, you really should be thinking about it.

DB: Thank you.

Then it was over to Paul Scriven.

PS: Good afternoon Professor Hunt, my name is Paul Scriven and I’m the uncle of Myles. The trust in its response, don’t know if you have evidence pack in front of you, includes report of medical divisional director, Dr Desai, keeps referring to 2% not 1%, I’m not going to argue over failure, way its implied is it’s so unusual a consultant may not have known about it, looking after Myles. In your experience would a consultant in respiratory medicine, would they not be aware of failure of rivaroxaban in someone who had had a DVT and a PE?

BH: So I am a consultant in thrombosis and haematosis, I’d expect myself to know, think you need to ask another consultant in respiratory medicine whether they think this doctor should know about failure of rivaroxaban. I would have hoped that would have been considered, but can’t speak for that branch of the profession I’m afraid

PS: OK, if someone came in as Myles did, you’d expect the NICE Guidelines to be available to that person and be used as guidance to determine what should happen in cases of potential recurrences of a DVT?

BH: Yes

PS: And at the time the guidance from NICE was very clear, talked about failure due to non-compliance, which it’s very clear the trust pursued at length, but also talked about looking for any underlying reasons the clot was reoccurring not due to non-compliance. In your scanning of notes and evidence have you seen anything was done at that point to determine whether anything was happening other than on compliance with rivaroxaban?

BH: No, the haematology registrar did say he needed further investigation, unfortunately I didn’t find any evidence anyone took that up. A young man with recurrent clot on rivaroxaban, low frequency, you’d have to start thinking about other causes. Do mention in my report, classically if you have failure on rivaroxaban and history of auto immune disease, know Myles had psoriasis at younger age, we’d automatically be thinking Antiphospholipid Syndrome, another auto immune disease, and Klinefelter Syndrome, another cause of DVT and associated with learning disabilities in some people, but really there isn’t anything in the notes to help me, and I might be wrong on both counts

C: Right just to intervene here, without becoming very arcane and disappearing into theoretical propositions, you were previously quite plain, I invite you to confirm or otherwise, look rivaroxaban had failed, period. He should have been on warfarin, period.

BH: Yes

C: That’s what haematologist recommended

BH: Yes

C: That was available to Dr Hardy, therefore Myles should have been on warfarin and it would have saved his life?

BH: Yes, yes

PS: Professor Hunt do you have access to the documentation?

The coroner explained due to weight restrictions on luggage for Professor Hunt’s flight, and the size of coronial bundles, she did not have the evidence bundle with her, but he suggested Paul says what the evidence says so that she could comment on it.  

PS: In recommendations of trust page 57 of documentation for people in court, says trust accepts expert report of Professor Hunt with the exception of one point, will read to you. Page 12 of your report compliance, when non-compliance suspected important to gain some evidence to support this… measure blood levels of rivaroxaban and trust says trust guidance is based on NICE Guidance that does not recommend measuring blood levels on rivaroxaban…. [missed but Paul asked her view on that]

BH: So I think it’s the version of NICE Guidelines I was involved in, what it says about rivaroxaban levels is there is no need to routinely measure rivaroxaban levels in patients, I don’t think it says anything about not measuring them in someone who is non-compliant or suspect is non-compliant.

PS: You say page 12 should have happened, do you think should have happened to ascertain whether Myles was compliant or not compliant on his rivaroxaban?

BH: If one was investigating him and you wanted to continue rivaroxaban, I think you’d have to prove he was non-compliant. As we were discussing earlier, the haematology registrar came along and said he’s failed rivaroxaban, he needs to go on warfarin, and really that was the step that was required. So really the business of whether he was compliant or not is immaterial, but you could definitely do rivaroxaban levels if you wanted to.

C: Fact is evidence we’ve heard he was compliant, if taken seriously at time would merely have doubled and underscored the need to get him on the warfarin.

BH: Yes

C: Yes

PS: My final question is this, this seems to be quite a 1% 2% people have this particular issue, advice was taken from haematologist who did suggest he took warfarin, would you suggest to prevent future deaths, it might be advisable for such patients to be under the care of a haematologist rather than someone who wasn’t a specialist in haematology?

BH: So if I look at care of venous thromboembolism across NHS England its highly variable, we don’t have enough consultant haematologists with interest in thrombosis and haemostasis … other trusts don’t have consultant haematologists with interest and respiratory and x take care and some of them are marvellous, so I don’t think we could do that ruling because we don’t have sufficient with an interest.

Myles’s family had no further questions. Ms Hayton, legal representative for Dr Hardy had no questions. It was then over to Mr Chawatama representing the GP Practice, Dalton Surgery.

He introduced himself and checked Professor Hunt could hear him, she could.

SC: Just want to ask you about timelines and ability to clear clots, internal page 17 of your report, your addendum of March 2025 you reviewed echocardiogram performed November 2022, said showed an essentially normal heart, in keeping with his recovery from the October PE. Your evidence this afternoon, correct me if I’m mistaken, your evidence has been that Myles had an ability to clear clots, that’s right isn’t it?

BH: Yes, so its highly variable how people clear clots. But the fact he was no longer breathless, had normal echocardiogram strongly suggests he was very good at clearing clots, and most young people are, as you get a bit older you’re less able to clear them.

SC: We know he was discharged from October admission on or around 25 October 2022, and he attends for his echocardiogram on 4 November 2022, and by that time it appears he had demonstrated his ability to clear the clot, now it just so happens the echocardiogram performed on 4 November, is it likely or probable he had cleared his clot maybe a week, couple of weeks before that echocardiogram, is there any way of extrapolating or giving a view on when?

SC: OK, a good guide to how well people are clearing clots is they get less breathless over time and return to normal, we don’t know, we don’t have any evidence from that time when he left hospital to when he had an echocardiogram so I really can’t comment on when or how quickly

SC: Then he is seen by Dr Martland on 20 November, sorry 20 March 2023. The evidence suggests, we know there was no further contact with the medical services until he sadly collapsed, I think it is suggested the breathlessness occurred on or around the day or the day before his collapse which was on the 16 April, about a month after his contact with the GP.

The point I’m trying to get across in a clumsy way, is what is the likelihood if had been emboli or multiple emboli, sorry a clot present on 17 March, that Myles had as he had previously demonstrated cleared that clot in the weeks following his consultations with the GPs?

BH: The problem here is we have no evidence at all, I haven’t heard any family members evidence of how he was after seeing the GPs in March. I see someone putting their hand up?

C: Just continue for the minute, and I’ve a follow up question

BH: On the balance of probabilities in March he was having pulmonary emboli that were making him breathless, and he therefore must have been extending his deep vein thrombosis and bits of it breaking off traveling up to the lungs and gradually making him more breathless.

That process must have continued, then he had some really big clots break off in April, which ultimately led to his demise, does that help you?

SC: As a follow up…

C: No stop, I’d like to ask some questions. He had a predisposition to developing clots, yes?

BH: Yes clearly, because he failed rivaroxaban

C: He failed rivaroxaban, he had predisposition to developing clots, you described echocardiogram 4 November as demonstrating he was recovering, and not recovered but recovering?

BH: Yes

C: And you are working on a model as it were, a mental model that his condition thereafter does not actually finally resolve but his underlying condition creates a disruption [think he said?] thus by 17-20 March he is in a position where he is suffering from a PE, at that point on the balance of probabilities, yes?

BH: Yes, yes

C: That condition going forward from there leads to a fatal clot?

BH: Yes

C: Developing in April, that ultimately kills him, is that right?

BH: Yes correct

C: So that’s your overall model, on the balance of probabilities?

BH: That is my overall model yes

C: Go on Mr Chawatama

SC: You mentioned in your last answer to my question to you, process evident on 17-20 March continued thereafter?

BH: Yes

SC: What is your justification for that opinion? On what evidence do you base that opinion that process continued from 17-20 March, rather than being a fresh event on or around 16 April?

BH: So, I would like to hear from the family about the shortness of breath, but the fact is here he was having pulmonary emboli in March, he must have continued to develop a clot, through to the time in April when he had the final pulmonary embolism.

There is variability with people who have pulmonary emboli, there’s waxes and waning in releasing clots, it’s not a clear process, it varies between individuals, but that time in March was evidence from his symptoms that on the balance of probability he was having pulmonary emboli then.

They would have continued, maybe only one or two small ones in next days and big one at time he died, I don’t know, can’t say, haven’t heard about his breathlessness in that period of time

SC: Thank you sir, that’s my questions

C: To confirm, that remains your model how unfolded from echocardiogram in November thru to attendance with GPs in March, on balance of probabilities?

BH: You’ve beautifully described how I’m thinking and underlying tendency to form clots was clearly variable, so yes it fits in well, thank you

C: Yes, I try to help the court, I think that’s right, unless anyone else has anything else?

PS: Sir can I just clarify what I said on Day 1 about Myles’s breathing?

C: Let me just go back to day one and your evidence. Right now, Professor there’s going to be a question developing, I’m just tracking back to some evidence given a month ago, just want to make sure I’ve got this right.

Paul the note I’ve got of your evidence is after the GP attendance culminating 20 March, his condition remained the same save for developing a slight cough, he, Myles, would not have interpreted this as him getting worse, you said he remained the same but got a cough

PS: Yes, his breathing remained exactly same as the day he presented to the GP until the day he had a slight cough

C: Did you get that?

BH: I did

C: Evidence from family monitoring him at time, in way families do, his condition remained same but latterly developed a cough. Now how does that feed into your model?

BH: So his clot burden probably remained constant over that period of time, until the time of his death, when he got very unwell, the cough would indicate perhaps he was having a few more clots, overall, of similar number.

We have to remember he was pretty good at dissolving clots, may well be was still having little clots and dissolving some of them, he must have had a big clot at the end

C: Can I play back to you what I think you’ve told me as imprinted itself on my mind, after that attendance on 20 March, he’s basically in a point of let’s say stability, but not safe stability, because of what he’s got

BH: Yes

C: He’s holding his own, some clots are dissolving, some are occurring, it’s a stability but not a safe one, latterly he effectively has a catastrophic clot which is what takes him to hospital, is that what you’re describing?

BH: Yes thank you, well said

C: Like I say I try to relay the evidence as I hear it. Right fine, anything arising out of that?

No one had any matters arising so the coroner thanked Professor Hunt for her clear evidence and wished her well for the remainder of her trip and a safe journey home.

Court then took a short break before the second Prevention of Future Deaths witness, Dr Desai, the first Matron McKie being heard before Professor Hunt, and the final one Elizabeth Morley at the end of the day.

[I don’t usually report PFD witnesses but may return to report some of Matron McKie’s evidence as she was involved with Myles’s case, but if I do it wont be until later this week at the earliest.

With thanks to those reading, sharing and my crowdfunders who fund my reporting, it wouldn’t happen without your support, thank you].