Ah I've found what I was looking for -
[
BBM]
Two examples
Mother A - pg 23/24 -
Q. What we know -- and, my Lady, we see at page 38 in our bundle --
the reply from the coroner to your solicitors: "Thank you for your letter which arrived whilst I was attending a conference. I too was disappointed with the brevity of the report which I received. However, I have no power to order a hospital to conduct an investigation and still less give directions as to the nature and extent of any investigation that is undertaken." Later on, it continues: "I'll not be adjourning the inquest next week; it would be inappropriate for me to do so. As you know, the Consultant Paediatric Pathologist was unable to determine the cause of death.
It is to be hoped that the Pathologist with the benefit of hearing the clinical evidence may be able to give an opinion as to the cause of death, although we will have to wait and see whether this turns out to be the case."
Mother C - pg 120/121 -
Q. Suggestions and recommendations. You say you think that there should have been greater analysis of unexpected deaths where no clear cause had been found on post-mortem.
A. Yeah.
Q. Have you given any further thought to how that can be ensured that that takes place, or whether patients should have a voice in seeing whether that's taken place, or anything like that?
A. I think it's difficult to say, without knowing the ins and outs of all of the specific processes that exist at the moment, but what I will say is, you know, there was some discussion and debate at the time between the pathologist and John Gibbs as to whether the findings on the post-mortem were the cause of the collapse, or the consequence of it. And with there being several strange answers on post-mortem reports, or unusual answers such as "unascertained" or, you know, prematurity being given as a cause, I feel like there should have been something that tied all these together as being an unusual collection of events, rather than looking at each one individually; looking with greater scrutiny at the picture as a whole, however that can happen.
Q. You also say: "I do not understand why the coroner's office did not recognise the increase in deaths as being an unusual peak, especially when taken in the context of post-mortem findings that were not 'typical' and clinical details that showed the sudden and unexpected nature of the deaths.
When someone dies in hospital the post-mortem is conducted to establish a natural cause of death even in cases of unexpected death. I feel this needs to change to include toxicology and a greater index of suspicion for all unexpected deaths in hospital."
A. Yes.
Q. Would you like to add to that all, or does it speak for itself?
A. I think it speaks for itself, really. You know, I think it's very sad that we have to consider that somebody could come to deliberate harm in a healthcare setting, but unfortunately this isn't the first, and it won't be the last, time that that occurs.
So the index of suspicion needs to be higher.
Transcript of Part A Evidence: Mother A & B, Mother C
thirlwall.public-inquiry.uk
