When we walked into the court’s waiting room for my father’s inquest I was asked if we had a barrister coming? I replied no. I can’t remember the exact response, but it was along the lines of an expensive waste, these things are better settled without them. By the time we left that court I disagreed wholeheartedly with this statement; if you are seeking justice then engage a barrister.
I wasn’t seeking justice, my father’s death, although unexpected, was caused by a combination of factors which weren’t all preventable. My issue was the care he received during his stay in Cheltenham Hospital and their seeming eagerness to despatch him to another hospital over the Christmas period. After his death, I initially said no to involving a coroner, even though I’d expressed concerns about the necessity of transferring him back to Cirencester. I was also concerned about an incident during his recovery which my aunt had witnessed but I couldn’t get any information from the hospital about it. After discussion with my father’s doctor in Cirencester, I agreed to ask for an inquest into the circumstances of my father’s death
Up until now my knowledge of how investigations of death are conducted has been gleaned mainly from various TV programmes. In our case no crime had been committed, there was no indication that medical negligence had occurred during his operation, one nurse had even prevented him being sent home as he had no one to care for him (prior to being hospitalised for a swollen leg he had lived independently). My concern was his aftercare in Cheltenham and the ordeal of enduring an ambulance transfer to Cirencester, only for him to be sent back to Cheltenham who told me there was nothing wrong with my father and insisted he was returned to Cirencester, all within forty-eight hours.
Speaking to the coroner’s clerk I was persistently told that it was not their role to ‘blame’ anyone. They would gather evidence to present to the coroner who would decide if any issues occurred that caused my father additional suffering. This process was expected to take six months. I could also raise a separate complaint with Cheltenham. My father died on January 1st so we were looking at June/July for the inquest.
Reports started to be sent to me, most were handwritten, others were typed statements after the event. Doctors were mainly locums who were no longer working in Cheltenham. Extra statements were requested. Time passed, and nothing appeared to happen. Finally, in October we received the missing statements. The preliminary hearing was set for December.
A couple of weeks before the preliminary hearing I received a response from Cheltenham. It was not helpful. My query about the incident my aunt had witnessed was dismissed as the doctor I’d named (using reports) was not on duty. My discussion with three nurses was unrecorded, only that I’d agreed to transfer. I had only agreed as I had been told there was no nursing cover in Cheltenham, as the ward was empty, except for one able patient, I felt pressured to allow the transfer.
In December we had the preliminary hearing where a representative from Cheltenham hospital had a vast file with documents we had no access to. There were no records of the ambulance trips. It was agreed a full inquest would be held, calling witnesses, in March, no later than April. As I was on holiday in May I gave dates. Afterwards, I spoke with the lady from Cheltenham who shown me the nurse’s report at the time of the incident, it had a blood sugar level of 24, the highest reading I’d ever seen for Dad. The lady, who said she was a former nurse, was surprised at my reaction. She also told me that the hold-up was not due to Cheltenham, showing me reports sent in April. When I got home I checked and the missing reports from doctors working in Cheltenham were dated September.
When the date came through it wasn’t March or even April, but the day before I was due to go on holiday. Christmas was difficult, as was the anniversary of his death. My father’s birthday was the end of March and the anniversary of my mother’s death, now five years ago, was in April. By now I had the answers to my questions. My father had suffered a diabetic-related seizure which affected his recovery. Instead of being cared for in hospital he was subjected to travelling around Gloucestershire. It seems that the journey back to Cheltenham was late and he spent the night in Gloucester before being transferred to Cheltenham in the morning, hence my being called on Boxing Day morning with the gruff, ‘I was told to call you when he arrived, and he’s just arrived.’ After a brief medical procedure, he was deemed ‘fit’ by a doctor to return to Cirencester.
The court is a proper courtroom, without a jury. The judge sat high above us and it was an intimidating atmosphere. We were limited to the events we could talk about. I should emphasise that I received no support from the court during the procedure and I quickly felt out-of-my-depth.
The doctor from Cheltenham referred to my father as ‘elderly and frail’. I objected to the phrase as I felt it misleading, my father had been living independently and had been recovering prior to the incident, after which he declined rapidly. My objection was overruled, and the doctor continued to use the phrase. His registrar had arranged to send him to Cirencester and had seen him on Boxing Day, he was a young man and very nervous. He mentioned my father’s cancer, which unknown to us had returned, I tried to highlight he had been clear for thirteen years and we were unaware it had returned. He denied noting delirium in my father’s behaviour. He also claimed to have seen that my father had received a fluid drip in A&E but was unsure when. As he’d arrived with a swollen leg due to fluids it was very unlikely they would have pumped more fluids into him. (Later I would realise he referred to the visit we made in the early part of the year after my father suffered from gastroenteritis, way out of time range).
When it came to explaining the Christmas Day/Boxing Day journey, suddenly the lady from Cheltenham hospital jumped up to show reports she had obtained from ambulance drivers’ records. At no time was I shown these reports. The judge muttered there were in order. It seemed strange that a year after asking these reports they were suddenly available but had not been supplied prior to this hearing.
Only the anomaly with his blood sugar remained to be questioned. I took the stand to introduce the subject. Immediately the lady from Cheltenham was on her feet again, she knew exactly what I was referring to and showed records to prove that no such level had been recorded. It was my word, that I was willing to take an oath for, against hers. She was not called on to take an oath. Once again, the judge accepted her report.
Weirdly I felt the judge’s wording of her decision concentrated more on the cause of death, which we were not disputing, then the suffering my father endured. She even repeated the phrase ‘elderly and frail’ to me. In his statement, the doctor from Cirencester had stated that as there was no overnight doctor cover in Cirencester he’d decided not to admit my father but return him to Cheltenham. He mentioned signs of deliria and that he didn’t expect him to return so swiftly. She appeared to ignore the evidence from this Cirencester doctor.
In hindsight, I would use a legal representative if I ever have to go through this process again. However, even though it was not recognised in court I believe I obtained the answers to my questions. I am sorry for any future patients that I fail to change Cheltenham’s policy regarding the clearing of their wards for Christmas and not showing the simple generosity of allowing families to enjoy what may be their loved one’s last Christmas with them.
Recently Doctor Goodall made the news. He was 104 years old, articulate, active and living independently when he had a fall. He was told that from now on he needed care and could no longer live alone. A fiercely independent man who felt he’d had a good life, he was unwilling to submit to his inevitable decline so opted to go to Switzerland and end his own life. I know my father never wanted to go into a home and be dependent on others. Nor would he have been strong enough to survive cancer a third time. Doctor Goodall’s decision has helped me come to terms with my father’s death.