All language subtitles for Malpractice.S01E03_EngCP

af Afrikaans
sq Albanian
am Amharic
ar Arabic
hy Armenian
az Azerbaijani
eu Basque
be Belarusian
bn Bengali
bs Bosnian
bg Bulgarian
ca Catalan
ceb Cebuano
ny Chichewa
zh-CN Chinese (Simplified)
zh-TW Chinese (Traditional)
co Corsican
hr Croatian
cs Czech
da Danish
nl Dutch Download
en English
eo Esperanto
et Estonian
tl Filipino
fi Finnish
fr French
fy Frisian
gl Galician
ka Georgian
de German
el Greek
gu Gujarati
ht Haitian Creole
ha Hausa
haw Hawaiian
iw Hebrew
hi Hindi
hmn Hmong
hu Hungarian
is Icelandic
ig Igbo
id Indonesian
ga Irish
it Italian
ja Japanese
jw Javanese
kn Kannada
kk Kazakh
km Khmer
ko Korean
ku Kurdish (Kurmanji)
ky Kyrgyz
lo Lao
la Latin
lv Latvian
lt Lithuanian
lb Luxembourgish
mk Macedonian
mg Malagasy
ms Malay
ml Malayalam
mt Maltese
mi Maori
mr Marathi
mn Mongolian
my Myanmar (Burmese)
ne Nepali
no Norwegian
ps Pashto
fa Persian
pl Polish
pt Portuguese
pa Punjabi
ro Romanian
ru Russian
sm Samoan
gd Scots Gaelic
sr Serbian
st Sesotho
sn Shona
sd Sindhi
si Sinhala
sk Slovak
sl Slovenian
so Somali
es Spanish
su Sundanese
sw Swahili
sv Swedish Download
tg Tajik
ta Tamil
te Telugu
th Thai
tr Turkish
uk Ukrainian
ur Urdu
uz Uzbek
vi Vietnamese
cy Welsh
xh Xhosa
yi Yiddish
yo Yoruba
zu Zulu
or Odia (Oriya)
rw Kinyarwanda
tk Turkmen
tt Tatar
ug Uyghur
Would you like to inspect the original subtitles? These are the user uploaded subtitles that are being translated: 1 00:00:01,160 --> 00:00:02,839 This is 23-year-old Edith Owusu. 2 00:00:02,840 --> 00:00:05,599 One of Rob's patients accidentally overdosed. 3 00:00:05,600 --> 00:00:09,639 He called me and asked me to code that overdose is deliberate. 4 00:00:09,640 --> 00:00:10,959 Why is this going to an inquest? 5 00:00:10,960 --> 00:00:12,039 Just stick to the facts 6 00:00:12,040 --> 00:00:14,359 regarding the treatment you gave Edith, you'll be fine. 7 00:00:14,360 --> 00:00:16,759 Don't do this, please, I'm begging you. Stop it! 8 00:00:16,760 --> 00:00:19,239 I'll tell them you're an addict! I am not an addict! 9 00:00:20,520 --> 00:00:21,679 What happened? 10 00:00:21,680 --> 00:00:25,080 Local GP, Dr Rob Thornbury, got hit by a car in Park Square. 11 00:00:28,960 --> 00:00:33,759 So, the assumption is whoever owns that number 12 00:00:33,760 --> 00:00:37,399 alerted Lucinda to Edith's overdose. 13 00:00:37,400 --> 00:00:39,279 I'd like to invite the founder, 14 00:00:39,280 --> 00:00:41,599 Dr Jubair Singh, to present the award. 15 00:00:41,600 --> 00:00:46,119 The winners of the Outstanding Covid Response Award are... 16 00:00:46,120 --> 00:00:48,599 West Yorkshire Royal Hospital's A&E team. 17 00:00:48,600 --> 00:00:52,039 How about I give you something that's going to help you calm down? 18 00:00:52,040 --> 00:00:54,479 Fetch me four 10mg diazepam tablets. 19 00:00:54,480 --> 00:00:57,879 40mg? You'll knock her out. 20 00:00:57,880 --> 00:00:59,520 I need to get my phone fixed, please. 21 00:01:01,280 --> 00:01:03,519 Rob, they need to know if you dealt with her. 22 00:01:03,520 --> 00:01:05,159 If this goes any further then, trust me, 23 00:01:05,160 --> 00:01:07,320 you'll be the one going down with her. 24 00:01:27,000 --> 00:01:28,360 Shit! 25 00:01:57,560 --> 00:02:01,079 So, Lucinda's phone records finally arrived yesterday. 26 00:02:01,080 --> 00:02:02,439 Right. 27 00:02:02,440 --> 00:02:05,559 I cross-referenced it with the dates she treated opioid overdoses 28 00:02:05,560 --> 00:02:09,319 and, look, the same number that called Lucinda the day Edith died 29 00:02:09,320 --> 00:02:10,959 called her twice on January 7th, 30 00:02:10,960 --> 00:02:14,759 before Alexander Taylor arrived in A&E with a deliberate overdose, 31 00:02:14,760 --> 00:02:18,879 and again, twice, February 23rd, 32 00:02:18,880 --> 00:02:22,199 when Camilla Woodham presented in exactly the same way. 33 00:02:22,200 --> 00:02:24,959 And I checked with the 999 call centre, 34 00:02:24,960 --> 00:02:27,639 both overdoses were called in by that number, 35 00:02:27,640 --> 00:02:29,599 just like Edith. 36 00:02:29,600 --> 00:02:31,439 Well, that IS interesting. 37 00:02:31,440 --> 00:02:33,120 Isn't it? 38 00:02:36,640 --> 00:02:39,999 Did they call before Milo Hanbury came in? Uh, no. 39 00:02:40,000 --> 00:02:42,959 But, I mean, even if we discount Milo for now. 40 00:02:42,960 --> 00:02:47,240 It looks like she's working with someone but... who? 41 00:02:48,760 --> 00:02:50,159 Let's get the notes 42 00:02:50,160 --> 00:02:53,319 for Alexander Taylor and Camilla Woodham, 43 00:02:53,320 --> 00:02:56,679 see if there's anything linking them to each other, 44 00:02:56,680 --> 00:02:58,159 to Lucinda, to Edith. 45 00:02:58,160 --> 00:03:00,359 Already on it. I'm picking them up later this morning. 46 00:03:00,360 --> 00:03:02,879 Steady on, George - you'll have my job next. 47 00:03:02,880 --> 00:03:05,039 Well done. 48 00:03:05,040 --> 00:03:06,759 Right, I better get to this inquest. 49 00:03:06,760 --> 00:03:08,040 Oh, yes. 50 00:03:09,160 --> 00:03:10,639 Right, the facts are, Lucinda, 51 00:03:10,640 --> 00:03:12,479 you had to deal with a gunshot victim, 52 00:03:12,480 --> 00:03:16,439 so you left Edith Owusu in Ramya's capable hands 53 00:03:16,440 --> 00:03:20,039 with a clear management plan, which you, Ramya, followed. 54 00:03:20,040 --> 00:03:23,479 We did everything we could, but this is the tragic result 55 00:03:23,480 --> 00:03:25,799 of a girl trying to take her own life. 56 00:03:25,800 --> 00:03:28,599 Just to warn you, Edith's dad, Sir Anthony, 57 00:03:28,600 --> 00:03:29,879 used to be a barrister, 58 00:03:29,880 --> 00:03:31,319 so he's going to be acting 59 00:03:31,320 --> 00:03:33,599 as the family's legal representation. 60 00:03:33,600 --> 00:03:35,639 I know, I know, it feels daunting, 61 00:03:35,640 --> 00:03:38,359 but, remember, none of you are on trial, OK? 62 00:03:38,360 --> 00:03:41,199 This is just a fact-finding exercise 63 00:03:41,200 --> 00:03:44,039 to help the coroner determine the exact cause of death, 64 00:03:44,040 --> 00:03:46,799 so what you've got to do is stick to the hospital line - 65 00:03:46,800 --> 00:03:48,919 you each did your best to treat Edith, 66 00:03:48,920 --> 00:03:50,599 but these things happen. 67 00:03:50,600 --> 00:03:53,000 Right? Nobody is culpable. 68 00:03:54,440 --> 00:03:57,359 And what's the worst that could happen? 69 00:03:57,360 --> 00:03:59,719 Well, if the coroner concludes it's medical negligence 70 00:03:59,720 --> 00:04:01,039 that's caused Edith's death 71 00:04:01,040 --> 00:04:03,359 then that could open us up to lawsuits from the family, 72 00:04:03,360 --> 00:04:04,839 the police could get involved, 73 00:04:04,840 --> 00:04:07,479 so let's not give them the opportunity. 74 00:04:07,480 --> 00:04:09,599 However, if he rules it's a suicide, 75 00:04:09,600 --> 00:04:13,200 then the hospital will look less responsible. So... 76 00:04:14,920 --> 00:04:16,919 Good luck. Let's get going. 77 00:04:16,920 --> 00:04:17,960 Thank you. 78 00:04:19,480 --> 00:04:22,119 I can see that this is difficult for you, 79 00:04:22,120 --> 00:04:24,120 but when did you last see Edith? 80 00:04:25,880 --> 00:04:27,839 The day she died. 81 00:04:27,840 --> 00:04:31,320 What was your impression of Edith's mental state during those times? 82 00:04:33,760 --> 00:04:37,119 We had no reason to believe she was using drugs. 83 00:04:37,120 --> 00:04:40,039 Was there a hint of suicidal thinking? 84 00:04:40,040 --> 00:04:41,320 No. 85 00:04:42,680 --> 00:04:43,720 None. 86 00:04:44,880 --> 00:04:47,919 Thank you. If you'd wait there, please. 87 00:04:47,920 --> 00:04:50,639 Mrs Roberts, do you have any questions? 88 00:04:50,640 --> 00:04:54,479 Verity Roberts, legal counsel, West Yorkshire Royal Hospital. 89 00:04:54,480 --> 00:04:55,839 When Edith left your home, 90 00:04:55,840 --> 00:04:57,999 did she mention any anxiety about the new job, 91 00:04:58,000 --> 00:05:01,040 any problems with friends or a partner? 92 00:05:02,320 --> 00:05:04,639 Edith didn't have a partner. 93 00:05:04,640 --> 00:05:07,599 She was excited about the new job, 94 00:05:07,600 --> 00:05:11,520 but I don't believe she was trying to kill herself. 95 00:05:12,560 --> 00:05:15,999 I'd like to play part of the 999 call that was made 96 00:05:16,000 --> 00:05:17,639 the night that Edith died, 97 00:05:17,640 --> 00:05:21,919 and if you find that too distressing I can read out a transcript instead. 98 00:05:21,920 --> 00:05:23,039 No, it's fine. 99 00:05:23,040 --> 00:05:24,759 Please, go ahead. 100 00:05:24,760 --> 00:05:26,479 Can we play the recording, please. 101 00:05:26,480 --> 00:05:28,399 I need a... 102 00:05:28,400 --> 00:05:30,999 I need an ambulance to 9 Somerville Road. 103 00:05:31,000 --> 00:05:33,279 My friend, Edith, I think she's tried to kill herself. 104 00:05:33,280 --> 00:05:34,999 OK, who am I speaking to? 105 00:05:35,000 --> 00:05:36,319 And what has Edith done? 106 00:05:36,320 --> 00:05:37,679 I don't know. She's... She's... 107 00:05:37,680 --> 00:05:40,199 I think she's dying, she's not responding. 108 00:05:40,200 --> 00:05:43,159 Please, you need to send someone right away. 9 Somerville Road. 109 00:05:44,440 --> 00:05:46,159 Do you know this friend of Edith's? 110 00:05:46,160 --> 00:05:47,360 No. 111 00:05:48,800 --> 00:05:50,799 No, I don't. Never heard... 112 00:05:50,800 --> 00:05:54,119 I've never heard that voice ever before, but she had many friends. 113 00:05:54,120 --> 00:05:56,079 She was... 114 00:05:56,080 --> 00:05:59,559 She was popular, it was hard to keep up with everyone. 115 00:05:59,560 --> 00:06:03,519 He states very clearly that Edith tried to kill herself. 116 00:06:03,520 --> 00:06:05,799 Is it not possible that during those last days 117 00:06:05,800 --> 00:06:08,439 that Edith hid her drug use and her suicidal thoughts...? 118 00:06:08,440 --> 00:06:10,839 It wasn't suicide. 119 00:06:10,840 --> 00:06:14,639 If I thought for one second Edith intended to harm herself 120 00:06:14,640 --> 00:06:17,599 I would never have left her on her own. 121 00:06:17,600 --> 00:06:18,640 Never. 122 00:06:23,360 --> 00:06:27,479 Edith's overdose was an accident, 123 00:06:27,480 --> 00:06:32,400 and your hospital missed an opportunity to save her life. 124 00:06:34,000 --> 00:06:35,599 I'm sorry. 125 00:06:35,600 --> 00:06:36,880 Thank you. 126 00:06:37,920 --> 00:06:39,440 You may step down now. 127 00:07:20,160 --> 00:07:23,799 The post-mortem indicated Edith was using opioids regularly. 128 00:07:23,800 --> 00:07:26,159 There were multiple puncture marks on her body 129 00:07:26,160 --> 00:07:28,079 consistent with drug injection, 130 00:07:28,080 --> 00:07:30,879 and hair follicle samples contained opioid metabolites, 131 00:07:30,880 --> 00:07:32,919 indicating long-term use. 132 00:07:32,920 --> 00:07:36,439 In your opinion, did opioids contribute to Edith's death? 133 00:07:36,440 --> 00:07:37,799 Yes. 134 00:07:37,800 --> 00:07:41,439 Toxicology and pathology confirm intravenous administration 135 00:07:41,440 --> 00:07:44,720 of the opioid drug fentanyl caused Edith's death. 136 00:07:45,880 --> 00:07:48,240 Had Edith taken a large amount of fentanyl? 137 00:07:49,280 --> 00:07:53,559 We found high levels of fentanyl in Edith's blood. 138 00:07:53,560 --> 00:07:56,639 63.8 micrograms per litre. 139 00:07:56,640 --> 00:07:59,479 So, given the high levels of fentanyl found in Edith's blood, 140 00:07:59,480 --> 00:08:03,199 was the overdose likely to have been deliberate or accidental? 141 00:08:03,200 --> 00:08:06,079 Fentanyl is 50 times stronger than heroin, 142 00:08:06,080 --> 00:08:08,959 but a seasoned drug user like Edith 143 00:08:08,960 --> 00:08:12,639 would know you only need a small amount to feel its effect. 144 00:08:12,640 --> 00:08:15,959 So why did she take so much? 145 00:08:15,960 --> 00:08:19,359 On the other hand, she could easily just be pursuing a greater high 146 00:08:19,360 --> 00:08:21,920 and miscalculated the dose. 147 00:08:23,680 --> 00:08:26,399 Thank you. I have no further questions. 148 00:08:26,400 --> 00:08:27,919 Mrs Roberts? 149 00:08:27,920 --> 00:08:29,959 No, sir. Sir Anthony? 150 00:08:29,960 --> 00:08:31,239 No, sir. 151 00:08:31,240 --> 00:08:34,720 In that case I'd like to thank you, Dr Adeyemi. You may step down. 152 00:08:43,520 --> 00:08:47,960 The next witness I would like to call is Dr Eva Tait. 153 00:09:04,040 --> 00:09:07,079 Dr Tait, would you care to swear or affirm? 154 00:09:07,080 --> 00:09:08,279 I'll swear. 155 00:09:08,280 --> 00:09:11,119 In that case, there is a small card on the ledge in front of you, 156 00:09:11,120 --> 00:09:12,919 if you'd read from that, please. 157 00:09:12,920 --> 00:09:14,639 "I swear by the Almighty God 158 00:09:14,640 --> 00:09:17,039 "that the evidence I give shall be the truth, 159 00:09:17,040 --> 00:09:18,920 "the whole truth, and nothing but the truth." 160 00:09:20,480 --> 00:09:23,159 Thank you, Dr Tait, for taking time out of your maternity leave 161 00:09:23,160 --> 00:09:24,719 to be with us today. 162 00:09:24,720 --> 00:09:26,519 The court much appreciates that. 163 00:09:26,520 --> 00:09:28,239 It's the least I could do. 164 00:09:28,240 --> 00:09:31,239 Now, you were Edith's addiction consultant 165 00:09:31,240 --> 00:09:35,119 at the Guelder Clinic from May to October 2021? 166 00:09:35,120 --> 00:09:36,600 Yes, that's right. 167 00:09:37,760 --> 00:09:43,599 Edith had a complex history of drug misuse, 168 00:09:43,600 --> 00:09:47,079 including cocaine, alcohol and heroin, 169 00:09:47,080 --> 00:09:49,239 which was her main problem. 170 00:09:49,240 --> 00:09:50,600 And she wanted to be free of it. 171 00:09:51,880 --> 00:09:54,279 But she engaged well with the treatment, 172 00:09:54,280 --> 00:09:55,639 and she achieved this. 173 00:09:55,640 --> 00:09:57,959 She was abstinent when she left us. 174 00:09:57,960 --> 00:10:00,479 So, was there any possibility that she could have relapsed? 175 00:10:00,480 --> 00:10:03,279 Well, yes, sadly. 176 00:10:03,280 --> 00:10:06,319 For opiate addicts, their risk of relapse is high. 177 00:10:06,320 --> 00:10:10,519 Particularly now that it's easier to buy synthetic opioids, 178 00:10:10,520 --> 00:10:13,000 such as fentanyl, on the streets. 179 00:10:14,280 --> 00:10:16,879 And when Edith was under your care 180 00:10:16,880 --> 00:10:19,240 did she ever express suicidal tendencies? 181 00:10:20,480 --> 00:10:22,719 Yes. 182 00:10:22,720 --> 00:10:24,439 Erm... 183 00:10:24,440 --> 00:10:26,039 We did extensive work 184 00:10:26,040 --> 00:10:29,159 on her negative thoughts and core beliefs, 185 00:10:29,160 --> 00:10:34,439 but her suicidal ideation remained a prominent problem. 186 00:10:34,440 --> 00:10:36,039 She... 187 00:10:36,040 --> 00:10:38,760 It's OK, take your time. Thank you. 188 00:10:40,960 --> 00:10:42,200 It's very sad. 189 00:10:47,520 --> 00:10:50,479 Why the hell didn't you say you knew Edith from the Guelder Clinic? 190 00:10:50,480 --> 00:10:52,639 Shh, Lucinda, have you forgotten where we are? 191 00:10:52,640 --> 00:10:54,719 We're at the inquest of a girl who died 192 00:10:54,720 --> 00:10:57,839 because Rob prescribed her fentanyl. What the fuck was he thinking? 193 00:10:57,840 --> 00:11:00,319 You can't prove that the fentanyl came from Rob. 194 00:11:00,320 --> 00:11:02,560 Edith could easily have bought it off the street. 195 00:11:03,760 --> 00:11:05,640 He told me he was prescribing her... 196 00:11:09,160 --> 00:11:11,080 He told me he was prescribing her methadone. 197 00:11:13,000 --> 00:11:14,839 She was a patient of YOURS. 198 00:11:14,840 --> 00:11:17,519 No, she was not my patient when she died. 199 00:11:17,520 --> 00:11:19,359 I hadn't seen her for months. 200 00:11:19,360 --> 00:11:20,799 No, Rob specifically called me 201 00:11:20,800 --> 00:11:23,679 because he didn't want anyone looking into his prescribing. 202 00:11:23,680 --> 00:11:26,119 He was covering up what the hell you two were doing. 203 00:11:26,120 --> 00:11:27,320 No, I haven't done anything. 204 00:11:28,480 --> 00:11:31,199 If Rob was prescribing for Edith, I knew nothing about it. 205 00:11:31,200 --> 00:11:32,799 OK, so how did he know them? 206 00:11:32,800 --> 00:11:36,079 How did he know Camilla, Alexander, all the other patients - 207 00:11:36,080 --> 00:11:37,560 is it just a fucking coincidence? 208 00:11:39,120 --> 00:11:42,159 Is it just a coincidence that they were all being treated 209 00:11:42,160 --> 00:11:44,439 at the Guelder Clinic? 210 00:11:44,440 --> 00:11:45,999 I have done nothing wrong, 211 00:11:46,000 --> 00:11:48,719 but you have covered up, what, three overdoses for Rob, 212 00:11:48,720 --> 00:11:50,439 so you're just as implicated now. 213 00:11:50,440 --> 00:11:52,919 He was prescribing legal drugs to addicts. 214 00:11:52,920 --> 00:11:55,159 Yeah - addicts like you. 215 00:11:55,160 --> 00:11:58,759 Listen to you, accusing me and Rob and... 216 00:11:58,760 --> 00:12:01,679 you seem to have forgotten about your own drug habit. 217 00:12:01,680 --> 00:12:04,839 I wonder what the MIU would make of that? 218 00:12:04,840 --> 00:12:07,279 You wouldn't dare. Wouldn't I? 219 00:12:07,280 --> 00:12:09,279 If you don't stop pointing the finger at us 220 00:12:09,280 --> 00:12:10,360 I will have no choice. 221 00:12:11,760 --> 00:12:15,439 And judging by the sound of you, you're due a refill. 222 00:12:15,440 --> 00:12:18,279 If you weren't so busy accusing me 223 00:12:18,280 --> 00:12:20,480 I might have been able to help you. 224 00:12:34,560 --> 00:12:36,559 Tom? 225 00:12:36,560 --> 00:12:37,600 Abi? 226 00:12:52,920 --> 00:12:55,559 I've gone through the A&E notes for Alexander Taylor 227 00:12:55,560 --> 00:12:59,440 and Camilla Woodham, but nothing indicates Lucinda knew them. 228 00:13:03,240 --> 00:13:05,079 How was the inquest? 229 00:13:05,080 --> 00:13:07,319 Oh, you know, long. 230 00:13:07,320 --> 00:13:09,639 None of the RH team even gave evidence today, 231 00:13:09,640 --> 00:13:11,399 so it was just the pathologist, 232 00:13:11,400 --> 00:13:14,799 Edith's psychiatrist from the Guelder Clinic, and her mum. 233 00:13:14,800 --> 00:13:15,959 The Guelder Clinic? 234 00:13:15,960 --> 00:13:17,119 Wait, hold on. 235 00:13:17,120 --> 00:13:18,679 I'm sure... 236 00:13:18,680 --> 00:13:20,639 Oh, yeah, yeah. 237 00:13:20,640 --> 00:13:23,960 Both Camilla and Alexander were detoxed there. 238 00:13:26,160 --> 00:13:28,199 Well, that can't be a coincidence. 239 00:13:28,200 --> 00:13:30,479 Could Lucinda have a connection to the clinic? 240 00:13:30,480 --> 00:13:32,959 Will you go there tomorrow and see what you can find out? 241 00:13:32,960 --> 00:13:34,440 Yeah, yeah. Will do. 242 00:13:43,720 --> 00:13:45,400 Camilla... 243 00:14:18,400 --> 00:14:21,399 In your statement, 244 00:14:21,400 --> 00:14:24,079 you said there weren't any options. 245 00:14:24,080 --> 00:14:27,759 Edith was the most stable patient, she needed to be moved, 246 00:14:27,760 --> 00:14:31,319 so Dr Edwards showed poor clinical judgement, 247 00:14:31,320 --> 00:14:33,079 wasn't able to prioritise, 248 00:14:33,080 --> 00:14:37,320 and delayed Edith's transfer for, what, no reason? 249 00:14:38,640 --> 00:14:40,359 Uh, perhaps, I don't remember. 250 00:14:40,360 --> 00:14:42,199 Really? 251 00:14:42,200 --> 00:14:45,039 You don't recall pressurising Dr Edward's 252 00:14:45,040 --> 00:14:47,719 into prioritising Patient X 253 00:14:47,720 --> 00:14:51,199 because, I quote, "She's just a child," 254 00:14:51,200 --> 00:14:54,079 over Edith who, I quote, 255 00:14:54,080 --> 00:14:55,519 "Was just a junkie?" 256 00:14:55,520 --> 00:14:57,400 No! 257 00:14:58,800 --> 00:15:00,519 Well... 258 00:15:00,520 --> 00:15:04,679 we have a statement from a porter who alleges you did just that. 259 00:15:04,680 --> 00:15:09,639 No, I would never use the word junkie to describe a patient. 260 00:15:09,640 --> 00:15:11,479 That's derogatory. I... 261 00:15:11,480 --> 00:15:15,839 I just wouldn't... I wouldn't use that word. 262 00:15:15,840 --> 00:15:17,119 Hmm. 263 00:15:17,120 --> 00:15:20,039 You know, sometimes facts like that are... 264 00:15:20,040 --> 00:15:22,360 Well, they're hard to remember, aren't they? 265 00:15:23,880 --> 00:15:26,239 No further questions, sir. 266 00:15:26,240 --> 00:15:27,839 Thank you, Sir Anthony. 267 00:15:27,840 --> 00:15:30,079 Mrs Roberts, any questions? 268 00:15:30,080 --> 00:15:31,439 No, sir. 269 00:15:31,440 --> 00:15:32,719 Thank you. 270 00:15:32,720 --> 00:15:34,639 Thank you, Mrs Relph, you're free to go. 271 00:15:34,640 --> 00:15:35,680 Please step down. 272 00:15:40,760 --> 00:15:45,680 Our next witness is Dr Ramya Morgan. 273 00:15:57,280 --> 00:16:00,119 Would you care to swear or affirm? 274 00:16:00,120 --> 00:16:01,280 I'll swear. 275 00:16:02,480 --> 00:16:04,479 Would you like an alternative text? 276 00:16:04,480 --> 00:16:07,159 No, the regular Bible's fine. Thanks. 277 00:16:07,160 --> 00:16:08,359 OK, thank you. 278 00:16:08,360 --> 00:16:11,480 If you would read from the card in front of you, please. 279 00:16:13,160 --> 00:16:14,519 "I swear by Almighty God 280 00:16:14,520 --> 00:16:16,919 "that the evidence I give shall be the truth, 281 00:16:16,920 --> 00:16:19,279 "the whole truth, and nothing but the truth." 282 00:16:19,280 --> 00:16:20,719 Thank you. 283 00:16:20,720 --> 00:16:22,599 Sir Anthony, your witness. 284 00:16:22,600 --> 00:16:23,639 Dr Morgan. 285 00:16:26,200 --> 00:16:28,839 Can you take us through your involvement 286 00:16:28,840 --> 00:16:32,079 in Edith's A&E care? 287 00:16:32,080 --> 00:16:34,199 Um... 288 00:16:34,200 --> 00:16:37,199 I was bleeped to Resus to watch Edith 289 00:16:37,200 --> 00:16:40,799 while Dr Edwards took care of an emergency in reception. 290 00:16:40,800 --> 00:16:42,319 And when she came back 291 00:16:42,320 --> 00:16:45,199 I thought she would continue looking after Edith, 292 00:16:45,200 --> 00:16:50,999 but instead I was told a Patient X needed Edith's bed, 293 00:16:51,000 --> 00:16:53,079 and I was going to Majors with Edith, 294 00:16:53,080 --> 00:16:54,959 and Dr Edwards gave me a treatment plan. 295 00:16:54,960 --> 00:16:57,479 And what was that treatment plan? 296 00:16:57,480 --> 00:17:01,599 Dr Edwards asked me to give 800 micrograms naloxone, 297 00:17:01,600 --> 00:17:04,360 and if Edith's breathing improved, to let her know. 298 00:17:06,240 --> 00:17:07,879 And what happened next? 299 00:17:07,880 --> 00:17:11,199 Well, after the naloxone was given, Edith's respiratory rate improved, 300 00:17:11,200 --> 00:17:12,279 so I returned to Resus. 301 00:17:12,280 --> 00:17:13,799 Leaving Edith alone? 302 00:17:13,800 --> 00:17:15,959 There were other staff around. 303 00:17:15,960 --> 00:17:18,679 But no-one dedicated to her care, correct? 304 00:17:18,680 --> 00:17:20,119 Correct. 305 00:17:20,120 --> 00:17:22,759 Did you consider waiting and observing Edith 306 00:17:22,760 --> 00:17:24,279 to see if the improvement 307 00:17:24,280 --> 00:17:26,639 in her breathing would be maintained? 308 00:17:26,640 --> 00:17:28,159 I waited to see the improvement. 309 00:17:28,160 --> 00:17:30,159 And then you left - immediately? 310 00:17:30,160 --> 00:17:33,280 No, no. Uh, not immediately. 311 00:17:34,520 --> 00:17:36,679 Uh, I can't remember how long I stayed. 312 00:17:36,680 --> 00:17:37,960 Hmm. 313 00:17:39,680 --> 00:17:44,559 Dr Morgan, do you know how quickly the initial effects of naloxone 314 00:17:44,560 --> 00:17:45,640 can wear off? 315 00:17:46,600 --> 00:17:48,639 I now know. 316 00:17:48,640 --> 00:17:53,679 But you didn't know when you prescribed the drug for Edith? 317 00:17:53,680 --> 00:17:54,920 Did you? 318 00:17:56,480 --> 00:18:00,919 How long have you been a qualified doctor? 319 00:18:00,920 --> 00:18:02,039 About 18 months. 320 00:18:02,040 --> 00:18:05,880 How long did Dr Edwards ask you to wait and observe Edith? 321 00:18:07,080 --> 00:18:08,559 I'm not... 322 00:18:08,560 --> 00:18:10,159 I don't remember. 323 00:18:10,160 --> 00:18:13,919 I'm so sorry, could you speak up, so the whole court can hear you. 324 00:18:13,920 --> 00:18:16,519 I don't remember. 325 00:18:16,520 --> 00:18:19,199 And when you returned to Resus, 326 00:18:19,200 --> 00:18:21,320 was Dr Edwards grateful for your... 327 00:18:22,520 --> 00:18:23,720 extra pair of hands? 328 00:18:26,000 --> 00:18:28,279 I don't remember. 329 00:18:28,280 --> 00:18:30,599 Well, let me help you there, shall I? 330 00:18:30,600 --> 00:18:33,439 I'm quoting from her statement - 331 00:18:33,440 --> 00:18:36,479 "When Dr Morgan returned to Resus 332 00:18:36,480 --> 00:18:39,679 "I asked her why she wasn't with the overdosed patient." 333 00:18:39,680 --> 00:18:44,119 So, clearly Dr Edwards wasn't expecting you back, 334 00:18:44,120 --> 00:18:45,199 so I'll ask you again, 335 00:18:45,200 --> 00:18:47,799 why did you leave Edith so quickly and return to Resus 336 00:18:47,800 --> 00:18:49,279 to a different patient, 337 00:18:49,280 --> 00:18:52,799 who was already being handled by doctors with far more experience? 338 00:18:52,800 --> 00:18:55,319 Dr Edwards never said that I needed to stay longer 339 00:18:55,320 --> 00:18:57,319 in case the naloxone stopped working. 340 00:18:57,320 --> 00:19:00,119 I'm sorry, are you saying that Dr Edwards lied? 341 00:19:00,120 --> 00:19:01,239 No, no. 342 00:19:01,240 --> 00:19:03,679 What she said in her written statement was false? 343 00:19:03,680 --> 00:19:06,319 No, but I can only tell you what I remember. 344 00:19:06,320 --> 00:19:07,799 OK. 345 00:19:07,800 --> 00:19:12,199 So, in this hospital, full of competent doctors, 346 00:19:12,200 --> 00:19:15,559 Dr Edwards didn't tell you how long to wait with Edith, 347 00:19:15,560 --> 00:19:19,399 and after 18 months as a qualified medical practitioner 348 00:19:19,400 --> 00:19:21,799 you didn't know how long to wait either. 349 00:19:21,800 --> 00:19:24,159 A&E is really hectic. 350 00:19:24,160 --> 00:19:26,679 And patients turn up all the time with conditions 351 00:19:26,680 --> 00:19:28,559 that you don't know how to treat, 352 00:19:28,560 --> 00:19:33,359 so you have to rely on your seniors for the support to work safely. 353 00:19:33,360 --> 00:19:35,919 OK, so what you're really saying is 354 00:19:35,920 --> 00:19:38,879 that without instructions from a senior 355 00:19:38,880 --> 00:19:41,319 you don't know how to treat an overdose. 356 00:19:41,320 --> 00:19:43,039 No, I didn't say that. 357 00:19:43,040 --> 00:19:45,479 But I'm a junior - I'm there to learn, 358 00:19:45,480 --> 00:19:47,199 and there's a lot to remember. 359 00:19:47,200 --> 00:19:53,639 And after giving only one dose of naloxone to my daughter, 360 00:19:53,640 --> 00:19:55,360 you returned to Resus. 361 00:19:58,080 --> 00:20:02,999 If you'd only waited a few minutes more 362 00:20:03,000 --> 00:20:06,759 you'd have noticed the initial effects of the naloxone wearing off 363 00:20:06,760 --> 00:20:09,159 and been able to administer a second, 364 00:20:09,160 --> 00:20:12,480 potentially life-saving dose, but you left her... 365 00:20:14,960 --> 00:20:19,000 struggling to breathe and under-medicated. 366 00:20:22,400 --> 00:20:26,359 You effectively left Edith to die, didn't you? 367 00:20:26,360 --> 00:20:27,560 Hmm? 368 00:20:32,360 --> 00:20:35,479 No further questions, sir. Thank you. 369 00:20:35,480 --> 00:20:37,839 Mrs Roberts, questions from yourself? 370 00:20:37,840 --> 00:20:39,599 No, sir. 371 00:20:39,600 --> 00:20:42,919 Thank you. You may step down when you're ready. Thank you. 372 00:20:42,920 --> 00:20:47,279 Do you have any idea - any idea - how damaging this is to the trust? 373 00:20:47,280 --> 00:20:51,439 You threw me under the bus as soon as he questioned your competence. 374 00:20:51,440 --> 00:20:52,839 But I didn't know how long to wait. 375 00:20:52,840 --> 00:20:55,439 And you didn't tell me the naloxone would wear off so quickly. 376 00:20:55,440 --> 00:20:57,239 Well, if you'd stayed like I told you, 377 00:20:57,240 --> 00:20:59,239 you would've seen how quickly it wears off. 378 00:20:59,240 --> 00:21:01,839 Instead you came to Resus. You need to control your juniors, Leo. 379 00:21:01,840 --> 00:21:04,359 This has got nothing to do with me. I wasn't there. 380 00:21:04,360 --> 00:21:07,599 Yeah, and you should have been... Hey, come on, guys, guys, come on. 381 00:21:07,600 --> 00:21:08,959 Come on, rein this in. 382 00:21:08,960 --> 00:21:10,559 We can recover from this, 383 00:21:10,560 --> 00:21:13,719 but it is all going to depend heavily on you, Lucinda, 384 00:21:13,720 --> 00:21:16,359 not messing it up this afternoon. 385 00:21:16,360 --> 00:21:19,759 You've got to stick to the script. Have you got that? 386 00:21:19,760 --> 00:21:21,319 Lucinda? 387 00:21:21,320 --> 00:21:22,360 Have you? 388 00:21:24,000 --> 00:21:26,919 I'm an A&E doctor, I'm not a mental health specialist. 389 00:21:26,920 --> 00:21:28,479 Assessing whether a patient 390 00:21:28,480 --> 00:21:31,159 deliberately wanted to kill themselves, 391 00:21:31,160 --> 00:21:34,319 that should be done by a psychiatrist, not me. 392 00:21:34,320 --> 00:21:36,639 But Edith had deliberately overdosed before. 393 00:21:36,640 --> 00:21:39,359 Past behaviour usually predicts future behaviour, 394 00:21:39,360 --> 00:21:41,559 and in cases where intent isn't clear 395 00:21:41,560 --> 00:21:45,439 I always err on the side of caution and code it as deliberate. 396 00:21:45,440 --> 00:21:48,519 This ensures that the patients are reviewed by psychiatry 397 00:21:48,520 --> 00:21:49,840 prior to discharge. 398 00:21:51,920 --> 00:21:53,799 And when did you become aware 399 00:21:53,800 --> 00:21:56,599 that there was a problem with Edith's care? 400 00:21:56,600 --> 00:21:58,719 Shortly after we stabilised Patient X 401 00:21:58,720 --> 00:22:00,999 the alarms in Majors went off. 402 00:22:01,000 --> 00:22:05,239 I ran to Edith, but she was already in respiratory failure. 403 00:22:05,240 --> 00:22:08,720 Edith shortly went into cardiac arrest. 404 00:22:09,880 --> 00:22:12,679 We worked on her for half an hour but we never got her back. 405 00:22:12,680 --> 00:22:15,200 Thank you, Dr Edwards. If you'd wait there, please. 406 00:22:16,640 --> 00:22:18,199 Sir Anthony, your witness. 407 00:22:18,200 --> 00:22:19,880 Thank you, sir. 408 00:22:21,200 --> 00:22:23,879 Dr Edwards, would you say Dr Morgan 409 00:22:23,880 --> 00:22:26,920 is prone to forgetting simple instructions? 410 00:22:29,440 --> 00:22:30,799 Uh... 411 00:22:30,800 --> 00:22:34,119 We're all prone to occasional forgetfulness. 412 00:22:34,120 --> 00:22:37,479 Yes, but it's highly unlikely that a doctor capable of learning 413 00:22:37,480 --> 00:22:42,199 enough facts to pass her finals, with distinction, 18 months prior, 414 00:22:42,200 --> 00:22:44,159 wouldn't remember the simple instructions 415 00:22:44,160 --> 00:22:46,959 of watch, wait, and repeat a dose? 416 00:22:46,960 --> 00:22:50,239 Well, in normal circumstances, yes. 417 00:22:50,240 --> 00:22:52,599 But A&E isn't normal. 418 00:22:52,600 --> 00:22:54,119 And with all due respect, sir, 419 00:22:54,120 --> 00:22:57,479 memorising facts for an exam is very different 420 00:22:57,480 --> 00:22:58,959 to processing information 421 00:22:58,960 --> 00:23:01,719 in a real-life, high-pressure situation. 422 00:23:01,720 --> 00:23:04,119 Yes, but even with all this pressure, 423 00:23:04,120 --> 00:23:07,559 Dr Morgan correctly remembered the more complex details 424 00:23:07,560 --> 00:23:12,039 you gave her vis-a-vis the type of drug and the dose. 425 00:23:12,040 --> 00:23:16,279 Isn't it more likely that your instructions were unclear? 426 00:23:16,280 --> 00:23:17,720 No, because she wasn't listening. 427 00:23:19,080 --> 00:23:22,439 Yes, you said that Dr Morgan wasn't listening, 428 00:23:22,440 --> 00:23:25,119 and your colleague spoke of your reluctance 429 00:23:25,120 --> 00:23:27,959 to leave Edith with her, so why did you? 430 00:23:27,960 --> 00:23:30,559 Because I had no choice and I had to make a decision, that's why. 431 00:23:30,560 --> 00:23:32,720 Yes, you made all the decisions. 432 00:23:34,040 --> 00:23:36,679 You dithered, and Edith... No. No, no. But I didn't... 433 00:23:36,680 --> 00:23:39,879 deteriorated. You chose to leave Edith with a doctor 434 00:23:39,880 --> 00:23:42,519 whose incompetence has been shown today, 435 00:23:42,520 --> 00:23:45,559 and that choice killed her. 436 00:23:48,440 --> 00:23:51,479 Are you not therefore guilty of gross negligence? 437 00:23:51,480 --> 00:23:52,999 Sir, this is NOT a criminal court. 438 00:23:53,000 --> 00:23:54,399 If I may remind counsel, 439 00:23:54,400 --> 00:23:57,199 whilst I understand the emotional distress of this hearing, 440 00:23:57,200 --> 00:24:00,359 he must refrain from accusing witnesses of criminal offences 441 00:24:00,360 --> 00:24:01,560 they're not on trial for. 442 00:24:07,280 --> 00:24:11,400 You treated my daughter without diligence or due care. 443 00:24:14,080 --> 00:24:17,120 A total disregard for the... 444 00:24:20,800 --> 00:24:22,440 for the severity... 445 00:24:24,360 --> 00:24:26,200 of the symptoms. 446 00:24:30,520 --> 00:24:31,680 Erm... 447 00:24:34,240 --> 00:24:37,000 Sir, I apologise. 448 00:24:39,760 --> 00:24:41,240 No further questions. 449 00:24:46,520 --> 00:24:47,920 Thank you. 450 00:24:50,080 --> 00:24:52,680 In that case, I'd like to bring the session to a close. 451 00:24:53,960 --> 00:24:57,320 I'll retire to consider my verdict. 452 00:24:59,480 --> 00:25:03,400 We will reconvene in... three hours. 453 00:25:04,640 --> 00:25:05,800 Thank you. 454 00:25:06,920 --> 00:25:09,359 Thank you, Dr Edwards, you may step down. 455 00:25:09,360 --> 00:25:11,400 And thank you, everyone else, for your time. 456 00:25:34,800 --> 00:25:36,520 Excuse me, Sir Anthony, I just... 457 00:25:38,240 --> 00:25:39,840 I'm very sorry for your loss. 458 00:26:01,000 --> 00:26:04,719 Can I get a bottle of the liquid NightSoothe. 459 00:26:04,720 --> 00:26:06,560 Yeah. Yeah, and... 460 00:26:07,960 --> 00:26:09,880 the one-a-night. 461 00:26:12,160 --> 00:26:16,319 These both contain diphenhydramine, so don't take them both together. 462 00:26:16,320 --> 00:26:17,639 They're sedatives. 463 00:26:17,640 --> 00:26:20,199 Take one tablet at bedtime or a dose of the liquid... 464 00:26:20,200 --> 00:26:22,279 Yeah, I'm a doctor, I know how to take them. 465 00:26:22,280 --> 00:26:23,480 All right, OK. 466 00:26:30,320 --> 00:26:32,560 For fuck sake. 467 00:26:48,040 --> 00:26:50,239 Hello! Hello! 468 00:26:50,240 --> 00:26:51,999 How did it go? Awful. 469 00:26:52,000 --> 00:26:54,959 Let's just say I'm happy to be back on the shop floor. 470 00:26:54,960 --> 00:26:57,559 What are you doing? Are you STILL doing that audit? 471 00:26:57,560 --> 00:27:00,239 I've told you, Oscar, nobody wastes medication in my A&E. 472 00:27:00,240 --> 00:27:01,639 You know that. 473 00:27:01,640 --> 00:27:03,959 Mm, you sure about that? 474 00:27:03,960 --> 00:27:05,919 Mm-hm. Yeah? 475 00:27:05,920 --> 00:27:07,199 What's this? 476 00:27:07,200 --> 00:27:09,759 A patient that Ramya saw with Lucinda. 477 00:27:09,760 --> 00:27:12,759 The patient needed 10, not 40, milligrams of diazepam. 478 00:27:12,760 --> 00:27:15,359 Hang on, are you telling me that Ramya threw away 30mg? 479 00:27:15,360 --> 00:27:18,199 Come on, it might not be Ramya's fault. 480 00:27:18,200 --> 00:27:20,319 Maybe they thought the patient needed that much. 481 00:27:20,320 --> 00:27:23,639 No, Oscar. Absolutely not. 482 00:27:23,640 --> 00:27:26,159 40mg of diazepam for mild sedation? 483 00:27:26,160 --> 00:27:29,599 That sounds like a Ramya cock up, doesn't it? 484 00:27:29,600 --> 00:27:31,759 Listen... Mm? 485 00:27:31,760 --> 00:27:35,039 If you take medication from the store 486 00:27:35,040 --> 00:27:37,279 it is your responsibility to make sure 487 00:27:37,280 --> 00:27:39,879 you take the amount that's actually needed. 488 00:27:39,880 --> 00:27:41,480 I know. Right. 489 00:27:48,960 --> 00:27:51,719 Hi. Hi. Can I help you? 490 00:27:51,720 --> 00:27:54,999 Yes, my name's Dr George Adjei from the Medical Investigation Unit. 491 00:27:55,000 --> 00:27:56,639 We're investigating a doctor 492 00:27:56,640 --> 00:27:59,079 who treated four of your former patients - 493 00:27:59,080 --> 00:28:04,039 Edith Owusu, Camilla Woodham, Alexander Taylor and Milo Hanbury. 494 00:28:04,040 --> 00:28:07,959 One of our doctors? She's called Dr Lucinda Edwards. 495 00:28:07,960 --> 00:28:09,599 She's currently at the RH, 496 00:28:09,600 --> 00:28:12,159 but I was hoping you could tell me if she's ever worked here 497 00:28:12,160 --> 00:28:14,239 or has any connection to the clinic. 498 00:28:14,240 --> 00:28:18,679 The name isn't familiar, but I'll check our staffing records. Thanks. 499 00:28:18,680 --> 00:28:22,119 No, no, she's never worked here. 500 00:28:22,120 --> 00:28:23,239 Oh. 501 00:28:23,240 --> 00:28:26,879 Has the clinic ever received a referral from Dr Edwards? 502 00:28:26,880 --> 00:28:29,599 No. Or have you ever referred any patients to her at the RH? 503 00:28:29,600 --> 00:28:30,839 No, no, there's nothing. 504 00:28:30,840 --> 00:28:32,600 The name isn't anywhere on our system. 505 00:28:34,680 --> 00:28:36,599 OK. Uh... 506 00:28:36,600 --> 00:28:39,519 Could I get copies of the notes for the patients I mentioned? 507 00:28:39,520 --> 00:28:41,159 I'm afraid not. We... 508 00:28:41,160 --> 00:28:43,759 We would written consent from each patient first. 509 00:28:43,760 --> 00:28:45,799 Fine, can you contact and ask? 510 00:28:45,800 --> 00:28:47,519 Of course, yeah. 511 00:28:47,520 --> 00:28:49,119 I'll let you know. Do you have a card? 512 00:28:49,120 --> 00:28:51,399 Oh, sorry. One... 513 00:28:51,400 --> 00:28:55,439 Edith was treated by a Dr Eva Tait - 514 00:28:55,440 --> 00:28:57,519 do you know if any of the others were? 515 00:28:57,520 --> 00:28:58,920 I... I can check. 516 00:29:03,520 --> 00:29:07,279 No, no, they all had different doctors. 517 00:29:07,280 --> 00:29:09,559 Besides, Dr Tait's on maternity leave, 518 00:29:09,560 --> 00:29:11,839 she hasn't worked here for six months. 519 00:29:11,840 --> 00:29:13,079 Right. 520 00:29:13,080 --> 00:29:15,599 I can tell you they were all successfully detoxed 521 00:29:15,600 --> 00:29:17,839 and rehabilitated during their time here. 522 00:29:17,840 --> 00:29:21,079 They were all completely drug free when they were discharged? 523 00:29:21,080 --> 00:29:22,839 Yeah. 524 00:29:22,840 --> 00:29:25,759 We've broken that revolving door addiction-patient tradition 525 00:29:25,760 --> 00:29:27,799 so often perpetuated by the NHS. 526 00:29:27,800 --> 00:29:32,599 Once our clients are discharged, they don't need to come back. 527 00:29:32,600 --> 00:29:34,040 They get what they pay for. 528 00:29:35,680 --> 00:29:39,319 But the patients I mentioned all relapsed and overdosed 529 00:29:39,320 --> 00:29:40,520 after leaving this clinic. 530 00:29:41,920 --> 00:29:43,239 You know Edith Owusu died? 531 00:29:43,240 --> 00:29:46,359 Well, that had nothing to do with the treatment they received here. 532 00:29:46,360 --> 00:29:47,759 Yeah, but... 533 00:29:47,760 --> 00:29:49,959 it's not what they paid for, right? 534 00:29:49,960 --> 00:29:52,760 No complaints have ever been made against the Guelder Clinic. 535 00:29:53,800 --> 00:29:56,119 OK. Not yet, but if you keep focusing 536 00:29:56,120 --> 00:29:59,119 on getting patients out of the door quickly 537 00:29:59,120 --> 00:30:01,559 instead of giving them proper treatment, 538 00:30:01,560 --> 00:30:03,559 it won't take long, will it? 539 00:30:03,560 --> 00:30:05,839 Is that everything? 540 00:30:05,840 --> 00:30:07,160 Yeah, for now. 541 00:30:08,360 --> 00:30:09,679 Thanks. 542 00:30:09,680 --> 00:30:15,319 Edith had taken a large amount of a dangerous opioid, fentanyl. 543 00:30:15,320 --> 00:30:17,279 It's impossible to determine 544 00:30:17,280 --> 00:30:20,039 whether she intended to take her own life, 545 00:30:20,040 --> 00:30:21,600 or whether this was accidental. 546 00:30:23,880 --> 00:30:27,119 Whilst I can find no fault with the doctors' actions in relation 547 00:30:27,120 --> 00:30:29,799 to the outcome of Edith's overdose, 548 00:30:29,800 --> 00:30:31,919 I find it unacceptable that a doctor 549 00:30:31,920 --> 00:30:35,079 working in a high-pressure environment like A&E 550 00:30:35,080 --> 00:30:37,999 should be reliant on instruction from a senior 551 00:30:38,000 --> 00:30:41,359 to correctly treat an opioid overdose. 552 00:30:41,360 --> 00:30:42,879 There is, therefore, 553 00:30:42,880 --> 00:30:46,399 something amiss in the training of junior doctors 554 00:30:46,400 --> 00:30:48,960 within the Royal Hospital's A&E department. 555 00:30:49,920 --> 00:30:51,519 And, as such, I shall write 556 00:30:51,520 --> 00:30:54,039 a prevention of future deaths report 557 00:30:54,040 --> 00:30:57,320 recommending the trust review its medical education programme. 558 00:30:59,720 --> 00:31:02,839 I would like to give a narrative conclusion 559 00:31:02,840 --> 00:31:05,519 that Edith Owusu died 560 00:31:05,520 --> 00:31:09,599 following the self administration of a large quantity of fentanyl, 561 00:31:09,600 --> 00:31:13,439 resulting in cardiac arrest and death. 562 00:31:13,440 --> 00:31:16,559 That is the end of my conclusion. 563 00:31:16,560 --> 00:31:18,759 I would like to thank you for your time, 564 00:31:18,760 --> 00:31:20,960 and please feel free to leave. 565 00:31:39,920 --> 00:31:42,199 Well, that could have been loads worse. 566 00:31:42,200 --> 00:31:44,839 Were you listening to a different verdict? 567 00:31:44,840 --> 00:31:47,919 Thank you so much for all your hard work today, Lucinda. 568 00:31:47,920 --> 00:31:49,039 You really did us proud. 569 00:31:49,040 --> 00:31:50,959 Hey, all right, Mike. Leave it. 570 00:31:50,960 --> 00:31:52,279 She did her best, yeah? 571 00:32:04,040 --> 00:32:05,400 Are you happy now? 572 00:32:06,880 --> 00:32:08,599 Excuse me? 573 00:32:08,600 --> 00:32:11,000 Edith's death wasn't my fault - I assume we're done. 574 00:32:12,240 --> 00:32:14,080 You know that's not how this works. 575 00:32:43,440 --> 00:32:47,079 Oh, mate, you're so lucky you were out of it. 576 00:32:47,080 --> 00:32:48,639 I mean, it was horrendous. Oh, really? 577 00:32:48,640 --> 00:32:51,639 It literally made me feel like the worst doctor in the world. 578 00:32:51,640 --> 00:32:55,079 All I do is try my best, and every time I get shat on. 579 00:32:55,080 --> 00:32:56,599 I mean, what is the point? 580 00:32:56,600 --> 00:32:58,759 Hey, our jobs make a difference. 581 00:32:58,760 --> 00:33:00,359 Do they? Yeah. 582 00:33:00,360 --> 00:33:02,679 OK, how long have you been working on that audit for? 583 00:33:02,680 --> 00:33:05,279 And is it really going to save the department any money? 584 00:33:05,280 --> 00:33:07,759 Yeah, actually, I think it will, yeah. 585 00:33:07,760 --> 00:33:10,479 I don't know. I think you should've recycled last year's audit, 586 00:33:10,480 --> 00:33:11,599 like the rest of us. 587 00:33:11,600 --> 00:33:14,399 It's a tick-box exercise, Oscar, nobody actually cares. 588 00:33:14,400 --> 00:33:16,679 THUMP Being an A&E doctor is a privilege, 589 00:33:16,680 --> 00:33:19,039 and maybe instead of complaining all the time 590 00:33:19,040 --> 00:33:20,239 you should focus on your work 591 00:33:20,240 --> 00:33:22,960 and then you wouldn't make so many mistakes, would ya? 592 00:33:26,720 --> 00:33:29,319 Sorry, what the fuck have I done this time? 593 00:33:29,320 --> 00:33:31,999 Sorry, it may be my bad. 594 00:33:32,000 --> 00:33:34,639 I may have mentioned a dispensing error that you made. 595 00:33:34,640 --> 00:33:36,560 What?! When? 596 00:33:39,640 --> 00:33:41,080 Takes a look at that. 597 00:33:42,680 --> 00:33:45,119 Lucinda told me to get 40mg, 598 00:33:45,120 --> 00:33:48,119 and I even questioned the dose at the time. I said... 599 00:33:48,120 --> 00:33:50,079 I wouldn't worry about this, all right? 600 00:33:50,080 --> 00:33:51,759 Look, look, look, my audits... Oscar... 601 00:33:51,760 --> 00:33:54,279 Listen, my audits aren't about individual mistakes, 602 00:33:54,280 --> 00:33:55,479 they're about saving money 603 00:33:55,480 --> 00:33:59,599 that we're wasting on chucking unused meds, OK? 604 00:33:59,600 --> 00:34:00,959 Beth's going to get over it. 605 00:34:04,640 --> 00:34:06,039 Hmm. 606 00:34:06,040 --> 00:34:09,999 Right, so, Edith, Alexander, Camilla and Milo were all treated 607 00:34:10,000 --> 00:34:12,319 by different doctors at the Guelder Clinic. 608 00:34:12,320 --> 00:34:15,279 Eva Tait wasn't even there when they overdosed, 609 00:34:15,280 --> 00:34:16,679 she was on maternity leave. 610 00:34:16,680 --> 00:34:21,039 So, Lucinda is still the only concrete link we have between them. 611 00:34:21,040 --> 00:34:22,279 Shit. 612 00:34:22,280 --> 00:34:24,159 Well, besides them relapsing 613 00:34:24,160 --> 00:34:26,639 and deliberately overdosing after discharge. 614 00:34:26,640 --> 00:34:29,239 Isn't it odd that they all tried to kill themselves? 615 00:34:29,240 --> 00:34:33,559 And using the same method - I mean, what are the chances? 616 00:34:33,560 --> 00:34:38,239 Isn't it more likely that they came out of treatment 617 00:34:38,240 --> 00:34:42,519 and accidentally overdosed because they'd been off drugs for a while? 618 00:34:42,520 --> 00:34:44,600 But if that were true... 619 00:34:45,680 --> 00:34:48,680 why would Lucinda code them all as deliberate? Look. 620 00:34:52,320 --> 00:34:54,479 Do we have Edith's file here? 621 00:34:54,480 --> 00:34:56,080 Yeah, yeah, sure. 622 00:34:57,200 --> 00:34:58,400 Oh, yeah, here you go. 623 00:34:59,440 --> 00:35:05,320 All right, we asked Lucinda that in her first interview. 624 00:35:06,640 --> 00:35:09,159 And she said she changed this to deliberate 625 00:35:09,160 --> 00:35:11,120 to ensure Edith got a psych review. 626 00:35:13,640 --> 00:35:16,919 She said it again at the inquest, but... 627 00:35:16,920 --> 00:35:18,040 what if she... 628 00:35:19,160 --> 00:35:23,559 What if she just didn't want anyone to know it was an accident? 629 00:35:23,560 --> 00:35:26,279 But what does she stand to gain by coding them as deliberate 630 00:35:26,280 --> 00:35:27,959 if she knew they were accidents? 631 00:35:27,960 --> 00:35:30,879 Because when it's an accident 632 00:35:30,880 --> 00:35:33,440 you look at what caused the accident. 633 00:35:35,720 --> 00:35:36,959 The drugs! 634 00:35:36,960 --> 00:35:38,319 Yes. 635 00:35:38,320 --> 00:35:39,399 The drugs. 636 00:35:39,400 --> 00:35:41,240 We've been focusing on the wrong thing. 637 00:35:43,040 --> 00:35:46,480 Her parents had Edith stop buying street drugs a long time ago. 638 00:35:48,000 --> 00:35:50,680 So... where was she getting them? 639 00:36:08,920 --> 00:36:12,879 We understand your disappointment at the coroner's conclusions. 640 00:36:12,880 --> 00:36:14,680 Edith deserved better. 641 00:36:16,400 --> 00:36:19,759 If those doctors had done their job properly, 642 00:36:19,760 --> 00:36:22,399 Edith would still be alive. 643 00:36:22,400 --> 00:36:24,199 Well... 644 00:36:24,200 --> 00:36:25,919 regarding that, 645 00:36:25,920 --> 00:36:28,799 we would really appreciate your permission 646 00:36:28,800 --> 00:36:33,199 to take a little look around Edith's flat. 647 00:36:33,200 --> 00:36:34,559 What for? 648 00:36:34,560 --> 00:36:39,719 Well, we're looking for anything that might tell us 649 00:36:39,720 --> 00:36:42,759 where she got the drugs she overdosed on. 650 00:36:42,760 --> 00:36:47,839 Are you trying to say that it was Edith's fault that she died? 651 00:36:47,840 --> 00:36:49,399 No, not at all. 652 00:36:49,400 --> 00:36:52,439 We feel there might be potentially something in there 653 00:36:52,440 --> 00:36:57,599 linking Edith to whoever supplied her with the fentanyl 654 00:36:57,600 --> 00:36:58,880 that ended her life. 655 00:37:04,160 --> 00:37:05,999 Hmm... 656 00:37:06,000 --> 00:37:08,879 Is she... behind the mirror? 657 00:37:08,880 --> 00:37:11,199 Nope! 658 00:37:11,200 --> 00:37:13,039 Behind the curtain? 659 00:37:13,040 --> 00:37:15,039 No! 660 00:37:15,040 --> 00:37:17,080 Mummy, Mummy, where are you? 661 00:37:18,200 --> 00:37:21,359 Is she... 662 00:37:21,360 --> 00:37:22,960 on top of the bed? 663 00:37:24,000 --> 00:37:25,519 No. 664 00:37:48,760 --> 00:37:51,159 Hello. Camilla... Camilla, hi. 665 00:37:51,160 --> 00:37:52,999 This isn't Rob. 666 00:37:53,000 --> 00:37:56,559 No, no, I'm the new doctor that took over from Rob. 667 00:37:56,560 --> 00:37:59,280 OK, can we meet at Southern Square? 668 00:38:00,760 --> 00:38:03,680 Yeah, I can meet you there in half an hour. 669 00:38:05,000 --> 00:38:07,759 Right. OK, great. 670 00:38:07,760 --> 00:38:08,840 OK, see you then. 671 00:38:12,080 --> 00:38:13,799 Mummy, come and find me. 672 00:38:13,800 --> 00:38:15,200 Is she... 673 00:38:18,360 --> 00:38:20,759 under the bed? 674 00:38:22,120 --> 00:38:24,439 I haven't been out of the house since the inquest. Please. 675 00:38:24,440 --> 00:38:26,999 Yeah, it's fine. OK, OK. Yeah? 676 00:38:27,000 --> 00:38:28,559 Yeah, yeah. Fine, fine, fine. 677 00:38:28,560 --> 00:38:30,279 Are you going to be good for Daddy? 678 00:38:30,280 --> 00:38:33,159 These are stickers! Oh, she's got stickers for you! 679 00:38:33,160 --> 00:38:35,920 Come show me, what have you got there? 680 00:38:37,680 --> 00:38:40,560 Thank you again so much for this. We really do appreciate it. 681 00:38:42,040 --> 00:38:44,999 OK, so, this key is for the front door 682 00:38:45,000 --> 00:38:49,119 and this key is to Edith's flat - Flat B. 683 00:38:49,120 --> 00:38:50,639 You're not coming in? 684 00:38:50,640 --> 00:38:54,079 Uh... it's too difficult. 685 00:38:54,080 --> 00:38:57,759 Just put the key through the letterbox when you're done. 686 00:38:57,760 --> 00:38:58,800 Thank you. 687 00:39:11,520 --> 00:39:12,959 Did you remember gloves? 688 00:39:12,960 --> 00:39:14,440 Oh. Yes. 689 00:39:20,600 --> 00:39:24,239 Um, well, I'll take this room and the kitchen, 690 00:39:24,240 --> 00:39:27,079 and you take that first bedroom on the way in, 691 00:39:27,080 --> 00:39:29,639 and the middle one, and that bathroom. 692 00:39:29,640 --> 00:39:31,480 Yes, boss. All right. 693 00:39:44,920 --> 00:39:46,800 Excuse me, uh, Camilla? 694 00:39:48,800 --> 00:39:50,760 Yeah. Jesus fucking Christ. 695 00:39:54,920 --> 00:39:56,240 Jesus... 696 00:39:58,000 --> 00:39:59,399 We've actually met before. 697 00:39:59,400 --> 00:40:02,360 I treated you a couple of months ago in A&E. 698 00:40:04,280 --> 00:40:05,640 OK. 699 00:40:07,440 --> 00:40:10,279 Well, I don't pay this much to be kept waiting, so... 700 00:40:10,280 --> 00:40:11,840 Oh, of course. 701 00:40:18,800 --> 00:40:22,039 Fentanyl, 50 patches, enough for a month. 702 00:40:22,040 --> 00:40:23,159 Did you say a month? 703 00:40:23,160 --> 00:40:24,880 Yeah, that's what Rob prescribes me. 704 00:40:32,800 --> 00:40:34,759 There's a week prescription. 705 00:40:34,760 --> 00:40:36,239 A week? 706 00:40:36,240 --> 00:40:37,839 What the fuck am I meant to do with that? 707 00:40:37,840 --> 00:40:39,879 I don't know. You figure it out. 708 00:40:39,880 --> 00:40:42,599 You're either going to take it or leave it. 709 00:40:44,800 --> 00:40:47,479 How do you pay Rob? Do you pay him here or later? 710 00:40:47,480 --> 00:40:49,999 I pay the pharmacy, like I usually do. 711 00:40:50,000 --> 00:40:51,440 See ya. 712 00:41:54,920 --> 00:41:56,720 Norma! 713 00:41:57,960 --> 00:42:00,560 Right, are you ready for some dinner, darling? 714 00:42:01,920 --> 00:42:03,240 What are you doing? 715 00:42:05,840 --> 00:42:08,120 Eh, Abi? 716 00:42:14,640 --> 00:42:16,480 Abi? 717 00:42:40,800 --> 00:42:42,160 Come on, come on! 718 00:42:53,320 --> 00:42:54,600 Come on, move! 719 00:43:08,080 --> 00:43:10,039 Help in bay four, please. 720 00:43:10,040 --> 00:43:11,440 Help, please, help. 721 00:43:14,360 --> 00:43:15,920 Here. 722 00:43:17,520 --> 00:43:18,879 Tom? She's not... 723 00:43:18,880 --> 00:43:22,359 She wasn't breathing, she was just lying there. OK, OK. 724 00:43:22,360 --> 00:43:24,879 Just calm down, take a breath. Now tell me what happened. 725 00:43:24,880 --> 00:43:26,359 I think she got hold of some... 726 00:43:26,360 --> 00:43:27,559 some diazepam. 727 00:43:27,560 --> 00:43:29,719 Can you page ITU now, please? 728 00:43:29,720 --> 00:43:30,999 Is she going to be OK? 729 00:43:31,000 --> 00:43:32,799 Are you sure it was diazepam? 730 00:43:32,800 --> 00:43:37,679 Yeah, there was an empty strip of 10mg tablets lying next to her. 731 00:43:37,680 --> 00:43:41,799 Why do you have that strength of diazepam lying around the house? 732 00:43:41,800 --> 00:43:43,279 I had a... 733 00:43:43,280 --> 00:43:45,799 a shoulder injury. I had a prescription. 734 00:43:45,800 --> 00:43:47,759 OK, and how many tablets were left in the strip? 735 00:43:47,760 --> 00:43:50,239 I don't know, maybe a couple. OK. 736 00:43:50,240 --> 00:43:53,119 Is she going to be OK? Even if there was only one... Yeah, OK. 737 00:43:53,120 --> 00:43:56,319 Tell me she's not going to die. We're going to need flumazenil. 738 00:43:56,320 --> 00:43:58,999 Beth, could you give her 120 micrograms over 15 seconds 739 00:43:59,000 --> 00:44:00,999 and set up an infusion, please. Thank you. 740 00:44:01,000 --> 00:44:02,359 She's not going to die, is she? 741 00:44:02,360 --> 00:44:04,959 She's going to be fine. She's not going to die, is she? 742 00:44:04,960 --> 00:44:07,119 Need airways securing? Yes, please, thank you, Sam. 743 00:44:07,120 --> 00:44:10,039 And could someone take Tom to the relatives' room, please? 744 00:44:10,040 --> 00:44:11,960 Come on, it's just this way. 745 00:44:22,000 --> 00:44:23,519 Luce, it's Tom. 746 00:44:23,520 --> 00:44:27,599 You have to come... Come to the hospital. We're in A&E. 747 00:44:27,600 --> 00:44:29,799 It's Abi, she's really sick, right? 748 00:44:29,800 --> 00:44:32,479 So just come... come to the hospital. 749 00:44:32,480 --> 00:44:34,320 Call me back. Call me... 750 00:44:46,960 --> 00:44:48,199 Hi. 751 00:44:48,200 --> 00:44:50,199 Hey, are you all right? How can I help? 752 00:44:50,200 --> 00:44:54,439 The young lady who was just in here, I'm her GP. 753 00:44:54,440 --> 00:44:57,319 Erm, what young lady? 754 00:44:57,320 --> 00:45:01,119 The one who just paid you for her fentanyl prescription. 755 00:45:01,120 --> 00:45:04,439 She paid the normal NHS prescription charge, 756 00:45:04,440 --> 00:45:05,919 like everybody else, so... 757 00:45:05,920 --> 00:45:08,120 I know she paid you extra. 758 00:45:10,680 --> 00:45:13,719 Can I speak to your manager, please? 759 00:45:13,720 --> 00:45:16,720 I don't want to cause any trouble, I would just like to meet them. 760 00:45:18,480 --> 00:45:21,720 Right, yeah. Wait here. Thank you. 761 00:45:25,800 --> 00:45:29,160 Luce, just pick up your phone. Why aren't you picking up? 762 00:45:31,920 --> 00:45:33,960 Fucking... 763 00:46:11,680 --> 00:46:14,639 Luce, it's Tom. Pick up your phone. 764 00:46:14,640 --> 00:46:17,719 Call me back. Something's happened. 765 00:46:17,720 --> 00:46:19,679 Right, you can come through to the back. 766 00:46:19,680 --> 00:46:21,919 Pick up your phone, it's Abi. She's not well. 767 00:46:21,920 --> 00:46:24,479 OK? Just come to the hospital. Are you all right? Abi... 768 00:46:24,480 --> 00:46:26,639 Abi's not well. She's taken some pills. 769 00:46:26,640 --> 00:46:28,999 Lucinda, it's Beth, I need you to come into the hospital. 770 00:46:29,000 --> 00:46:31,159 Call me back. He's waiting for you in the back. 771 00:46:31,160 --> 00:46:33,359 Pick up your fucking phone. It's Abi. Hello? 772 00:46:33,360 --> 00:46:34,759 Lucinda, it's Leo here... 773 00:46:34,760 --> 00:46:36,239 Do you want me to go and get him? 774 00:46:36,240 --> 00:46:37,559 I need you to come to the hospital 775 00:46:37,560 --> 00:46:39,519 as quickly as you possibly can, please. 776 00:46:39,520 --> 00:46:41,640 Abi's not well, come to the hospital now. 777 00:47:31,120 --> 00:47:34,480 Subtitles by accessibility@itv.com 59417

Can't find what you're looking for?
Get subtitles in any language from opensubtitles.com, and translate them here.