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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
00:00:19,240 --> 00:00:20,519
CAR BRAKES SCREECH
10
00:00:20,520 --> 00:00:21,679
What happened?
11
00:00:21,680 --> 00:00:25,080
Local GP, Dr Rob Thornbury,
got hit by a car in Park Square.
12
00:00:28,960 --> 00:00:33,759
So, the assumption is
whoever owns that number
13
00:00:33,760 --> 00:00:37,399
alerted Lucinda
to Edith's overdose.
14
00:00:37,400 --> 00:00:39,279
I'd like to invite the founder,
15
00:00:39,280 --> 00:00:41,599
Dr Jubair Singh,
to present the award.
16
00:00:41,600 --> 00:00:46,119
The winners of the Outstanding
Covid Response Award are...
17
00:00:46,120 --> 00:00:48,599
West Yorkshire
Royal Hospital's A&E team.
18
00:00:48,600 --> 00:00:52,039
How about I give you something
that's going to help you calm down?
19
00:00:52,040 --> 00:00:54,479
Fetch me four 10mg diazepam tablets.
20
00:00:54,480 --> 00:00:57,879
40mg? You'll knock her out.
21
00:00:57,880 --> 00:00:59,520
I need to get
my phone fixed, please.
22
00:01:01,280 --> 00:01:03,519
Rob, they need to know
if you dealt with her.
23
00:01:03,520 --> 00:01:05,159
If this goes any further
then, trust me,
24
00:01:05,160 --> 00:01:07,320
you'll be the one
going down with her.
25
00:01:13,680 --> 00:01:15,960
SHE MUTTERS
26
00:01:19,800 --> 00:01:21,720
SHE SIGHS
27
00:01:27,000 --> 00:01:28,360
Shit!
28
00:01:40,440 --> 00:01:45,800
SHE BREATHES DEEPLY
29
00:01:55,640 --> 00:01:57,559
HE KNOCKS
30
00:01:57,560 --> 00:02:01,079
So, Lucinda's phone records
finally arrived yesterday.
31
00:02:01,080 --> 00:02:02,439
Right.
32
00:02:02,440 --> 00:02:05,559
I cross-referenced it with the dates
she treated opioid overdoses
33
00:02:05,560 --> 00:02:09,319
and, look, the same number that
called Lucinda the day Edith died
34
00:02:09,320 --> 00:02:10,959
called her twice on January 7th,
35
00:02:10,960 --> 00:02:14,759
before Alexander Taylor arrived
in A&E with a deliberate overdose,
36
00:02:14,760 --> 00:02:18,879
and again, twice, February 23rd,
37
00:02:18,880 --> 00:02:22,199
when Camilla Woodham presented
in exactly the same way.
38
00:02:22,200 --> 00:02:24,959
And I checked
with the 999 call centre,
39
00:02:24,960 --> 00:02:27,639
both overdoses
were called in by that number,
40
00:02:27,640 --> 00:02:29,599
just like Edith.
41
00:02:29,600 --> 00:02:31,439
Well, that IS interesting.
42
00:02:31,440 --> 00:02:33,120
Isn't it?
43
00:02:36,640 --> 00:02:39,999
Did they call before
Milo Hanbury came in? Uh, no.
44
00:02:40,000 --> 00:02:42,959
But, I mean,
even if we discount Milo for now.
45
00:02:42,960 --> 00:02:47,240
It looks like she's working
with someone but...who?
46
00:02:48,760 --> 00:02:50,159
Let's get the notes
47
00:02:50,160 --> 00:02:53,319
for Alexander Taylor
and Camilla Woodham,
48
00:02:53,320 --> 00:02:56,679
see if there's anything
linking them to each other,
49
00:02:56,680 --> 00:02:58,159
to Lucinda, to Edith.
50
00:02:58,160 --> 00:03:00,359
Already on it. I'm picking them up
later this morning.
51
00:03:00,360 --> 00:03:02,879
Steady on, George -
you'll have my job next.
52
00:03:02,880 --> 00:03:05,039
Well done.
53
00:03:05,040 --> 00:03:06,759
Right, I better get to this inquest.
54
00:03:06,760 --> 00:03:08,040
Oh, yes.
55
00:03:09,160 --> 00:03:10,639
Right, the facts are, Lucinda,
56
00:03:10,640 --> 00:03:12,479
you had to deal
with a gunshot victim,
57
00:03:12,480 --> 00:03:16,439
so you left Edith Owusu
in Ramya's capable hands
58
00:03:16,440 --> 00:03:20,039
with a clear management plan,
which you, Ramya, followed.
59
00:03:20,040 --> 00:03:23,479
We did everything we could,
but this is the tragic result
60
00:03:23,480 --> 00:03:25,799
of a girl
trying to take her own life.
61
00:03:25,800 --> 00:03:28,599
Just to warn you,
Edith's dad, Sir Anthony,
62
00:03:28,600 --> 00:03:29,879
used to be a barrister,
63
00:03:29,880 --> 00:03:31,319
so he's going to be acting
64
00:03:31,320 --> 00:03:33,599
as the family's
legal representation.
65
00:03:33,600 --> 00:03:35,639
I know, I know, it feels daunting,
66
00:03:35,640 --> 00:03:38,359
but, remember,
none of you are on trial, OK?
67
00:03:38,360 --> 00:03:41,199
This is just a fact-finding exercise
68
00:03:41,200 --> 00:03:44,039
to help the coroner
determine the exact cause of death,
69
00:03:44,040 --> 00:03:46,799
so what you've got to do
is stick to the hospital line -
70
00:03:46,800 --> 00:03:48,919
you each did your best
to treat Edith,
71
00:03:48,920 --> 00:03:50,599
but these things happen.
72
00:03:50,600 --> 00:03:53,000
Right? Nobody is culpable.
73
00:03:54,440 --> 00:03:57,359
And what's the worst
that could happen?
74
00:03:57,360 --> 00:03:59,719
Well, if the coroner concludes
it's medical negligence
75
00:03:59,720 --> 00:04:01,039
that's caused Edith's death
76
00:04:01,040 --> 00:04:03,359
then that could open us up
to lawsuits from the family,
77
00:04:03,360 --> 00:04:04,839
the police could get involved,
78
00:04:04,840 --> 00:04:07,479
so let's not give them
the opportunity.
79
00:04:07,480 --> 00:04:09,599
However, if he rules it's a suicide,
80
00:04:09,600 --> 00:04:13,200
then the hospital will look
less responsible. So...
81
00:04:14,920 --> 00:04:16,919
Good luck. Let's get going.
82
00:04:16,920 --> 00:04:17,960
Thank you.
83
00:04:19,480 --> 00:04:22,119
I can see that
this is difficult for you,
84
00:04:22,120 --> 00:04:24,120
but when did you last see Edith?
85
00:04:25,880 --> 00:04:27,839
The day she died.
86
00:04:27,840 --> 00:04:31,320
What was your impression of Edith's
mental state during those times?
87
00:04:33,760 --> 00:04:37,119
We had no reason to believe
she was using drugs.
88
00:04:37,120 --> 00:04:40,039
Was there a hint
of suicidal thinking?
89
00:04:40,040 --> 00:04:41,320
No.
90
00:04:42,680 --> 00:04:43,720
None.
91
00:04:44,880 --> 00:04:47,919
Thank you.
If you'd wait there, please.
92
00:04:47,920 --> 00:04:50,639
Mrs Roberts,
do you have any questions?
93
00:04:50,640 --> 00:04:54,479
Verity Roberts, legal counsel,
West Yorkshire Royal Hospital.
94
00:04:54,480 --> 00:04:55,839
When Edith left your home,
95
00:04:55,840 --> 00:04:57,999
did she mention any anxiety
about the new job,
96
00:04:58,000 --> 00:05:01,040
any problems with friends
or a partner?
97
00:05:02,320 --> 00:05:04,639
Edith didn't have a partner.
98
00:05:04,640 --> 00:05:07,599
She was excited about the new job,
99
00:05:07,600 --> 00:05:11,520
but I don't believe
she was trying to kill herself.
100
00:05:12,560 --> 00:05:15,999
I'd like to play part of
the 999 call that was made
101
00:05:16,000 --> 00:05:17,639
the night that Edith died,
102
00:05:17,640 --> 00:05:21,919
and if you find that too distressing
I can read out a transcript instead.
103
00:05:21,920 --> 00:05:23,039
No, it's fine.
104
00:05:23,040 --> 00:05:24,759
Please, go ahead.
105
00:05:24,760 --> 00:05:26,479
Can we play the recording, please.
106
00:05:26,480 --> 00:05:28,399
BEEP
ON RECORDING: I need a...
107
00:05:28,400 --> 00:05:30,999
I need an ambulance
to 9 Somerville Road.
108
00:05:31,000 --> 00:05:33,279
My friend, Edith,
I think she's tried to kill herself.
109
00:05:33,280 --> 00:05:34,999
OK, who am I speaking to?
110
00:05:35,000 --> 00:05:36,319
And what has Edith done?
111
00:05:36,320 --> 00:05:37,679
I don't know. She's... She's...
112
00:05:37,680 --> 00:05:40,199
I think she's dying,
she's not responding.
113
00:05:40,200 --> 00:05:43,159
Please, you need to send someone
right away. 9 Somerville Road.
114
00:05:43,160 --> 00:05:44,439
PHONE BEEPS REPEATEDLY
115
00:05:44,440 --> 00:05:46,159
Do you know this friend of Edith's?
116
00:05:46,160 --> 00:05:47,360
No.
117
00:05:48,800 --> 00:05:50,799
No, I don't. Never heard...
118
00:05:50,800 --> 00:05:54,119
I've never heard that voice ever
before, but she had many friends.
119
00:05:54,120 --> 00:05:56,079
She was...
120
00:05:56,080 --> 00:05:59,559
She was popular, it was hard
to keep up with everyone.
121
00:05:59,560 --> 00:06:03,519
He states very clearly
that Edith tried to kill herself.
122
00:06:03,520 --> 00:06:05,799
Is it not possible that
during those last days
123
00:06:05,800 --> 00:06:08,439
that Edith hid her drug use
and her suicidal thoughts...?
124
00:06:08,440 --> 00:06:10,839
It wasn't suicide.
125
00:06:10,840 --> 00:06:14,639
If I thought for one second
Edith intended to harm herself
126
00:06:14,640 --> 00:06:17,599
I would never have left her
on her own.
127
00:06:17,600 --> 00:06:18,640
Never.
128
00:06:19,960 --> 00:06:21,960
SHE SNIFFS
129
00:06:23,360 --> 00:06:27,479
VOICE BREAKING: Edith's overdose
was an accident,
130
00:06:27,480 --> 00:06:32,400
and your hospital missed
an opportunity to save her life.
131
00:06:34,000 --> 00:06:35,599
I'm sorry.
132
00:06:35,600 --> 00:06:36,880
Thank you.
133
00:06:37,920 --> 00:06:39,440
You may step down now.
134
00:06:42,280 --> 00:06:44,680
SHE CRIES
135
00:07:20,160 --> 00:07:23,799
The post-mortem indicated
Edith was using opioids regularly.
136
00:07:23,800 --> 00:07:26,159
There were multiple puncture marks
on her body
137
00:07:26,160 --> 00:07:28,079
consistent with drug injection,
138
00:07:28,080 --> 00:07:30,879
and hair follicle samples
contained opioid metabolites,
139
00:07:30,880 --> 00:07:32,919
indicating long-term use.
140
00:07:32,920 --> 00:07:36,439
In your opinion, did opioids
contribute to Edith's death?
141
00:07:36,440 --> 00:07:37,799
Yes.
142
00:07:37,800 --> 00:07:41,439
Toxicology and pathology
confirm intravenous administration
143
00:07:41,440 --> 00:07:44,720
of the opioid drug fentanyl
caused Edith's death.
144
00:07:45,880 --> 00:07:48,240
Had Edith taken a large amount
of fentanyl?
145
00:07:49,280 --> 00:07:53,559
We found high levels of fentanyl
in Edith's blood.
146
00:07:53,560 --> 00:07:56,639
63.8 micrograms per litre.
147
00:07:56,640 --> 00:07:59,479
So, given the high levels
of fentanyl found in Edith's blood,
148
00:07:59,480 --> 00:08:03,199
was the overdose likely to have been
deliberate or accidental?
149
00:08:03,200 --> 00:08:06,079
Fentanyl is 50 times stronger
than heroin,
150
00:08:06,080 --> 00:08:08,959
but a seasoned drug user like Edith
151
00:08:08,960 --> 00:08:12,639
would know you only need
a small amount to feel its effect.
152
00:08:12,640 --> 00:08:15,959
So why did she take so much?
153
00:08:15,960 --> 00:08:19,359
On the other hand, she could easily
just be pursuing a greater high
154
00:08:19,360 --> 00:08:21,920
and miscalculated the dose.
155
00:08:23,680 --> 00:08:26,399
Thank you.
I have no further questions.
156
00:08:26,400 --> 00:08:27,919
Mrs Roberts?
157
00:08:27,920 --> 00:08:29,959
No, sir.
Sir Anthony?
158
00:08:29,960 --> 00:08:31,239
No, sir.
159
00:08:31,240 --> 00:08:34,720
In that case I'd like to thank you,
Dr Adeyemi. You may step down.
160
00:08:43,520 --> 00:08:47,960
The next witness I would
like to call is Dr Eva Tait.
161
00:09:04,040 --> 00:09:07,079
Dr Tait, would you care
to swear or affirm?
162
00:09:07,080 --> 00:09:08,279
I'll swear.
163
00:09:08,280 --> 00:09:11,119
In that case, there is a small card
on the ledge in front of you,
164
00:09:11,120 --> 00:09:12,919
if you'd read from that, please.
165
00:09:12,920 --> 00:09:14,639
"I swear by the Almighty God
166
00:09:14,640 --> 00:09:17,039
"that the evidence I give
shall be the truth,
167
00:09:17,040 --> 00:09:18,920
"the whole truth,
and nothing but the truth."
168
00:09:20,480 --> 00:09:23,159
Thank you, Dr Tait, for taking time
out of your maternity leave
169
00:09:23,160 --> 00:09:24,719
to be with us today.
170
00:09:24,720 --> 00:09:26,519
The court much appreciates that.
171
00:09:26,520 --> 00:09:28,239
It's the least I could do.
172
00:09:28,240 --> 00:09:31,239
Now, you were Edith's
addiction consultant
173
00:09:31,240 --> 00:09:35,119
at the Guelder Clinic
from May to October 2021?
174
00:09:35,120 --> 00:09:36,600
Yes, that's right.
175
00:09:37,760 --> 00:09:43,599
Edith had a complex history
of drug misuse,
176
00:09:43,600 --> 00:09:47,079
including cocaine,
alcohol and heroin,
177
00:09:47,080 --> 00:09:49,239
which was her main problem.
178
00:09:49,240 --> 00:09:50,600
And she wanted to be free of it.
179
00:09:51,880 --> 00:09:54,279
But she engaged well
with the treatment,
180
00:09:54,280 --> 00:09:55,639
and she achieved this.
181
00:09:55,640 --> 00:09:57,959
She was abstinent when she left us.
182
00:09:57,960 --> 00:10:00,479
So, was there any possibility
that she could have relapsed?
183
00:10:00,480 --> 00:10:03,279
Well, yes, sadly.
184
00:10:03,280 --> 00:10:06,319
For opiate addicts,
their risk of relapse is high.
185
00:10:06,320 --> 00:10:10,519
Particularly now that it's easier
to buy synthetic opioids,
186
00:10:10,520 --> 00:10:13,000
such as fentanyl, on the streets.
187
00:10:14,280 --> 00:10:16,879
And when Edith was under your care
188
00:10:16,880 --> 00:10:19,240
did she ever express
suicidal tendencies?
189
00:10:20,480 --> 00:10:22,719
Yes.
190
00:10:22,720 --> 00:10:24,439
Erm...
191
00:10:24,440 --> 00:10:26,039
We did extensive work
192
00:10:26,040 --> 00:10:29,159
on her negative thoughts
and core beliefs,
193
00:10:29,160 --> 00:10:34,439
but her suicidal ideation
remained a prominent problem.
194
00:10:34,440 --> 00:10:36,039
She...
195
00:10:36,040 --> 00:10:38,760
It's OK, take your time.
Thank you.
196
00:10:40,960 --> 00:10:42,200
It's very sad.
197
00:10:47,520 --> 00:10:50,479
Why the hell didn't you say you knew
Edith from the Guelder Clinic?
198
00:10:50,480 --> 00:10:52,639
Shh, Lucinda, have you
forgotten where we are?
199
00:10:52,640 --> 00:10:54,719
We're at the inquest
of a girl who died
200
00:10:54,720 --> 00:10:57,839
because Rob prescribed her fentanyl.
What the fuck was he thinking?
201
00:10:57,840 --> 00:11:00,319
You can't prove that
the fentanyl came from Rob.
202
00:11:00,320 --> 00:11:02,560
Edith could easily
have bought it off the street.
203
00:11:03,760 --> 00:11:05,640
He told me he was prescribing her...
204
00:11:09,160 --> 00:11:11,080
He told me he was
prescribing her methadone.
205
00:11:13,000 --> 00:11:14,839
She was a patient of YOURS.
206
00:11:14,840 --> 00:11:17,519
No, she was not my patient
when she died.
207
00:11:17,520 --> 00:11:19,359
I hadn't seen her for months.
208
00:11:19,360 --> 00:11:20,799
No, Rob specifically called me
209
00:11:20,800 --> 00:11:23,679
because he didn't want anyone
looking into his prescribing.
210
00:11:23,680 --> 00:11:26,119
He was covering up
what the hell you two were doing.
211
00:11:26,120 --> 00:11:27,320
No, I haven't done anything.
212
00:11:28,480 --> 00:11:31,199
If Rob was prescribing for Edith,
I knew nothing about it.
213
00:11:31,200 --> 00:11:32,799
OK, so how did he know them?
214
00:11:32,800 --> 00:11:36,079
How did he know Camilla, Alexander,
all the other patients -
215
00:11:36,080 --> 00:11:37,560
is it just a fucking coincidence?
216
00:11:39,120 --> 00:11:42,159
Is it just a coincidence
that they were all being treated
217
00:11:42,160 --> 00:11:44,439
at the Guelder Clinic?
218
00:11:44,440 --> 00:11:45,999
I have done nothing wrong,
219
00:11:46,000 --> 00:11:48,719
but you have covered up, what,
three overdoses for Rob,
220
00:11:48,720 --> 00:11:50,439
so you're just as implicated now.
221
00:11:50,440 --> 00:11:52,919
He was prescribing
legal drugs to addicts.
222
00:11:52,920 --> 00:11:55,159
Yeah - addicts like you.
223
00:11:55,160 --> 00:11:58,759
Listen to you,
accusing me and Rob and...
224
00:11:58,760 --> 00:12:01,679
you seem to have forgotten
about your own drug habit.
225
00:12:01,680 --> 00:12:04,839
I wonder what the MIU
would make of that?
226
00:12:04,840 --> 00:12:07,279
You wouldn't dare.
Wouldn't I?
227
00:12:07,280 --> 00:12:09,279
If you don't stop
pointing the finger at us
228
00:12:09,280 --> 00:12:10,360
I will have no choice.
229
00:12:11,760 --> 00:12:15,439
And judging by the sound of you,
you're due a refill.
230
00:12:15,440 --> 00:12:18,279
If you weren't so busy accusing me
231
00:12:18,280 --> 00:12:20,480
I might have been able to help you.
232
00:12:34,560 --> 00:12:36,559
Tom?
233
00:12:36,560 --> 00:12:37,600
Abi?
234
00:12:52,920 --> 00:12:55,559
I've gone through the A&E notes
for Alexander Taylor
235
00:12:55,560 --> 00:12:59,440
and Camilla Woodham, but nothing
indicates Lucinda knew them.
236
00:13:00,720 --> 00:13:03,239
SHE SIGHS
237
00:13:03,240 --> 00:13:05,079
How was the inquest?
238
00:13:05,080 --> 00:13:07,319
Oh, you know, long.
239
00:13:07,320 --> 00:13:09,639
None of the RH team even
gave evidence today,
240
00:13:09,640 --> 00:13:11,399
so it was just the pathologist,
241
00:13:11,400 --> 00:13:14,799
Edith's psychiatrist from
the Guelder Clinic, and her mum.
242
00:13:14,800 --> 00:13:15,959
The Guelder Clinic?
243
00:13:15,960 --> 00:13:17,119
Wait, hold on.
244
00:13:17,120 --> 00:13:18,679
I'm sure...
245
00:13:18,680 --> 00:13:20,639
Oh, yeah, yeah.
246
00:13:20,640 --> 00:13:23,960
Both Camilla and Alexander
were detoxed there.
247
00:13:26,160 --> 00:13:28,199
Well, that can't be a coincidence.
248
00:13:28,200 --> 00:13:30,479
Could Lucinda have
a connection to the clinic?
249
00:13:30,480 --> 00:13:32,959
Will you go there tomorrow
and see what you can find out?
250
00:13:32,960 --> 00:13:34,440
Yeah, yeah. Will do.
251
00:13:37,160 --> 00:13:40,000
LUCINDA MUTTERS
252
00:13:43,720 --> 00:13:45,400
Camilla...
253
00:14:03,640 --> 00:14:06,160
SHE MUTTERS
254
00:14:14,040 --> 00:14:15,760
SHE EXHALES
255
00:14:18,400 --> 00:14:21,399
In your statement,
256
00:14:21,400 --> 00:14:24,079
you said there weren't any options.
257
00:14:24,080 --> 00:14:27,759
Edith was the most stable patient,
she needed to be moved,
258
00:14:27,760 --> 00:14:31,319
so Dr Edwards
showed poor clinical judgement,
259
00:14:31,320 --> 00:14:33,079
wasn't able to prioritise,
260
00:14:33,080 --> 00:14:37,320
and delayed Edith's transfer
for, what, no reason?
261
00:14:38,640 --> 00:14:40,359
Uh, perhaps, I don't remember.
262
00:14:40,360 --> 00:14:42,199
Really?
263
00:14:42,200 --> 00:14:45,039
You don't recall pressurising
Dr Edward's
264
00:14:45,040 --> 00:14:47,719
into prioritising Patient X
265
00:14:47,720 --> 00:14:51,199
because, I quote,
"She's just a child,"
266
00:14:51,200 --> 00:14:54,079
over Edith who, I quote,
267
00:14:54,080 --> 00:14:55,519
"Was just a junkie?"
268
00:14:55,520 --> 00:14:57,400
MURMURING IN COURT
No!
269
00:14:58,800 --> 00:15:00,519
Well...
270
00:15:00,520 --> 00:15:04,679
we have a statement from a porter
who alleges you did just that.
271
00:15:04,680 --> 00:15:09,639
No, I would never use the word
junkie to describe a patient.
272
00:15:09,640 --> 00:15:11,479
That's derogatory. I...
273
00:15:11,480 --> 00:15:15,839
I just wouldn't...
I wouldn't use that word.
274
00:15:15,840 --> 00:15:17,119
Hmm.
275
00:15:17,120 --> 00:15:20,039
You know,
sometimes facts like that are...
276
00:15:20,040 --> 00:15:22,360
Well, they're hard
to remember, aren't they?
277
00:15:23,880 --> 00:15:26,239
No further questions, sir.
278
00:15:26,240 --> 00:15:27,839
Thank you, Sir Anthony.
279
00:15:27,840 --> 00:15:30,079
Mrs Roberts, any questions?
280
00:15:30,080 --> 00:15:31,439
No, sir.
281
00:15:31,440 --> 00:15:32,719
Thank you.
282
00:15:32,720 --> 00:15:34,639
Thank you, Mrs Relph,
you're free to go.
283
00:15:34,640 --> 00:15:35,680
Please step down.
284
00:15:40,760 --> 00:15:45,680
Our next witness is Dr Ramya Morgan.
285
00:15:57,280 --> 00:16:00,119
Would you care to swear or affirm?
286
00:16:00,120 --> 00:16:01,280
I'll swear.
287
00:16:02,480 --> 00:16:04,479
Would you like an alternative text?
288
00:16:04,480 --> 00:16:07,159
No, the regular Bible's fine.
Thanks.
289
00:16:07,160 --> 00:16:08,359
OK, thank you.
290
00:16:08,360 --> 00:16:11,480
If you would read from the card
in front of you, please.
291
00:16:13,160 --> 00:16:14,519
"I swear by Almighty God
292
00:16:14,520 --> 00:16:16,919
"that the evidence
I give shall be the truth,
293
00:16:16,920 --> 00:16:19,279
"the whole truth,
and nothing but the truth."
294
00:16:19,280 --> 00:16:20,719
Thank you.
295
00:16:20,720 --> 00:16:22,599
Sir Anthony, your witness.
296
00:16:22,600 --> 00:16:23,639
Dr Morgan.
297
00:16:23,640 --> 00:16:26,199
SIR ANTHONY CLEARS HIS THROAT
298
00:16:26,200 --> 00:16:28,839
Can you take us through
your involvement
299
00:16:28,840 --> 00:16:32,079
in Edith's A&E care?
300
00:16:32,080 --> 00:16:34,199
Um...
301
00:16:34,200 --> 00:16:37,199
I was bleeped to Resus
to watch Edith
302
00:16:37,200 --> 00:16:40,799
while Dr Edwards took care
of an emergency in reception.
303
00:16:40,800 --> 00:16:42,319
And when she came back
304
00:16:42,320 --> 00:16:45,199
I thought she would continue
looking after Edith,
305
00:16:45,200 --> 00:16:50,999
but instead I was told
a Patient X needed Edith's bed,
306
00:16:51,000 --> 00:16:53,079
and I was going to Majors
with Edith,
307
00:16:53,080 --> 00:16:54,959
and Dr Edwards gave me
a treatment plan.
308
00:16:54,960 --> 00:16:57,479
And what was that treatment plan?
309
00:16:57,480 --> 00:17:01,599
Dr Edwards asked me to give
800 micrograms naloxone,
310
00:17:01,600 --> 00:17:04,360
and if Edith's breathing improved,
to let her know.
311
00:17:06,240 --> 00:17:07,879
And what happened next?
312
00:17:07,880 --> 00:17:11,199
Well, after the naloxone was given,
Edith's respiratory rate improved,
313
00:17:11,200 --> 00:17:12,279
so I returned to Resus.
314
00:17:12,280 --> 00:17:13,799
Leaving Edith alone?
315
00:17:13,800 --> 00:17:15,959
There were other staff around.
316
00:17:15,960 --> 00:17:18,679
But no-one dedicated
to her care, correct?
317
00:17:18,680 --> 00:17:20,119
Correct.
318
00:17:20,120 --> 00:17:22,759
Did you consider waiting
and observing Edith
319
00:17:22,760 --> 00:17:24,279
to see if the improvement
320
00:17:24,280 --> 00:17:26,639
in her breathing
would be maintained?
321
00:17:26,640 --> 00:17:28,159
I waited to see the improvement.
322
00:17:28,160 --> 00:17:30,159
And then you left - immediately?
323
00:17:30,160 --> 00:17:33,280
No, no. Uh, not immediately.
324
00:17:34,520 --> 00:17:36,679
Uh, I can't remember
how long I stayed.
325
00:17:36,680 --> 00:17:37,960
Hmm.
326
00:17:39,680 --> 00:17:44,559
Dr Morgan, do you know how quickly
the initial effects of naloxone
327
00:17:44,560 --> 00:17:45,640
can wear off?
328
00:17:46,600 --> 00:17:48,639
I now know.
329
00:17:48,640 --> 00:17:53,679
But you didn't know when
you prescribed the drug for Edith?
330
00:17:53,680 --> 00:17:54,920
Did you?
331
00:17:56,480 --> 00:18:00,919
How long have you been
a qualified doctor?
332
00:18:00,920 --> 00:18:02,039
About 18 months.
333
00:18:02,040 --> 00:18:05,880
How long did Dr Edwards
ask you to wait and observe Edith?
334
00:18:07,080 --> 00:18:08,559
I'm not...
335
00:18:08,560 --> 00:18:10,159
I don't remember.
336
00:18:10,160 --> 00:18:13,919
I'm so sorry, could you speak up,
so the whole court can hear you.
337
00:18:13,920 --> 00:18:16,519
I don't remember.
338
00:18:16,520 --> 00:18:19,199
And when you returned to Resus,
339
00:18:19,200 --> 00:18:21,320
was Dr Edwards grateful for your...
340
00:18:22,520 --> 00:18:23,720
..extra pair of hands?
341
00:18:26,000 --> 00:18:28,279
I don't remember.
342
00:18:28,280 --> 00:18:30,599
Well, let me help you there,
shall I?
343
00:18:30,600 --> 00:18:33,439
I'm quoting from her statement -
344
00:18:33,440 --> 00:18:36,479
"When Dr Morgan returned to Resus
345
00:18:36,480 --> 00:18:39,679
"I asked her why she wasn't
with the overdosed patient."
346
00:18:39,680 --> 00:18:44,119
So, clearly Dr Edwards
wasn't expecting you back,
347
00:18:44,120 --> 00:18:45,199
so I'll ask you again,
348
00:18:45,200 --> 00:18:47,799
why did you leave Edith so quickly
and return to Resus
349
00:18:47,800 --> 00:18:49,279
to a different patient,
350
00:18:49,280 --> 00:18:52,799
who was already being handled
by doctors with far more experience?
351
00:18:52,800 --> 00:18:55,319
Dr Edwards never said that
I needed to stay longer
352
00:18:55,320 --> 00:18:57,319
in case the naloxone
stopped working.
353
00:18:57,320 --> 00:19:00,119
I'm sorry, are you saying
that Dr Edwards lied?
354
00:19:00,120 --> 00:19:01,239
No, no.
355
00:19:01,240 --> 00:19:03,679
What she said in her
written statement was false?
356
00:19:03,680 --> 00:19:06,319
No, but I can only tell you
what I remember.
357
00:19:06,320 --> 00:19:07,799
OK.
358
00:19:07,800 --> 00:19:12,199
So, in this hospital,
full of competent doctors,
359
00:19:12,200 --> 00:19:15,559
Dr Edwards didn't tell you
how long to wait with Edith,
360
00:19:15,560 --> 00:19:19,399
and after 18 months
as a qualified medical practitioner
361
00:19:19,400 --> 00:19:21,799
you didn't know how long
to wait either.
362
00:19:21,800 --> 00:19:24,159
A&E is really hectic.
363
00:19:24,160 --> 00:19:26,679
And patients turn up all the time
with conditions
364
00:19:26,680 --> 00:19:28,559
that you don't know how to treat,
365
00:19:28,560 --> 00:19:33,359
so you have to rely on your seniors
for the support to work safely.
366
00:19:33,360 --> 00:19:35,919
OK, so what you're really saying is
367
00:19:35,920 --> 00:19:38,879
that without instructions
from a senior
368
00:19:38,880 --> 00:19:41,319
you don't know how
to treat an overdose.
369
00:19:41,320 --> 00:19:43,039
No, I didn't say that.
370
00:19:43,040 --> 00:19:45,479
But I'm a junior -
I'm there to learn,
371
00:19:45,480 --> 00:19:47,199
and there's a lot to remember.
372
00:19:47,200 --> 00:19:53,639
And after giving only one dose
of naloxone to my daughter,
373
00:19:53,640 --> 00:19:55,360
you returned to Resus.
374
00:19:58,080 --> 00:20:02,999
If you'd only waited
a few minutes more
375
00:20:03,000 --> 00:20:06,759
you'd have noticed the initial
effects of the naloxone wearing off
376
00:20:06,760 --> 00:20:09,159
and been able to administer
a second,
377
00:20:09,160 --> 00:20:12,480
potentially life-saving dose,
but you left her...
378
00:20:14,960 --> 00:20:19,000
..struggling to breathe
and under-medicated.
379
00:20:22,400 --> 00:20:26,359
You effectively
left Edith to die, didn't you?
380
00:20:26,360 --> 00:20:27,560
Hmm?
381
00:20:32,360 --> 00:20:35,479
No further questions, sir.
Thank you.
382
00:20:35,480 --> 00:20:37,839
Mrs Roberts,
questions from yourself?
383
00:20:37,840 --> 00:20:39,599
No, sir.
384
00:20:39,600 --> 00:20:42,919
Thank you. You may step down
when you're ready. Thank you.
385
00:20:42,920 --> 00:20:47,279
Do you have any idea - any idea -
how damaging this is to the trust?
386
00:20:47,280 --> 00:20:51,439
You threw me under the bus as soon
as he questioned your competence.
387
00:20:51,440 --> 00:20:52,839
But I DIDN'T know how long to wait.
388
00:20:52,840 --> 00:20:55,439
And you didn't tell me the naloxone
would wear off so quickly.
389
00:20:55,440 --> 00:20:57,239
Well, if you'd stayed
like I told you,
390
00:20:57,240 --> 00:20:59,239
you would've seen
how quickly it wears off.
391
00:20:59,240 --> 00:21:01,839
Instead you came to Resus. You need
to control your juniors, Leo.
392
00:21:01,840 --> 00:21:04,359
This has got nothing to do with me.
I wasn't there.
393
00:21:04,360 --> 00:21:07,599
Yeah, and you should have been...
Hey, come on, guys, guys, come on.
394
00:21:07,600 --> 00:21:08,959
Come on, rein this in.
395
00:21:08,960 --> 00:21:10,559
We CAN recover from this,
396
00:21:10,560 --> 00:21:13,719
but it is all going
to depend heavily on you, Lucinda,
397
00:21:13,720 --> 00:21:16,359
not messing it up this afternoon.
398
00:21:16,360 --> 00:21:19,759
You've got to stick to the script.
Have you got that?
399
00:21:19,760 --> 00:21:21,319
Lucinda?
400
00:21:21,320 --> 00:21:22,360
Have you?
401
00:21:24,000 --> 00:21:26,919
I'm an A&E doctor,
I'm not a mental health specialist.
402
00:21:26,920 --> 00:21:28,479
Assessing whether a patient
403
00:21:28,480 --> 00:21:31,159
deliberately wanted
to kill themselves,
404
00:21:31,160 --> 00:21:34,319
that should be done
by a psychiatrist, not me.
405
00:21:34,320 --> 00:21:36,639
But Edith had deliberately
overdosed before.
406
00:21:36,640 --> 00:21:39,359
Past behaviour usually predicts
future behaviour,
407
00:21:39,360 --> 00:21:41,559
and in cases
where intent isn't clear
408
00:21:41,560 --> 00:21:45,439
I always err on the side of caution
and code it as deliberate.
409
00:21:45,440 --> 00:21:48,519
This ensures that the patients
are reviewed by psychiatry
410
00:21:48,520 --> 00:21:49,840
prior to discharge.
411
00:21:51,920 --> 00:21:53,799
And when did you become aware
412
00:21:53,800 --> 00:21:56,599
that there was a problem
with Edith's care?
413
00:21:56,600 --> 00:21:58,719
Shortly after
we stabilised Patient X
414
00:21:58,720 --> 00:22:00,999
the alarms in Majors went off.
415
00:22:01,000 --> 00:22:05,239
I ran to Edith, but she was already
in respiratory failure.
416
00:22:05,240 --> 00:22:08,720
Edith shortly went
into cardiac arrest.
417
00:22:09,880 --> 00:22:12,679
We worked on her for half an hour
but we never got her back.
418
00:22:12,680 --> 00:22:15,200
Thank you, Dr Edwards.
If you'd wait there, please.
419
00:22:16,640 --> 00:22:18,199
Sir Anthony, your witness.
420
00:22:18,200 --> 00:22:19,880
Thank you, sir.
421
00:22:21,200 --> 00:22:23,879
Dr Edwards, would you say Dr Morgan
422
00:22:23,880 --> 00:22:26,920
is prone to forgetting
simple instructions?
423
00:22:29,440 --> 00:22:30,799
Uh...
424
00:22:30,800 --> 00:22:34,119
We're all prone
to occasional forgetfulness.
425
00:22:34,120 --> 00:22:37,479
Yes, but it's highly unlikely
that a doctor capable of learning
426
00:22:37,480 --> 00:22:42,199
enough facts to pass her finals,
with distinction, 18 months prior,
427
00:22:42,200 --> 00:22:44,159
wouldn't remember
the simple instructions
428
00:22:44,160 --> 00:22:46,959
of watch, wait, and repeat a dose?
429
00:22:46,960 --> 00:22:50,239
Well, in normal circumstances, yes.
430
00:22:50,240 --> 00:22:52,599
But A&E isn't normal.
431
00:22:52,600 --> 00:22:54,119
And with all due respect, sir,
432
00:22:54,120 --> 00:22:57,479
memorising facts for an exam
is very different
433
00:22:57,480 --> 00:22:58,959
to processing information
434
00:22:58,960 --> 00:23:01,719
in a real-life,
high-pressure situation.
435
00:23:01,720 --> 00:23:04,119
Yes, but even with
all this pressure,
436
00:23:04,120 --> 00:23:07,559
Dr Morgan correctly remembered
the more complex details
437
00:23:07,560 --> 00:23:12,039
you gave her vis-a-vis
the type of drug and the dose.
438
00:23:12,040 --> 00:23:16,279
Isn't it more likely that
your instructions were unclear?
439
00:23:16,280 --> 00:23:17,720
No, because she wasn't listening.
440
00:23:19,080 --> 00:23:22,439
Yes, you said that Dr Morgan
wasn't listening,
441
00:23:22,440 --> 00:23:25,119
and your colleague spoke
of your reluctance
442
00:23:25,120 --> 00:23:27,959
to leave Edith with her,
so why did you?
443
00:23:27,960 --> 00:23:30,559
Because I had no choice and I had
to make a decision, that's why.
444
00:23:30,560 --> 00:23:32,720
Yes, you made all the decisions.
445
00:23:34,040 --> 00:23:36,679
You dithered, and Edith...
No. No, no. But I didn't...
446
00:23:36,680 --> 00:23:39,879
..deteriorated. You chose
to leave Edith with a doctor
447
00:23:39,880 --> 00:23:42,519
whose incompetence
has been shown today,
448
00:23:42,520 --> 00:23:45,559
and that choice killed her.
449
00:23:45,560 --> 00:23:48,439
MURMURING IN COURT
450
00:23:48,440 --> 00:23:51,479
Are you not therefore guilty
of gross negligence?
451
00:23:51,480 --> 00:23:52,999
Sir, this is NOT a criminal court.
452
00:23:53,000 --> 00:23:54,399
If I may remind counsel,
453
00:23:54,400 --> 00:23:57,199
whilst I understand the
emotional distress of this hearing,
454
00:23:57,200 --> 00:24:00,359
he must refrain from accusing
witnesses of criminal offences
455
00:24:00,360 --> 00:24:01,560
they're not on trial for.
456
00:24:07,280 --> 00:24:11,400
You treated my daughter
without diligence or due care.
457
00:24:14,080 --> 00:24:17,120
A total disregard for the...
458
00:24:20,800 --> 00:24:22,440
VOICE BREAKING: ..for the
severity...
459
00:24:24,360 --> 00:24:26,200
..of the symptoms.
460
00:24:30,520 --> 00:24:31,680
Erm...
461
00:24:34,240 --> 00:24:37,000
Sir, I apologise.
462
00:24:39,760 --> 00:24:41,240
No further questions.
463
00:24:46,520 --> 00:24:47,920
Thank you.
464
00:24:50,080 --> 00:24:52,680
In that case, I'd like to bring
the session to a close.
465
00:24:53,960 --> 00:24:57,320
I'll retire to consider my verdict.
466
00:24:59,480 --> 00:25:03,400
We will reconvene in...three hours.
467
00:25:04,640 --> 00:25:05,800
Thank you.
468
00:25:06,920 --> 00:25:09,359
Thank you, Dr Edwards,
you may step down.
469
00:25:09,360 --> 00:25:11,400
And thank you, everyone else,
for your time.
470
00:25:34,800 --> 00:25:36,520
Excuse me, Sir Anthony, I just...
471
00:25:38,240 --> 00:25:39,840
I'm very sorry for your loss.
472
00:26:01,000 --> 00:26:04,719
Can I get a bottle of
the liquid NightSoothe.
473
00:26:04,720 --> 00:26:06,560
Yeah.
Yeah, and...
474
00:26:07,960 --> 00:26:09,880
..the one-a-night.
475
00:26:12,160 --> 00:26:16,319
These both contain diphenhydramine,
so don't take them both together.
476
00:26:16,320 --> 00:26:17,639
They're sedatives.
477
00:26:17,640 --> 00:26:20,199
Take one tablet at bedtime
or a dose of the liquid...
478
00:26:20,200 --> 00:26:22,279
Yeah, I'm a doctor,
I know how to take them.
479
00:26:22,280 --> 00:26:23,480
All right, OK.
480
00:26:30,320 --> 00:26:32,560
SHE SIGHS
For fuck sake.
481
00:26:41,880 --> 00:26:45,240
SHE EXHALES
482
00:26:48,040 --> 00:26:50,239
Hello!
Hello!
483
00:26:50,240 --> 00:26:51,999
How did it go?
Awful.
484
00:26:52,000 --> 00:26:54,959
Let's just say I'm happy
to be back on the shop floor.
485
00:26:54,960 --> 00:26:57,559
What are you doing?
Are you STILL doing that audit?
486
00:26:57,560 --> 00:27:00,239
I've told you, Oscar,
nobody wastes medication in my A&E.
487
00:27:00,240 --> 00:27:01,639
You know that.
488
00:27:01,640 --> 00:27:03,959
Mm, you sure about that?
489
00:27:03,960 --> 00:27:05,919
Mm-hm.
Yeah?
490
00:27:05,920 --> 00:27:07,199
What's this?
491
00:27:07,200 --> 00:27:09,759
A patient that Ramya saw
with Lucinda.
492
00:27:09,760 --> 00:27:12,759
The patient needed 10,
not 40, milligrams of diazepam.
493
00:27:12,760 --> 00:27:15,359
Hang on, are you telling me
that Ramya threw away 30mg?
494
00:27:15,360 --> 00:27:18,199
Come on, it might not
be Ramya's fault.
495
00:27:18,200 --> 00:27:20,319
Maybe they thought
the patient needed that much.
496
00:27:20,320 --> 00:27:23,639
No, Oscar. Absolutely not.
497
00:27:23,640 --> 00:27:26,159
40mg of diazepam for mild sedation?
498
00:27:26,160 --> 00:27:29,599
That sounds like a Ramya cock up,
doesn't it?
499
00:27:29,600 --> 00:27:31,759
Listen...
Mm?
500
00:27:31,760 --> 00:27:35,039
..if you take medication
from the store
501
00:27:35,040 --> 00:27:37,279
it is your responsibility
to make sure
502
00:27:37,280 --> 00:27:39,879
you take the amount
that's actually needed.
503
00:27:39,880 --> 00:27:41,480
I know.
Right.
504
00:27:48,960 --> 00:27:51,719
Hi.
Hi. Can I help you?
505
00:27:51,720 --> 00:27:54,999
Yes, my name's Dr George Adjei
from the Medical Investigation Unit.
506
00:27:55,000 --> 00:27:56,639
We're investigating a doctor
507
00:27:56,640 --> 00:27:59,079
who treated four
of your former patients -
508
00:27:59,080 --> 00:28:04,039
Edith Owusu, Camilla Woodham,
Alexander Taylor and Milo Hanbury.
509
00:28:04,040 --> 00:28:07,959
One of our doctors?
She's called Dr Lucinda Edwards.
510
00:28:07,960 --> 00:28:09,599
She's currently at the RH,
511
00:28:09,600 --> 00:28:12,159
but I was hoping you could tell me
if she's ever worked here
512
00:28:12,160 --> 00:28:14,239
or has any connection to the clinic.
513
00:28:14,240 --> 00:28:18,679
The name isn't familiar, but I'll
check our staffing records. Thanks.
514
00:28:18,680 --> 00:28:22,119
No, no, she's never worked here.
515
00:28:22,120 --> 00:28:23,239
Oh.
516
00:28:23,240 --> 00:28:26,879
Has the clinic ever received
a referral from Dr Edwards?
517
00:28:26,880 --> 00:28:29,599
No. Or have you ever referred
any patients to her at the RH?
518
00:28:29,600 --> 00:28:30,839
No, no, there's nothing.
519
00:28:30,840 --> 00:28:32,600
The name isn't anywhere
on our system.
520
00:28:34,680 --> 00:28:36,599
OK. Uh...
521
00:28:36,600 --> 00:28:39,519
Could I get copies of the notes
for the patients I mentioned?
522
00:28:39,520 --> 00:28:41,159
I'm afraid not. We...
523
00:28:41,160 --> 00:28:43,759
We would written consent
from each patient first.
524
00:28:43,760 --> 00:28:45,799
Fine, can you contact and ask?
525
00:28:45,800 --> 00:28:47,519
Of course, yeah.
526
00:28:47,520 --> 00:28:49,119
I'll let you know.
Do you have a card?
527
00:28:49,120 --> 00:28:51,399
Oh, sorry. One...
528
00:28:51,400 --> 00:28:55,439
Edith was treated
by a Dr Eva Tait -
529
00:28:55,440 --> 00:28:57,519
do you know if any
of the others were?
530
00:28:57,520 --> 00:28:58,920
I...I can check.
531
00:29:03,520 --> 00:29:07,279
No, no, they all
had different doctors.
532
00:29:07,280 --> 00:29:09,559
Besides,
Dr Tait's on maternity leave,
533
00:29:09,560 --> 00:29:11,839
she hasn't worked here
for six months.
534
00:29:11,840 --> 00:29:13,079
Right.
535
00:29:13,080 --> 00:29:15,599
I can tell you they were all
successfully detoxed
536
00:29:15,600 --> 00:29:17,839
and rehabilitated
during their time here.
537
00:29:17,840 --> 00:29:21,079
They were all completely drug free
when they were discharged?
538
00:29:21,080 --> 00:29:22,839
Yeah.
539
00:29:22,840 --> 00:29:25,759
We've broken that revolving door
addiction-patient tradition
540
00:29:25,760 --> 00:29:27,799
so often perpetuated by the NHS.
541
00:29:27,800 --> 00:29:32,599
Once our clients are discharged,
they don't need to come back.
542
00:29:32,600 --> 00:29:34,040
They get what they pay for.
543
00:29:35,680 --> 00:29:39,319
But the patients I mentioned
all relapsed and overdosed
544
00:29:39,320 --> 00:29:40,520
after leaving this clinic.
545
00:29:41,920 --> 00:29:43,239
You know Edith Owusu died?
546
00:29:43,240 --> 00:29:46,359
Well, that had nothing to do with
the treatment they received here.
547
00:29:46,360 --> 00:29:47,759
Yeah, but...
548
00:29:47,760 --> 00:29:49,959
it's not what they paid for, right?
549
00:29:49,960 --> 00:29:52,760
No complaints have ever been made
against the Guelder Clinic.
550
00:29:53,800 --> 00:29:56,119
OK. Not yet, but if you
keep focusing
551
00:29:56,120 --> 00:29:59,119
on getting patients
out of the door quickly
552
00:29:59,120 --> 00:30:01,559
instead of giving them
proper treatment,
553
00:30:01,560 --> 00:30:03,559
it won't take long, will it?
554
00:30:03,560 --> 00:30:05,839
Is that everything?
555
00:30:05,840 --> 00:30:07,160
Yeah, for now.
556
00:30:08,360 --> 00:30:09,679
Thanks.
557
00:30:09,680 --> 00:30:15,319
Edith had taken a large amount
of a dangerous opioid, fentanyl.
558
00:30:15,320 --> 00:30:17,279
It's impossible to determine
559
00:30:17,280 --> 00:30:20,039
whether she intended
to take her own life,
560
00:30:20,040 --> 00:30:21,600
or whether this was accidental.
561
00:30:23,880 --> 00:30:27,119
Whilst I can find no fault with
the doctors' actions in relation
562
00:30:27,120 --> 00:30:29,799
to the outcome of Edith's overdose,
563
00:30:29,800 --> 00:30:31,919
I find it unacceptable that a doctor
564
00:30:31,920 --> 00:30:35,079
working in a
high-pressure environment like A&E
565
00:30:35,080 --> 00:30:37,999
should be reliant on instruction
from a senior
566
00:30:38,000 --> 00:30:41,359
to correctly treat
an opioid overdose.
567
00:30:41,360 --> 00:30:42,879
There is, therefore,
568
00:30:42,880 --> 00:30:46,399
something amiss
in the training of junior doctors
569
00:30:46,400 --> 00:30:48,960
within the Royal Hospital's
A&E department.
570
00:30:49,920 --> 00:30:51,519
And, as such, I shall write
571
00:30:51,520 --> 00:30:54,039
a prevention of
future deaths report
572
00:30:54,040 --> 00:30:57,320
recommending the trust review
its medical education programme.
573
00:30:59,720 --> 00:31:02,839
I would like to give
a narrative conclusion
574
00:31:02,840 --> 00:31:05,519
that Edith Owusu died
575
00:31:05,520 --> 00:31:09,599
following the self administration
of a large quantity of fentanyl,
576
00:31:09,600 --> 00:31:13,439
resulting in cardiac arrest
and death.
577
00:31:13,440 --> 00:31:16,559
That is the end of my conclusion.
578
00:31:16,560 --> 00:31:18,759
I would like to thank you
for your time,
579
00:31:18,760 --> 00:31:20,960
and please feel free to leave.
580
00:31:39,920 --> 00:31:42,199
Well, that could
have been loads worse.
581
00:31:42,200 --> 00:31:44,839
Were you listening
to a different verdict?
582
00:31:44,840 --> 00:31:47,919
Thank you so much for all
your hard work today, Lucinda.
583
00:31:47,920 --> 00:31:49,039
You really did us proud.
584
00:31:49,040 --> 00:31:50,959
Hey, all right, Mike. Leave it.
585
00:31:50,960 --> 00:31:52,279
She did her best, yeah?
586
00:31:52,280 --> 00:31:53,480
MIKE SIGHS
587
00:32:04,040 --> 00:32:05,400
Are you happy now?
588
00:32:06,880 --> 00:32:08,599
Excuse me?
589
00:32:08,600 --> 00:32:11,000
Edith's death wasn't my fault -
I assume we're done.
590
00:32:12,240 --> 00:32:14,080
You know that's not how this works.
591
00:32:43,440 --> 00:32:47,079
Oh, mate, you're so lucky
you were out of it.
592
00:32:47,080 --> 00:32:48,639
I mean, it was horrendous.
Oh, really?
593
00:32:48,640 --> 00:32:51,639
It literally made me feel like
the worst doctor in the world.
594
00:32:51,640 --> 00:32:55,079
All I do is try my best,
and every time I get shat on.
595
00:32:55,080 --> 00:32:56,599
I mean, what is the point?
596
00:32:56,600 --> 00:32:58,759
Hey, our jobs make a difference.
597
00:32:58,760 --> 00:33:00,359
Do they?
Yeah.
598
00:33:00,360 --> 00:33:02,679
OK, how long have you been working
on that audit for?
599
00:33:02,680 --> 00:33:05,279
And is it really going to save
the department any money?
600
00:33:05,280 --> 00:33:07,759
Yeah, actually,
I think it will, yeah.
601
00:33:07,760 --> 00:33:10,479
I don't know. I think you should've
recycled last year's audit,
602
00:33:10,480 --> 00:33:11,599
like the rest of us.
603
00:33:11,600 --> 00:33:14,399
It's a tick-box exercise, Oscar,
nobody actually cares.
604
00:33:14,400 --> 00:33:16,679
THUMP
Being an A&E doctor is a privilege,
605
00:33:16,680 --> 00:33:19,039
and maybe instead of complaining
all the time
606
00:33:19,040 --> 00:33:20,239
you should focus on your work
607
00:33:20,240 --> 00:33:22,960
and then you wouldn't make
so many mistakes, would ya?
608
00:33:26,720 --> 00:33:29,319
Sorry, what the fuck
have I done this time?
609
00:33:29,320 --> 00:33:31,999
Sorry, it may be my bad.
610
00:33:32,000 --> 00:33:34,639
I may have mentioned
a dispensing error that you made.
611
00:33:34,640 --> 00:33:36,560
What?! When?
612
00:33:38,040 --> 00:33:39,639
HE GROANS
613
00:33:39,640 --> 00:33:41,080
Takes a look at that.
614
00:33:42,680 --> 00:33:45,119
Lucinda told me to get 40mg,
615
00:33:45,120 --> 00:33:48,119
and I even questioned the dose
at the time. I said...
616
00:33:48,120 --> 00:33:50,079
I wouldn't worry about this,
all right?
617
00:33:50,080 --> 00:33:51,759
Look, look, look, my audits...
Oscar...
618
00:33:51,760 --> 00:33:54,279
Listen, my audits aren't about
individual mistakes,
619
00:33:54,280 --> 00:33:55,479
they're about saving money
620
00:33:55,480 --> 00:33:59,599
that we're wasting
on chucking unused meds, OK?
621
00:33:59,600 --> 00:34:00,959
Beth's going to get over it.
622
00:34:00,960 --> 00:34:03,040
SHE SIGHS
623
00:34:04,640 --> 00:34:06,039
Hmm.
624
00:34:06,040 --> 00:34:09,999
Right, so, Edith, Alexander,
Camilla and Milo were all treated
625
00:34:10,000 --> 00:34:12,319
by different doctors
at the Guelder Clinic.
626
00:34:12,320 --> 00:34:15,279
Eva Tait wasn't even there
when they overdosed,
627
00:34:15,280 --> 00:34:16,679
she was on maternity leave.
628
00:34:16,680 --> 00:34:21,039
So, Lucinda is still the only
concrete link we have between them.
629
00:34:21,040 --> 00:34:22,279
Shit.
630
00:34:22,280 --> 00:34:24,159
Well, besides them relapsing
631
00:34:24,160 --> 00:34:26,639
and deliberately overdosing
after discharge.
632
00:34:26,640 --> 00:34:29,239
Isn't it odd that they all tried
to kill themselves?
633
00:34:29,240 --> 00:34:33,559
And using the same method -
I mean, what are the chances?
634
00:34:33,560 --> 00:34:38,239
Isn't it more likely
that they came out of treatment
635
00:34:38,240 --> 00:34:42,519
and accidentally overdosed because
they'd been off drugs for a while?
636
00:34:42,520 --> 00:34:44,600
But if that were true...
637
00:34:45,680 --> 00:34:48,680
..why would Lucinda code them all
as deliberate? Look.
638
00:34:52,320 --> 00:34:54,479
Do we have Edith's file here?
639
00:34:54,480 --> 00:34:56,080
Yeah, yeah, sure.
640
00:34:57,200 --> 00:34:58,400
Oh, yeah, here you go.
641
00:34:59,440 --> 00:35:05,320
All right, we asked Lucinda that
in her first interview.
642
00:35:06,640 --> 00:35:09,159
And she said she changed this
to deliberate
643
00:35:09,160 --> 00:35:11,120
to ensure Edith got a psych review.
644
00:35:13,640 --> 00:35:16,919
She said it again
at the inquest, but...
645
00:35:16,920 --> 00:35:18,040
what if she...
646
00:35:19,160 --> 00:35:23,559
What if she just didn't want anyone
to know it was an accident?
647
00:35:23,560 --> 00:35:26,279
But what does she stand to gain
by coding them as deliberate
648
00:35:26,280 --> 00:35:27,959
if she knew they were accidents?
649
00:35:27,960 --> 00:35:30,879
Because when it's an accident
650
00:35:30,880 --> 00:35:33,440
you look at
what caused the accident.
651
00:35:35,720 --> 00:35:36,959
The drugs!
652
00:35:36,960 --> 00:35:38,319
Yes.
653
00:35:38,320 --> 00:35:39,399
The drugs.
654
00:35:39,400 --> 00:35:41,240
We've been focusing on
the wrong thing.
655
00:35:43,040 --> 00:35:46,480
Her parents had Edith stop buying
street drugs a long time ago.
656
00:35:48,000 --> 00:35:50,680
So... where was she getting them?
657
00:36:06,800 --> 00:36:08,919
KNOCK ON DOOR
658
00:36:08,920 --> 00:36:12,879
We understand your disappointment
at the coroner's conclusions.
659
00:36:12,880 --> 00:36:14,680
Edith deserved better.
660
00:36:16,400 --> 00:36:19,759
If those doctors
had done their job properly,
661
00:36:19,760 --> 00:36:22,399
Edith would still be alive.
662
00:36:22,400 --> 00:36:24,199
Well...
663
00:36:24,200 --> 00:36:25,919
regarding that,
664
00:36:25,920 --> 00:36:28,799
we would really appreciate
your permission
665
00:36:28,800 --> 00:36:33,199
to take a little look
around Edith's flat.
666
00:36:33,200 --> 00:36:34,559
What for?
667
00:36:34,560 --> 00:36:39,719
Well, we're looking for anything
that might tell us
668
00:36:39,720 --> 00:36:42,759
where she got the drugs
she overdosed on.
669
00:36:42,760 --> 00:36:47,839
Are you trying to say that it was
Edith's fault that she died?
670
00:36:47,840 --> 00:36:49,399
No, not at all.
671
00:36:49,400 --> 00:36:52,439
We feel there might be
potentially something in there
672
00:36:52,440 --> 00:36:57,599
linking Edith to whoever
supplied her with the fentanyl
673
00:36:57,600 --> 00:36:58,880
that ended her life.
674
00:37:04,160 --> 00:37:05,999
Hmm...
675
00:37:06,000 --> 00:37:08,879
Is she...behind the mirror?
676
00:37:08,880 --> 00:37:11,199
ABI LAUGHS
Nope!
677
00:37:11,200 --> 00:37:13,039
Behind the curtain?
678
00:37:13,040 --> 00:37:15,039
No!
679
00:37:15,040 --> 00:37:17,080
Mummy, Mummy, where are you?
680
00:37:18,200 --> 00:37:21,359
OUT OF BREATH: Is she...
681
00:37:21,360 --> 00:37:22,960
..on top of the bed?
682
00:37:24,000 --> 00:37:25,519
SHE SIGHS
No.
683
00:37:25,520 --> 00:37:27,160
PHONE VIBRATES
684
00:37:34,400 --> 00:37:38,960
ABI TALKS INDISTINCTLY
685
00:37:46,800 --> 00:37:48,759
RINGING
686
00:37:48,760 --> 00:37:51,159
Hello.
Camilla... Camilla, hi.
687
00:37:51,160 --> 00:37:52,999
This isn't Rob.
688
00:37:53,000 --> 00:37:56,559
No, no, I'm the new doctor
that took over from Rob.
689
00:37:56,560 --> 00:37:59,280
OK, can we meet
at Southern Square?
690
00:38:00,760 --> 00:38:03,680
Yeah, I can meet you there
in half an hour.
691
00:38:05,000 --> 00:38:07,759
Right. OK, great.
692
00:38:07,760 --> 00:38:08,840
OK, see you then.
693
00:38:12,080 --> 00:38:13,799
Mummy, come and find me.
694
00:38:13,800 --> 00:38:15,200
Is she...
695
00:38:18,360 --> 00:38:20,759
..under the bed?
ABI SCREAMS
696
00:38:20,760 --> 00:38:22,119
THEY LAUGH
697
00:38:22,120 --> 00:38:24,439
I haven't been out of the house
since the inquest. Please.
698
00:38:24,440 --> 00:38:26,999
Yeah, it's fine. OK, OK.
Yeah?
699
00:38:27,000 --> 00:38:28,559
Yeah, yeah. Fine, fine, fine.
700
00:38:28,560 --> 00:38:30,279
Are you going to be good for Daddy?
701
00:38:30,280 --> 00:38:33,159
These are stickers!
Oh, she's got stickers for you!
702
00:38:33,160 --> 00:38:35,920
Come show me,
what have you got there?
703
00:38:37,680 --> 00:38:40,560
Thank you again so much for this.
We really do appreciate it.
704
00:38:42,040 --> 00:38:44,999
OK, so, this key
is for the front door
705
00:38:45,000 --> 00:38:49,119
and this key
is to Edith's flat - Flat B.
706
00:38:49,120 --> 00:38:50,639
You're not coming in?
707
00:38:50,640 --> 00:38:54,079
Uh...it's too difficult.
708
00:38:54,080 --> 00:38:57,759
Just put the key through
the letterbox when you're done.
709
00:38:57,760 --> 00:38:58,800
Thank you.
710
00:39:11,520 --> 00:39:12,959
Did you remember gloves?
711
00:39:12,960 --> 00:39:14,440
Oh. Yes.
712
00:39:20,600 --> 00:39:24,239
Um, well,
I'll take this room and the kitchen,
713
00:39:24,240 --> 00:39:27,079
and you take that first bedroom
on the way in,
714
00:39:27,080 --> 00:39:29,639
and the middle one,
and that bathroom.
715
00:39:29,640 --> 00:39:31,480
Yes, boss.
All right.
716
00:39:44,920 --> 00:39:46,800
Excuse me, uh, Camilla?
717
00:39:48,800 --> 00:39:50,760
Yeah.
Jesus fucking Christ.
718
00:39:54,920 --> 00:39:56,240
Jesus...
719
00:39:58,000 --> 00:39:59,399
We've actually met before.
720
00:39:59,400 --> 00:40:02,360
I treated you
a couple of months ago in A&E.
721
00:40:04,280 --> 00:40:05,640
OK.
722
00:40:07,440 --> 00:40:10,279
Well, I don't pay this much
to be kept waiting, so...
723
00:40:10,280 --> 00:40:11,840
Oh, of course.
724
00:40:18,800 --> 00:40:22,039
Fentanyl, 50 patches,
enough for a month.
725
00:40:22,040 --> 00:40:23,159
Did you say a month?
726
00:40:23,160 --> 00:40:24,880
Yeah, that's what Rob prescribes me.
727
00:40:29,120 --> 00:40:31,560
PEN SCRATCHING
728
00:40:32,800 --> 00:40:34,759
There's a week prescription.
729
00:40:34,760 --> 00:40:36,239
A week?
730
00:40:36,240 --> 00:40:37,839
What the fuck
am I meant to do with that?
731
00:40:37,840 --> 00:40:39,879
I don't know. You figure it out.
732
00:40:39,880 --> 00:40:42,599
You're either going
to take it or leave it.
733
00:40:42,600 --> 00:40:44,799
CAMILLA SCOFFS
734
00:40:44,800 --> 00:40:47,479
How do you pay Rob?
Do you pay him here or later?
735
00:40:47,480 --> 00:40:49,999
I pay the pharmacy,
like I usually do.
736
00:40:50,000 --> 00:40:51,440
See ya.
737
00:41:54,920 --> 00:41:56,720
Norma!
738
00:41:57,960 --> 00:42:00,560
Right, are you ready
for some dinner, darling?
739
00:42:01,920 --> 00:42:03,240
What are you doing?
740
00:42:05,840 --> 00:42:08,120
Eh, Abi?
741
00:42:14,640 --> 00:42:16,480
Abi?
742
00:42:23,120 --> 00:42:25,600
PHONE VIBRATES
743
00:42:40,800 --> 00:42:42,160
Come on, come on!
744
00:42:45,520 --> 00:42:48,400
HORN BEEPS
TYRES SCREECH
745
00:42:53,320 --> 00:42:54,600
Come on, move!
746
00:43:08,080 --> 00:43:10,039
Help in bay four, please.
747
00:43:10,040 --> 00:43:11,440
Help, please, help.
748
00:43:14,360 --> 00:43:15,920
Here.
749
00:43:17,520 --> 00:43:18,879
Tom?
She's not...
750
00:43:18,880 --> 00:43:22,359
She wasn't breathing,
she was just lying there. OK, OK.
751
00:43:22,360 --> 00:43:24,879
Just calm down, take a breath.
Now tell me what happened.
752
00:43:24,880 --> 00:43:26,359
I think she got hold of some...
753
00:43:26,360 --> 00:43:27,559
some diazepam.
754
00:43:27,560 --> 00:43:29,719
Can you page ITU now, please?
755
00:43:29,720 --> 00:43:30,999
Is she going to be OK?
756
00:43:31,000 --> 00:43:32,799
Are you sure it was diazepam?
757
00:43:32,800 --> 00:43:37,679
Yeah, there was an empty strip
of 10mg tablets lying next to her.
758
00:43:37,680 --> 00:43:41,799
Why do you have that strength
of diazepam lying around the house?
759
00:43:41,800 --> 00:43:43,279
I had a...
760
00:43:43,280 --> 00:43:45,799
a shoulder injury.
I had a prescription.
761
00:43:45,800 --> 00:43:47,759
OK, and how many tablets
were left in the strip?
762
00:43:47,760 --> 00:43:50,239
I don't know, maybe a couple.
OK.
763
00:43:50,240 --> 00:43:53,119
Is she going to be OK? Even if
there was only one... Yeah, OK.
764
00:43:53,120 --> 00:43:56,319
Tell me she's not going to die.
We're going to need flumazenil.
765
00:43:56,320 --> 00:43:58,999
Beth, could you give her
120 micrograms over 15 seconds
766
00:43:59,000 --> 00:44:00,999
and set up an infusion, please.
Thank you.
767
00:44:01,000 --> 00:44:02,359
She's not going to die, is she?
768
00:44:02,360 --> 00:44:04,959
She's going to be fine.
She's not going to die, is she?
769
00:44:04,960 --> 00:44:07,119
Need airways securing?
Yes, please, thank you, Sam.
770
00:44:07,120 --> 00:44:10,039
And could someone take Tom
to the relatives' room, please?
771
00:44:10,040 --> 00:44:11,960
Come on, it's just this way.
772
00:44:22,000 --> 00:44:23,519
PHONE BEEPS
Luce, it's Tom.
773
00:44:23,520 --> 00:44:27,599
You have to come...
Come to the hospital. We're in A&E.
774
00:44:27,600 --> 00:44:29,799
It's Abi, she's really sick, right?
775
00:44:29,800 --> 00:44:32,479
So just come...come to the hospital.
776
00:44:32,480 --> 00:44:34,320
Call me back. Call me...
777
00:44:46,960 --> 00:44:48,199
Hi.
778
00:44:48,200 --> 00:44:50,199
Hey, are you all right?
How can I help?
779
00:44:50,200 --> 00:44:54,439
The young lady
who was just in here, I'm her GP.
780
00:44:54,440 --> 00:44:57,319
Erm, what young lady?
781
00:44:57,320 --> 00:45:01,119
The one who just paid you
for her fentanyl prescription.
782
00:45:01,120 --> 00:45:04,439
She paid the normal
NHS prescription charge,
783
00:45:04,440 --> 00:45:05,919
like everybody else, so...
784
00:45:05,920 --> 00:45:08,120
I know she paid you extra.
785
00:45:10,680 --> 00:45:13,719
Can I speak to your manager, please?
786
00:45:13,720 --> 00:45:16,720
I don't want to cause any trouble,
I would just like to meet them.
787
00:45:18,480 --> 00:45:21,720
Right, yeah. Wait here.
Thank you.
788
00:45:25,800 --> 00:45:29,160
Luce, just pick up your phone.
Why aren't you picking up?
789
00:45:31,920 --> 00:45:33,960
HE EXHALES
Fucking...
790
00:45:37,640 --> 00:45:40,200
HE BREATHES DEEPLY
791
00:45:57,520 --> 00:45:59,840
PHONE VIBRATES
792
00:46:11,680 --> 00:46:14,639
TOM: Luce, it's Tom.
Pick up your phone.
793
00:46:14,640 --> 00:46:17,719
Call me back.
Something's happened.
794
00:46:17,720 --> 00:46:19,679
Right, you can come through
to the back.
795
00:46:19,680 --> 00:46:21,919
Pick up your phone, it's Abi.
She's not well.
796
00:46:21,920 --> 00:46:24,479
OK? Just come to the hospital.
Are you all right? Abi...
797
00:46:24,480 --> 00:46:26,639
Abi's not well.
She's taken some pills.
798
00:46:26,640 --> 00:46:28,999
Lucinda, it's Beth, I need you
to come into the hospital.
799
00:46:29,000 --> 00:46:31,159
Call me back.
He's waiting for you in the back.
800
00:46:31,160 --> 00:46:33,359
Pick up your fucking phone.
It's Abi. Hello?
801
00:46:33,360 --> 00:46:34,759
Lucinda, it's Leo here...
802
00:46:34,760 --> 00:46:36,239
Do you want me to go and get him?
803
00:46:36,240 --> 00:46:37,559
I need you to come to the hospital
804
00:46:37,560 --> 00:46:39,519
as quickly as you possibly can,
please.
805
00:46:39,520 --> 00:46:41,640
Abi's not well,
come to the hospital now.
806
00:47:31,120 --> 00:47:34,480
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