AC-2024-LON-003354 - [2025] EWHC 2270 (Admin)

A further category of documents to which the claimants referred me were coroners’ Records of Inquests and three Prevention of Future Deaths (‘PFD’) reports. The claimants assert that these documents (particularly the PFD reports) merit special attention because they are the product of an inquisitorial process specifically designed to identify the existence of systemic risks and call attention to them.

Ms Emily Chesterton, the daughter of the Second and Third Claimants, died on 8 November 2022 from a pulmonary embolism. An inquest into her death was opened on 15 November 2022, and a hearing was held on 20 March 2023. The coroner issued a Record of Inquest, which recorded that:

“[Ms Chesterton] attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”

In her witness statement, Emily’s mother explained that she had only learned that the person reviewing Emily was not a doctor at the inquest hearing itself. She set out her belief that Emily had not known that it was a non-medically qualified person who was reviewing her and that, had she known this, she would have sought a second opinion.

At the inquest, the coroner heard evidence that the GP surgery had conducted its own internal review into Emily’s case and written a report. This documented a catalogue of failures, including that the PA failed to introduce herself or explain her status to Emily; failed to take an adequate history; failed to allow enough time for the appointment to conduct a thorough assessment; and failed to discuss the case with a doctor before sending her home. There had been earlier concerns about the PA’s ability to recognise an unwell patient and escalate their case to a doctor. Multiple medical colleagues had raised concerns about this particular PA’s overconfidence and lack of insight into the limitations of her clinical knowledge and practice. The PA herself seemingly continued to deny, even at the inquest, that she had acted outside of her competence. Throughout the appointments, the PA had not been directly supervised by a doctor, and she had never herself sought their input or discussed Emily’s case with them. Although a GP signed off on the Propranolol prescription (as PAs are not allowed to prescribe medicine), this was based purely off the PA’s (incorrect) notes and diagnoses. The GP in question said that she had hundreds of prescriptions to sign off, and this prescription had ‘slipped through the net’. Further, the PA’s decision not to allow Emily’s partner to join her during the appointment was contrary to the GP surgery’s policy.

No PFD report was submitted by the coroner, nor was the case notified to the defendant by the coroner although the Second and Third Claimants brought their concerns to the attention of the defendant in writing in April 2024 and met with the Chief Executive, Mr Massey on 17 July 2024. During the hearing of this claim, a document prepared by the GP surgery was disclosed. The document was, in effect, a scope of practice for the associates working in Emily’s GP surgery. It had been devised by the GP practice and had been in force when Emily had attended. It set out a list of conditions which the associates could see and those which were off limits. Had the document been adhered to by the associate she ought not to have seen Emily (at least, not on the second visit).