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 Subtitles by accessibility@itv.com