Tag Archives: deputy coroner

Post-mortem process is corrupt…

Coroner calls for a post-mortem, pathologist carries out post-mortem, reports to Coroner on cause of death, Coroner looks at whether an inquest is needed, or accepts findings and holds no inquest, body is released for burial.
Pretty straight forward process in most cases.

The family are legally entitled to request an independent pathologist – one not connected in anyway, professionally, with the hospital concerned if it was involved in the care of the patient.

Our family requested this when the police officer visited the family home.
The police officer agreed and informed the East Lancs Deputy Coroner (Martin Hall) who’s office is at Royal Blackburn Hospital (RBH).
Within an hour, Martin Hall phoned the family home (in rather a heated exchange) insisting that RBH’s senior Pathologist, Dr Richard Prescott was “completely independent from the living side of the hospital” and that he would be carrying out the post-mortem.

The family didn’t want this.
In light of dad leaving hospital with a terminal cancer diagnosis, having a biopsy (cytology) done in September 2014 and the family/GP/MacMillan nursing staff were not informed of the “no evidence of malignancy” (and the need for a retest) results from the 26th September 2014 until the 21st October 2014, just one day prior to dad passing away. Trust in Royal Blackburn Hospital senior staff was very low.

Martin Hall, the deputy coroner for East Lancashire continued to proclaim his independence.
The post-mortem went ahead.
When the findings came back, after a delay said by Martin Hall to be, “due to waiting for histopathological biopsy tests” the cause of death was said to be 1a. Bronchopneumonia 1b. Pancreatic adenocarcinoma.
This immediately raised our suspicions as Bronchopneumonia is a serious bacterial infection, not related to cancer.
We asked to see the histopathology test results. Martin Hall didn’t produce them.
We asked the East Lancs Chief Coroner Richard Taylor for a review of these test results, which he kindly asked RBH’s histopathologist (Dr Richard Prescott) for.

Once again the review took some time, when it came back, Dr Prescott had just four lines to say about the samples he had taken/findings he declared in the post-mortem and samples he had sent away for testing (according to Martin Hall, deputy coroner) instead, Dr Prescott proceeded to attempt to discredit the “no evidence of malignancy” findings of the cytology biopsy taken from dad when he was in ward C1 at Royal Blackburn hospital.
Dr Prescott and Martin Hall both made attempts to claim that the cytology samples tested when our dad was alive, was to put it bluntly “a false negative as in effect, they are taken from a moving target” – we were astounded by this, not because of the terminology, we understood this, but by the identical claims of two independent and separate people involved in the process!
What they both failed to tell the family and the Chief Coroner was that when the cytology samples are taken, an ultrasound camera is used, which is considered to be highly accurate.
A negative cytology result is around 95% accurate, whereas a positive test result only has to be between 50% and 70% accurate to prove a diagnosis.
Dad’s test results came back showing “no evidence of malignancy”.

The Multi Disciplinary Team (HPB MDT) at RBH had ruled this a false negative also.

We dismissed this and asked for a further review from the Chief Coroner for East Lancs. He set this in motion.
Senior RBH pathologist Dr Prescott, once again mostly ignored his own post-mortem test results and instead analysed the cytology samples that returned negative, then changed his opinion.
After claiming in his first view of the cytology samples taken when dad was alive, that these were taken from a “moving target” he now claimed that he “had reviewed the same cytology samples and found there to be definite atypical cancer cells present, albeit in small amounts” – Dr Richard Prescott was now implying that the original findings reported from the cytology samples, were wrong.

The findings did not indicate any cancerous cells were present, according to common practice cytopathology reporting standards, the order of reporting is;

  • No evidence of malignancy
  • atypical cancer cells (cells that could turn into cancer cells in the future)
  • Definitive cancer cells present

We looked into the Cytopathologist whom originally found no evidence of malignancy, a Dr Robin Moseley, who is a clinical lead cytopathologist of Addenbrooke’s cancer hospital. A more expert Doctor we could not have found.

The Chief Coroner then closed down the inquest, refusing one, stating he was satisfied with the expert medical opinion given by Dr Richard Prescott and stated he must rely on this.
When we revealed to the Chief Coroner that we had discovered that Dr Richard Prescott sits alongside one Mr David Chang on the NSSG cancer network, whom is the clinical lead of Royal Blackburn hospital’s HPB MDT team, the very same HPB MDT team that diagnosed dad’s cancer and with held the “no evidence of malignancy” test results from MacMillan (read: Royal Blackburn’s specialist palliative cancer care team), dad’s GP and the family for weeks, the Chief Coroner simply dismissed it out of hand as having no relevance!

With no inquest to take place, it was only now that Dr Richard Prescott of Royal Blackburn hospital revealed to the Chief Coroner that he was not a qualified/practising cytopathologist and a second opinion should be sought.
Which begs the question, why was Dr Prescott giving the Chief Coroner his opinions (as fact) on the “no evidence of malignancy findings” and attempting to discredit them, when he was not qualified to do so?

Legally, Dr Prescott is duty bound to report any possible conflicts of interest to the Chief Coroner when asked to perform a post-mortem. Dr Prescott did not declare any possible conflict of interest, he went further in making representations via the deputy coroner, Martin Hall, that he was “completely independent from the living side of the hospital” – not a single mention that he sits on the NSSG cancer network alongside Mr David Chang, whom is also the clinical on Royal Blackburn’s HPB MDT team, the same expert team that diagnosed terminal stage T4 cancer in dad.

Despite numerous requests and assurances, over several weeks, that we could have a copy of the post-mortem biopsy test results from Martin Hall, East Lancs deputy coroner, we never received them.
The Chief Coroner admitted that he had never seen them either, but claimed it was not something he would be given unless requested.
That we have never received these test results, is no surprise, as Martin hall, deputy coroner let slip in a very heated exchange after the inquest had been refused, that the test results do not exist!
The confirmation of cancer being present in the post-mortem biopsy samples, was the opinion of just one person, the pathologist who carried out the post-mortem at Royal Blackburn hospital, one Dr Richard Prescott!
He doesn’t even have them tested, he simply looks at the slides through a microscope and gives his “expert” opinion.

So why did East Lancashire deputy coroner Martin Hall continue to claim the reason for the delays in Dr Prescott’s findings were due to him “awaiting the return of the post-mortem biopsy results”?
Why did Martin Hall continue to promise the family a copy of the post-mortem biopsy test results if they never existed?
Does Martin Hall (by all accounts an experienced deputy coroner) not know the basic procedure regarding post-mortem biopsy testing?

Benefit of the doubt many readers will no doubt give, fair point I would say. But please consider this.

Over a year after dad passed away, East Lancashire Hospitals Health Trust chairman, Kevin McGee, finally admitted in writing, that Dr Richard Prescott, the “independent pathologist”, whom carried out the post-mortem, is the very same Dr Richard Prescott that sits on the weekly HPB MDT meetings at Royal Blackburn hospital, under the clinical lead of Mr David Chang (sits with Dr Prescott on the NSSG cancer network) and was a member of the very same HPB MDT team, that diagnosed dad with terminal stage T4 cancer!
The same HPB MDT team that sat on dad’s negative test results and did not retest him or pass on the results to dad’s family, MacMillan nursing staff or GP.

Dr Prescott did not declare this clear conflict of interest to the East Lancs Chief Coroner and when we raised concerns about his independence, we were ignored.
The Chief Coroner ended the process by stating that if we had any issues with the post-mortem, we should take these up with Royal Blackburn Hospital.

More serious concerns are raised since we discovered that Dr Prescott had established cause of death (his main role as a pathologist) as Bronchopneumonia, then requested more time and permission to take samples of the pancreas from the Chief Coroner of East Lancashire.
This request was granted.
We cannot see what representations were made for this request, as the Chief Coroner’s office are currently blocking the family access to dad’s file that they hold.

The General Medical Council (GMC) can see nothing untoward in this process, despite it being against their own Good Medical Practice regulations, but that is for another post dedicated to their organisation…