Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0039, written 22 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jan 2025 |
|---|---|
| Reference | 2025-0039 |
| Deceased | Fahmida Khanam |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (East) |
| Category | Other related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Organisation Name: Savile Town Medical Centre GP Treatment of Immediate Family Members Policy Number Version Edited by Date issued STMC-301 1.0 T Jan 29/01/2025 Next review date 30/06/2026 Named individual Position Practice Manager Lead GP Deputy Lead GP Table of contents 1 1.1 1.2 1.3 1.4 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 INTRODUCTION Purpose Scope Policy Statement Status POLICY Definitions General Guidelines Ethical Considerations Exceptions Procedure Responsibility Enforcement References 2 2 2 2 2 2 2 2 3 3 3 4 4 4 1 1 Introduction 1.1 PURPOSE The purpose of this policy is to establish clear guidelines for GPs to follow regarding the treatment of immediate family members (i.e., spouse, children, parents, siblings) to maintain ethical medical practice and ensure patient safety, confidentiality, and professional boundaries. 1.2 SCOPE This policy applies to all General Practitioners (GPs) and healthcare providers working within the practice, including locum doctors, nurses, and allied health professionals. 1.3 POLICY STATEMENT GPs should avoid treating immediate family members due to potential conflicts of interest, emotional bias, and challenges in maintaining professional boundaries. Exceptions may be made in urgent or emergency situations, but these should be documented and reviewed in accordance with ethical and legal guidelines. 1.4 Status In accordance with the Equality Act 2010, we have considered how provisions within this policy might impact on different groups and individuals. This document and any procedures contained within it are non-contractual, which means they may be modified or withdrawn at any time. They apply to all employees and contractors working for the organisation. 2 Policy 2.1 Definitions • Immediate Family Member: A family member who is related by blood, marriage, or domestic partnership, including parents, children, siblings, and spouses. • Treatment: Any medical intervention, including but not limited to diagnosis, prescription of medications, surgery, or counselling. 2.2 General Guidelines 1. Avoidance of Direct Treatment: GPs are advised not to treat their immediate family members directly unless in an emergency where no other healthcare provider is available. 2. Referral Requirement: If a GP's immediate family member seeks treatment, the GP should refer them to another qualified healthcare professional or GP within the practice, ensuring continuity of care while maintaining professional objectivity. 3. Emergency Situations: In the case of an emergency, where treatment is necessary to prevent harm or injury and no other healthcare provider is available, the GP may provide initial treatment. However, this should be followed by referral to an external healthcare provider as soon as possible. 2 4. Clear Documentation: All decisions regarding the treatment of family members must be clearly documented in the patient’s medical record, including any referrals made, the reason for the GP's involvement, and any risks or conflicts of interest identified. 5. Patient Consent: If a GP must treat a family member in an emergency or unavoidable situation, informed consent should be obtained, acknowledging the potential conflict of interest. The GP should explain the reasons for their involvement and the limitations this might impose. 2.3 Ethical Considerations 1. Impartiality: Treatment of family members could be compromised by emotional involvement, which may impair the GP's ability to offer impartial and objective care. 2. Confidentiality: The GP should ensure that patient confidentiality is upheld at all times, even with immediate family members. GPs must avoid sharing any medical information about the family member with others, unless consent is provided. 3. Professional Boundaries: Clear professional boundaries should be maintained between the GP and their family member to avoid inappropriate dynamics and ensure effective care. 2.4 Exceptions While it is generally discouraged for GPs to treat family members, exceptions may include: • Emergencies: If immediate treatment is necessary to preserve life or prevent significant harm. • Geographic/Access Limitations: In areas with limited healthcare providers, a GP may need to treat a family member, but this should be a temporary solution until a referral to an external provider is possible. 2.5 Procedure 1. Family Member Requests Treatment: • The GP should first assess whether they can provide appropriate care without compromising ethical guidelines. • If possible, refer the family member to another GP or healthcare provider within the practice or externally. 2. In the Case of an Emergency: • Provide immediate care to the family member if no other healthcare provider is available. • After providing emergency care, make a formal referral to an external healthcare provider. • Ensure that all steps taken are thoroughly documented in the patient’s record. 3. Referral Process: 3 • For non-emergency situations, if the GP is unable or unwilling to treat a family member, they should refer the family member to another GP or specialist in a timely manner. • The GP must ensure a smooth transition and provide any necessary medical information to the treating physician with the family member’s consent. 4. Documentation: • Record all details of the decision-making process, including the rationale for any deviation from standard practice, consent obtained, and referrals made. 5. Review: • Periodically review the appropriateness of the policy and make adjustments as necessary based on patient feedback, staff input, and regulatory changes. 2.6 Responsibility All GPs and clinical staff within the practice are responsible for adhering to this policy and ensuring that immediate family members are treated with the highest standards of care while respecting professional boundaries. 2.7 Enforcement Failure to adhere to this policy may result in disciplinary action, including but not limited to formal warnings or review of clinical practice. 2.8 References GMC Good Medical Practice Guideline, 2024 4
OFFICE OF THE
SENIOR CORONER
for the County of West Yorkshire
(Eastern District)
His Majesty’s Coroner’s Office
The Coroner’s Courts
Burgage Square
Wakefield WF1 2TS
Telephone:
Email:
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. General Medical Council
2.
CORONER
1
2
3
I am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (East)
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
On 12th November 2024 I commenced an investigation into the death of Fahmida Khanam, 74.
The investigation concluded on 16th January 2025. The conclusion of the investigation that the
death was due to natural causes, specifically:
1a Myocardial infarction
1b Severe coronary artery atheroma
2 Hypertension, asthma, diabetes mellitus, chronic kidney disease
CIRCUMSTANCES
THE
OF
DEATH
4
Mrs Khanam died on 12th November 2024. A post mortem attributed her death to natural
causes. It emerged that her husband,
had been treating his wife. The
Medical Examiner refused to countersign the cause of death put forward by another doctor in
’s practice. This necessitated a post mortem.
CORONER’S CONCERNS
During the course of the investigation the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
5
The MATTERS OF CONCERN are as follows: –
It is NOT suggested that any suspicious conduct has taken place.
The matter is reported as it is understood to be a cardinal principle that a doctor should not
treat a close relative.
The following documents accompany this report:
1 Post mortem report dated 15th January 2025
2 My letter to
ACTION
dated 14th November 2024
SHOULD
BE
TAKEN
In my opinion action should be taken to prevent future deaths and I believe your organisation
has the power to take such action.
YOUR
RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely
period.
by
Coroner, may
19th March
extend
2025.
the
the
I,
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES
PUBLICATION
and
I have sent a copy of my report to the Chief Coroner
I am also under a duty
to send
the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
Signed:
7
6
8
9
KEVIN McLOUGHLIN
Senior Coroner
West Yorkshire (E)
Date: 22 January 2025
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
10 March 2025 Kevin McLoughlin His Majesty’s Coroner’s Office The Coroner’s Courts Burgage Square Wakefield WF1 2TS Sent via email: Dear Mr McLoughlin Thank you for sending the Rule 28 report arising from the investigation into the death of Mrs Fahmida Khanam. May I offer our sincere condolences to the family for their loss. You draw attention to the fact that Mrs Khanam’s husband, , had been treating her. While you concluded that Mrs Khanam died of natural causes and do not suggest any suspicious conduct on the part of , you have referred the matter to us based on your understanding that ‘it is a cardinal principle that a doctor should not treat a close relative’. As the independent statutory regulator of doctors, physician associates (PAs) and anaesthesia associates (AAs) in the UK, our focus is to support good, safe patient care. One of our key functions is to set and maintain the professional standards expected of our registrants. In the introduction to Good Medical Practice, we say: “. . . it isn’t a set of rules. You must use your professional judgement to apply the standards in Good medical practice to your day to day practice. This means working out which of the professional standards are relevant to the specific circumstances you are facing, and using your knowledge, skills and experience to follow them in that context.” On the specific concern that you highlight, in paragraph 97 of that guidance, we say ‘You must, wherever possible, avoid providing medical care to yourself or anyone with whom you have a close personal relationship’. You go on to point registrants to the more detailed guidance on Good practice in proposing, prescribing, providing and managing medicines and devices and in particular paragraphs 66 to 68 regarding record keeping and the issues around prescribing controlled drugs. So, our guidance does not forbid doctors from treating those close to them - there may be circumstances where no other doctor is available, for example when they live in remote rural areas. However, best practice would be to avoid doing so wherever possible because of the potential pitfalls. For example, it may be difficult to be objective when treating a family member (including issuing prescriptions): the family member may feel constrained in being open and honest about their condition. And not every departure from our standards will be considered serious enough to justify action affecting a registrant’s registration and licence to practice. The GMC is a charity registered in England and Wales (1089278) and Scotland (SC037750). When a concern is raised with us about a registrant, we must assess whether that individual poses any current and ongoing risk in line with our regulatory responsibilities: • protecting, promoting and maintaining the health, safety and wellbeing of the public • promoting and maintaining public confidence in the medical professions, and • promoting and maintaining proper professional standards and conduct for members of those professions. Further information about our processes and the types of action we might need to take can be found on our fitness to practise webpages. Thank you for highlighting this matter with us. Yours sincerely Medical Director and Director of Education and Standards gmc.uk.org 2
Saville Town Medical Centre, T. 01924 461124 E: admin.saviletownmedicalcentre@nhs.net Providing NHS Services Katie Lee Coroner's Services Team Leader His Majestys Coroners Office The Coroners Courts, Burgage Square, Merchant Gate, Wakefield, WF12TS Your Ref: Date: 28/01/2025 Dear Katie Thank you for sharing the report. Mrs. Khanam was registered with Leigh View Medical Practice from 2008 until July 2023. During this time, she had several comorbidities, including uncontrolled asthma, hypertension, type 2 diabetes mellitus (T2DM), and chronic kidney disease (CKD) stage 3. Being a GP myself, | observed that her clinical needs were not adequately met, particularly regarding her uncontrolled asthma and hypertension. Both Mrs Khanam and | were registered at Leigh View Medical Practice, but we were dissatisfied with the care provided, which led us to leave the practice and seek care elsewhere. Mrs. Khanam chose to register with Savile Town Medical Centre, where a team of Health care professionals including GPs could share the workload, ensuring better care. Mrs. Knanam also worked as a senior administrator at this practice. Prior to joining Savile Town Medical Centre, Mrs. Khanam was seen by a Nurse Practitioner at her former practice, but she expressed dissatisfaction with the care provided. She felt the treatment was inadequate and not aligned with current clinical pathways or NICE guidelines. After discussing her concerns with another colleague GP at Savile Town Medical Centre, | referred Mrs. Khanam to a respiratory physician for her uncontrolled asthma—something that had not been addressed at her previous practice. Additionally, based on her clinical symptoms, | also referred her to an ENT specialist. Once she has seen respiratory physician at the hospital, where her treatment management was reviewed with commencing of new medication which resulted her Well control of Asthma. Also, with hypertension management when she was prescribed new medication her blood pressure became well controlled. Mrs khanum was only issued repeat prescriptions for her Asthma and a couple of referrals to secondary care for treatment management, as mentioned above. However, | have discussed this with the GP partner and management, on how to avoid this happening again in the future. The practice is to adopt a protocol/procedure immediately to ensure a GP must not treat immediate family members according to GMC guidelines and current Good Medical Practice guidelines. Your Sincerely Address Saville Town Medical Centre, 786 Scarborough Street, Dewsbury West Yorkshire. WF12 9AY
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