LCA Medico-Legal Morning Reports
with Hempsons solicitors
Dr Vanderpump reported on a recent virtual seminar provided by Hempsons on Coroner’s inquests. The following issues were discussed:
- The 4 statutory questions that are answered at an inquest with the civil standard of proof (>50%):
- Who died?
- When did they die?
- Where did they die?
- How they died? Medical cause of death, how and in what circumstances they came about death.
The decision can be challenged and the coroner can request an investigation or root-cause analysis. A jury inquest may be organized in the following circumstances:
- Violent death;
- Result of act/omission of police officer;
- Notifiable disease.
There was discussion by members on their experience at inquests including as experts and the interaction with relatives of the Deceased who may have legal representation. Frank Chinegwundoh discussed his recent experience attending an inquest remotely by zoom.
Mr Chawla referenced the following case:
Involving an NHS Trust being found liable for the injuries a child sustained when a hospital diagnosed her with tonsillitis but failed to recognise that she also had meningitis. The hospital had not addressed the meningitis symptoms previously identified by the child’s GP or appreciated that antibiotics administered by him prior to hospital admission could have masked the development of the child’s symptoms, and that the only safe way to proceed was to carry out tests to exclude other possible diagnoses.
The case also confirmed that the SHO involved was judged as against the standard expected of a reasonably competent SHO (i.e. not against the standard of a Consultant). It was, in fact, the Consultant’s assessment of the child and his decision to discharge on the basis that this was tonsillitis which was impugned.
Dr Towlerton rounded off the meeting with a presentation regarding ‘Somatic symptom disorder and Bodily distress disorder’ –
There have been changes to how we categories this disorders over the last few years. Both in the DSM V (diagnostic statistical handbook) and International Classification of disease (ICD-11).
The newer definitions of SSD do not exclude an organic cause but merely reflect the psychological disabling nature of the pains.
The latest edition of DSM 5 has moved away from the need to have no medical explanation in order to make the diagnosis of ‘medically unexplained symptoms’ and gain access to appropriate treatment. The emphasis now is on symptoms that are substantially more severe than expected in association with distress and impairment. The diagnosis includes conditions with no medical explanation and conditions where there is some underlying pathology but an exaggerated response.
The commonest problem is to differentiate this disorder from the ‘histrionic elaboration of organically caused pain. Patients with organic pain for whom a definite physical diagnosis has not yet been reached may easily become frightened or resentful, with resulting attention-seeking behaviour’.
- Persistent somatoform pain disorder (ICD 10 F45.4) is defined as: ‘(A) persistent severe and distressing pain, experienced for greater than 6 months and continuous on most days, in any part of the body, which cannot be explained adequately by evidence of a physiological process or a physical disorder, and which is consistently the main focus of the patient’s attention ….’The result is usually a marked increase in support and attention, either personal or medical….. The commonest problem is to differentiate this disorder from the histrionic elaboration of organically caused pain. Patients with organic pain for whom a definite physical diagnosis has not yet been reached may easily become frightened or resentful, with resulting attention-seeking behaviour’.
- Bodily distress disorder (ICD-11 6C20 ) is characterized by the presence of bodily symptoms that are distressing to the individual and excessive attention directed toward the symptoms, which may be manifest by repeated contact with health care providers. If another health condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression. Excessive attention is not alleviated by appropriate clinical examination and investigations and appropriate reassurance. Bodily symptoms are persistent, being present on most days for at least several months. Typically, bodily distress disorder involves multiple bodily symptoms that may vary over time. Occasionally there is a single symptom—usually pain or fatigue—that is associated with the other features of the disorder.
- Somatic symptom disorder. The diagnostic criteria for Somatic Symptom Disorder noted in DSM 5 are:
- One or more somatic symptoms that are distressing or result in significant disruption of daily life.
- Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy devoted to these symptoms or health concerns.
- Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
Specify if: With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.
Specify if: Persistent: a persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).
- Mild:Only one of the symptoms specified in Criterion B is fulfilled.
- Moderate:Two or more of the symptoms specified in Criterion B are fulfilled.
- Severe:Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).
These are categorical diagnosis.
It has been considered there has been significant diagnostic amplification over the recent re-defining these disorders and now catch a lot more people.
It has been shown this could be applied to 15-25% all patients in cardiac clinics and most people in pain clinics.
They are graded as mild, moderate, severe but this is based on the number of sites, systems or psychological consequences involved not related to the patients physical functional status?
The LCA would like to thank everyone who attended, particular our presenters.
Future meetings in 2020
2nd December 2020.
All LCA members with an interest in Medico-legal work as expert witnesses are invited. The format may remain virtual given the current restrictions regarding meetings.