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Malpractice Season 1 Episode 3

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Transcript
00:00This is 23-year-old Edith the WUSA.
00:03One of Rob's patients accidentally overdosed.
00:06He called me and asked me to code.
00:08That overdose is deliberate.
00:09Why is this going to an end cost?
00:11Just stick to the facts regarding the treatment he gave Edith.
00:13You'll be fine.
00:14Don't do this, please! I'm begging you!
00:16Stop it! Stop it! Stop it!
00:17I'm telling you're an addict!
00:18I'm not an addict!
00:21Rob and local GP, Dr. Rob Thornberry,
00:23got hit by a car in Park Square.
00:25So, the assumption is whoever owns that number
00:34alerted Lucinda to Edith's overdose.
00:37I'd like to invite the founder, Dr. Joubert Singh,
00:40to present the award.
00:41The winners of the Outstanding Covid Response Award are
00:46West Yorkshire Royal Hospital's A&E team.
00:48How about I give you something that's going to help you calm down?
00:51Fetch me four ten milligram Diasman tablets.
00:55Forty milligrams?
00:57You'll knock her out.
00:58I need to get my phone fixed, please.
01:01Rob, I need to know if you've dealt with her.
01:03If this goes any further, then trust me,
01:05you'll be the one going down with her.
01:13I'm very sick of you.
01:15Get's serious.
01:16Come, Rob.
01:17I'm both dead figures.
01:18Look good.
01:20All right.
01:21How did you do that?
01:22I'm too much heteripples.
01:23I've been able to trust a replacement just to make her part
01:25to her shoulders.
01:26Why, no one can Bruce?
01:34I can't control you.
01:35Let us know where she is because she understands
01:36that she's not as serious opening up early.
01:38This is spreading.
01:39Something doesn't really need to know
01:40that the sword is back.
01:41The last weakness is to support Moses-
01:42so lucinda's phone records finally arrived yesterday right i cross-referenced it with
02:03the date she treated opioid overdoses and look the same number that called lucinda the day
02:08edith died called her twice on january 7th before alexander taylor arrived in aene with a
02:13deliberate overdose and again twice february 23rd when camilla would have presented in exactly the
02:20same way and i checked with the 999 call center both overdoses were called in by that number
02:26just like edith well that is interesting isn't it
02:32did they call before milo hanbury came in no but i mean even if we discount milo for now
02:42looks like she's working with someone but who let's get the notes for alexander taylor and
02:52camilla woodham see if there's anything linking them to each other to lucinda to edith already on
02:58yep i'm picking them up later this morning steady on george you'll have my job next well done
03:04right i better get to the same quest oh yes
03:07right the facts are lucinda you had to deal with a gunshot victim so you left edith uhusu in ramia's
03:14capable hands with a clear management plan which you ramia followed we did everything we could
03:21but this is the tragic result of a girl trying to take her own life just to warn you edith's dad
03:27sir anthony used to be a barrister so he's going to be acting as the family's legal representation i
03:33know i know it feels daunting but remember none of you are on trial okay this is just a fact-finding
03:40exercise to help the coroner determine the exact cause of death so what you've got to do is stick to
03:45the hospital line you each did your best to treat edith but these things happen right nobody is culpable
03:52and what's what's the worst that could happen well if the coroner concludes this medical negligence has
03:59caused edith's death then that could open us up to lawsuits from the family the police could get
04:04involved so let's not give him the opportunity however if he rules it's a suicide then the hospital
04:11will look less responsible so good luck let's get going thank you
04:17i can see that this is difficult for you but um when did you last see edith
04:24the day she died what was your impression of edith's mental state during those times
04:31we had no reason to believe she was using drugs was there a hint of suicidal thinking
04:38no none thank you if you'd wait there please uh mrs roberts do you have any questions
04:49uh very to roberts legal counsel west yorkshire royal hospital when edith left your home did she
04:56mention any anxiety about the new job any problems with friends or a partner edith didn't have a partner
05:03she was excited about the new job but i don't believe she was trying to kill herself
05:11i'd like to play part of the 999 call that was made the night that edith died and if you find that
05:18too distressing i can read out a transcript instead no it's fine please go ahead can we play the recording
05:25please i need an ambulance i need an ambulance to 9 somerville road my friend edith i think she's
05:32tried to kill herself okay who am i speaking to and what has edith done i i don't know she's
05:37she's just i think she's dying she's not responding please you need to send someone right away
05:419 somerville road do you know this friend of edith's no
05:46i don't know never heard never heard that voice before but she had many friends
05:53she was popular it's hard to keep up with everyone he states very clearly that edith tried to kill
06:02herself is it not possible that during those last days it's edith hid a drug use and a suicidal thought
06:08it wasn't suicide if i thought for one second edith intended to harm herself i would never have left
06:15around the road never the edith's overdose was an accident your hospital missed an opportunity to save
06:30her life sorry thank you you must have done that
06:39is
06:41is
06:42i
06:43is
06:45is
06:46is
06:48is
06:49is
06:50is
06:52who
06:53is
06:54is
06:58The post-mortem indicated Edith was using opioids regularly.
07:23There were multiple puncture marks on her body, consistent with drug injection, and hair follicle samples contained opioid metabolites, indicating long-term use.
07:33In your opinion, did opioids contribute to Edith's death?
07:36Yes. Toxicology and pathology confirm intravenous administration of the opioid drug fentanyl caused Edith's death.
07:46Did Edith check a large amount of fentanyl?
07:48We found high levels of fentanyl in Edith's blood.
07:5363.8 micrograms per litre.
07:56So, given the high levels of fentanyl found in Edith's blood, was the overdose likely to have been deliberate or accidental?
08:03Fentanyl is 50 times stronger than heroin, but a seasoned drug user like Edith would know you only need a small amount to feel its effect.
08:12So, why did she take so much?
08:15On the other hand, she could easily just be pursuing a greater high and miscalculated the dose.
08:24Thank you. I have no further questions.
08:26Mrs. Roberts?
08:27No, sir.
08:28Sir Anthony?
08:29No, sir.
08:30In that case, I'd like to thank you, Dr. Adeyemi.
08:33You may step down.
08:34The next witness I would like to call is Dr. Eva Tate.
08:50Dr. Tate, would you care to swear or affirm?
09:07I'll swear.
09:08In that case, there is a small card on the ledge in front of you, if you'd read from that, please.
09:12I swear by the Almighty God that the evidence I give shall be the truth, the whole truth, and nothing but the truth.
09:20Thank you, Dr. Tate, for taking time out of your maternity leave to be with us today.
09:24The court much appreciates that.
09:26It's the least I could do.
09:28Now, you were Edith's addiction consultant at the Gelber Clinic from May to October 2021?
09:35Yes, that's right.
09:36Edith had a complex history of drug misuse, including cocaine, alcohol, and heroin, which was her main problem, and she wanted to be free of it.
09:52But she engaged well with the treatment, and she achieved this.
09:55She was abstinent when she left us.
09:58So was there any possibility that she could have relapsed?
10:00Well, yes, sadly.
10:03For opiate addicts, the risk of relapse is high.
10:07Particularly now that it's easier to buy synthetic opioids, such as fentanyl, on the streets.
10:14And when Edith was under your care, did she ever express suicidal tendencies?
10:20Yes.
10:23We did extensive work on her negative thoughts and core beliefs, but suicidal ideation remained a prominent problem.
10:33It's okay.
10:36Take your time.
10:40It's very sad.
10:41Where the hell didn't you say you knew Edith from the Gilder Clinic?
10:50Shh.
10:51Jacinda, have you forgotten where we are?
10:52We were at the inquest of a girl who died because Rob prescribed her fentanyl.
10:56What the fuck was he thinking?
10:57You can't prove the fentanyl came from Rob.
11:00Edith Cleasley brought her off the street.
11:03He told me he was prescribing her...
11:04He told me he was prescribing her methadone.
11:13She was a patient of yours.
11:14No, she was not my patient when she died.
11:17I haven't seen her for months.
11:18No, Rob specifically called me because he didn't want anyone looking into his prescribing.
11:23He was covering up what the hell you two were doing.
11:25No, I haven't done anything.
11:28If Rob was prescribing for Edith, I knew nothing about it.
11:31Okay, so how did he know them?
11:32How did he know Camilla, Alexander, all the other patients?
11:35This is just a fucking coincidence.
11:39This is just a coincidence that they were all being treated at the Gilder Clinic.
11:43I have done nothing wrong.
11:46But you have covered up, what, three overdoses for Rob?
11:48So you're just as implicated now.
11:50He was prescribing illegal drugs to addicts.
11:52Yeah.
11:53Addicts like you.
11:55Listen to you.
11:57Accusing me and Rob and...
11:59You seem to have forgotten about your own drug habit.
12:01I wonder what the MIU would make of that.
12:04You wouldn't dare.
12:05Wouldn't I?
12:07If you don't stop pointing the finger at us, I will have no choice.
12:11Interested by the sound of you?
12:13You'll do a refill.
12:15If you weren't so busy accusing me, I might have been able to help you.
12:34Tom?
12:36Abby?
12:36Abby?
12:36I've gone through the A&E notes for Alexander Taylor and Camilla Woodham, but nothing indicates Lucinda knew them.
12:58Well, um, how was the inquest?
13:05You know, long.
13:07None of the RH team even gave evidence today, so it was just, um, the pathologist, uh, Edith's psychiatrist from the Gilder Clinic and her mum.
13:14Yeah, the Gilder Clinic.
13:16Wait, hold on.
13:18Oh, yeah, yeah.
13:19Uh, both Camilla and Alexander were detoxed there.
13:26Well, that can't be a coincidence.
13:28Could Lucinda have a connection to the clinic?
13:30Will you go there tomorrow and see what you can find out?
13:32Oh, yeah, yeah.
13:33Will do.
13:43You don't know, Camilla.
13:44I'm sorry.
13:54I'm sorry.
14:03I'm sorry.
14:14In your statement, you said there weren't any options.
14:24Edith was the most stable patient.
14:26She needed to be moved.
14:28So Dr. Edith showed poor clinical judgment.
14:31Wasn't able to prioritize and delayed Edith's transfer for what?
14:36No reason?
14:38Um, I'm sorry. I don't remember.
14:40Really?
14:40Oh, you don't recall pressurizing Dr. Edith into prioritizing patient X
14:47because, I quote, she's just a child over Edith,
14:52who, I quote, was just a junkie?
14:55No.
14:58Well, um, we have a statement from a porter who alleges you did just that.
15:04No, no, I would never use the word junkie to describe a patient.
15:09That's derogatory.
15:11I just wouldn't, I wouldn't use that word.
15:15Hmm.
15:17You know, sometimes facts like that are, well, they're hard to remember, aren't they?
15:24No further questions, sir?
15:26Thank you, Sir Anthony.
15:28Miss Roberts, any questions?
15:29No, sir.
15:32Thank you, Miss Ralph.
15:33Be free to go.
15:34Please step down.
15:41Our next witness is Dr. Ramya Morgan.
15:44Would you care to swear or affirm?
16:00I'll swear.
16:02Would you like an alternative text?
16:04Um, no, the regular Bible's fine, thanks.
16:07Okay, thank you.
16:08If you would, uh, read from the card in front of you, please.
16:13I swear by almighty God that the evidence I give shall be the truth, the whole truth, and nothing but the truth.
16:21Sir Anthony, your witness.
16:22Dr. Ramya Morgan, can you take us through your involvement in, uh, Edith's A&E care?
16:32Um, I was bleeped to resource to watch Edith while Dr. Edwards took care of an emergency in reception.
16:41And when she came back, I thought she would continue looking after Edith.
16:44Uh, but instead I was told, uh, patient X needed Edith's bed, and I was going to majors with Edith, and Dr. Edwards gave me a treatment plan.
16:55And what was that treatment plan?
16:57Uh, Dr. Edwards asked me to give 800 micrograms naloxone, and if Edith's breathing improved, to let her know.
17:06And what happened next?
17:07Well, after the naloxone was given, Edith's respiratory rate improved, so I returned to resource.
17:12Leaving Edith alone?
17:13Uh, there were other staff around.
17:15But no one dedicated to her care, correct?
17:18Correct.
17:19Did you consider waiting and observing Edith?
17:22To see if the improvement in her breathing would be maintained?
17:26I waited to see the improvement.
17:28And then you left?
17:29Immediately?
17:30Uh, no, no.
17:31Uh, not immediately.
17:33Uh, I can't remember how long I stayed.
17:37Hmm.
17:39Dr. Morgan, do you know how quickly the initial effects of naloxone can...
17:44And where else?
17:45Uh, I now know.
17:48But he didn't know when you prescribed the drug for Edith.
17:53Did you?
17:56How long have you been a qualified doctor?
18:00About 18 months.
18:01And how long did Dr. Edwards ask you to wait and observe Edith?
18:06I'm not...
18:07I don't remember.
18:10I'm so sorry.
18:10Could you speak up so the whole court can hear you?
18:14I don't remember.
18:16And when you returned, uh, to recess, what's Dr. Edwards grateful for your, um, extra pair of hands?
18:25I don't remember.
18:28Well, let me help you there, shall I?
18:30I'm quoting from her statement.
18:33When Dr. Morgan returned to recess, I asked her why she wasn't with the overdose patient.
18:39So, clearly, Dr. Edwards wasn't expecting you back.
18:44So I'll ask you again.
18:45Why did you leave Edith so quickly and return to recess to a different patient who's already been handled by doctors with far more experience?
18:52And Dr. Edwards never said that I needed to stay longer in case the naloxone stopped working.
18:57I'm sorry, are you saying that Dr. Edwards lied?
19:00No, no.
19:01What she said in her written statement was false.
19:03No, but I can only tell you what I remember.
19:06Okay.
19:08So, in this hospital full of competent doctors, Dr. Edwards didn't tell you how long to wait with Edith.
19:16And after 18 months as a qualified medical practitioner, you didn't know how long to wait either.
19:21A&E is really hectic.
19:24And patients turn up all the time with conditions that you don't know how to treat.
19:28So you have to rely on your seniors for the support to work safely.
19:33Okay.
19:33So what she was really saying is that without instructions from a senior, you don't know how to treat an overdose.
19:41No, I didn't say that.
19:43But I'm a junior.
19:44I'm there to learn.
19:46And there's a lot to remember.
19:47And after giving only one dose of naloxone to my daughter, you returned to resus.
19:58You should only wait a few minutes more.
20:01You don't notice the initial effects of naloxone wearing off and being able to administer a second potentially life-saving dose.
20:10But you left her struggling to breathe and under-medicated.
20:18You effectively left Edith to die, didn't you?
20:26Hmm?
20:32No further questions, sir.
20:35Mrs. Roberts, questions from yourself?
20:38No, sir.
20:40You may step down when you're ready.
20:42Do you have any idea, any idea, how damaging this is to the trust?
20:47You threw me under the bus as soon as he questioned your confidence.
20:50But I didn't know how long to wait.
20:52And you didn't tell me that naloxone would wear off so quickly.
20:54Well, if you stayed like I told you, you would have seen how quickly it wears off.
20:58Instead, you came to resus.
20:59But you need to control your juniors, Leo.
21:01This has got nothing to do with me.
21:03I wasn't there.
21:04Yeah, and you should have been.
21:05Hey, come on.
21:05Guys, guys, come on.
21:07Come on, rein it in.
21:08We can recover from this.
21:10But it is all going to depend heavily on you, Lucinda, not messing it up this afternoon.
21:16You've got to stick to the script.
21:18Have you got that?
21:20Lucinda?
21:21Have you?
21:23I'm an A&E doctor.
21:25I'm not a mental health specialist.
21:27Assessing whether a patient deliberately wanted to kill themselves,
21:31that should be done by a psychiatrist, not me.
21:33But either had deliberately overdosed before.
21:35Past behaviour usually predicts future behaviour.
21:39And in cases where intent is unclear, I always err on the side of caution and code it as deliberate.
21:45This ensures that the patients are reviewed by psychiatry prior to discharge.
21:51And when did you become aware that there was a problem with Edith's care?
21:56Shortly after we stabilised patient X, the alarms and majors went off.
22:00I ran to Edith, but she was already in respiratory failure.
22:05Edith shortly went into cardiac arrest.
22:09We worked on her for a half an hour, but we never got her back.
22:12Thank you, Dr Edwards.
22:13If you'd wait there, please.
22:16Sir Anthony, your witness.
22:18Thank you, sir.
22:20Dr Edwards, would you say Dr Morgan is prone to forgetting simple instructions?
22:26Uh, we're all prone to occasional forgetfulness.
22:34Yes, but it's highly unlikely that a doctor, capable of learning enough facts to pass her finals,
22:40with distinction, 18 months prior, wouldn't remember the simple instructions of watch, wait, and repeat a dose?
22:46Well, in normal circumstances, yes.
22:48Yes, but A&E isn't normal.
22:52And with all due respect, sir, memorising facts for an exam is very different to processing information in a real-life, high-pressure situation.
23:01Yes, but even with all this pressure, Dr Morgan correctly remembered the more complex details you gave her vis-à-vis the type of drug and the dose.
23:11Isn't it more likely that, uh, your instructions were unclear?
23:16No, because she wasn't listening.
23:19Yes, you said that Dr Morgan wasn't listening, and your colleague spoke of your reluctance to leave Edith with her.
23:27So why did you?
23:28Because I had no choice and I had to make a decision, that's why.
23:30Yes, you made all the decisions.
23:33You dithered.
23:35No, no, no, no, I didn't take that, but I didn't...
23:37You chose to leave Edith with a doctor whose incompetence has been shown today, and that choice killed her.
23:48Are you not therefore guilty of gross negligence?
23:51Sir, this is not a criminal court.
23:53If I may remind counsel, whilst I understand the emotional distress of this hearing,
23:56he must refrain from accusing witnesses of criminal offences they're not on trial for.
24:07You treated my daughter without diligence.
24:10Oh, do you care?
24:14Total disregard for the...
24:19For the severity...
24:24Of the symptoms.
24:33Um...
24:34Sir, I...
24:35I apologize.
24:37No further questions.
24:50In that case, I'd like to bring the session to a close.
24:53I'll retire to consider my verdict.
24:59We will reconvene in three hours.
25:07Thank you, Dr Edwards.
25:07You may step down.
25:09And thank you, everyone else, for your time.
25:10Excuse me, Mr. Antony, but I'm just very sorry for your loss.
25:40I got a bottle of the liquid night suit, and the one a night.
26:09These both contain diphenhydramine, so don't take them both together, they're sedatives.
26:17Take one tablet at bedtime, or it does the liquid.
26:19Yeah, I'm a doctor, I know how to take them.
26:22All right, okay.
26:22Oh, my God.
26:24Oh, my God.
26:26Oh, my God.
26:30Oh, my God.
26:34Hello.
26:35Hello.
26:36How did it go?
26:37Awful.
26:38Let's just say I'm happy to be back on the shop floor.
26:43What are you doing?
26:44You're still doing that?
26:45Oh, dear.
26:46I've told you, Oscar, nobody wastes medication in my A&E.
26:48You know that.
26:49Mm.
26:50You sure about that?
26:51Mm-hmm.
26:52Mm-hmm.
26:53Yeah?
26:54What's this?
26:55Patient that Ramya saw with Lucinda.
26:56Patient needed 10, not 40 milligrams of diazepam.
26:58Hang on.
26:59You're telling me that Ramya threw away 30 milligrams?
27:01Come on.
27:02It might not be Ramya's fault.
27:03Maybe they thought the patient needed that much.
27:04No, Oscar.
27:05Absolutely not.
27:0640 milligrams of diazepam for mild sedation.
27:07Mm-hmm.
27:08That sounds like a Ramya cock-up, doesn't it?
27:09Mm-hmm.
27:10Listen.
27:11Mm-hmm.
27:12If you take medication, you take medication for mild sedation,
27:14you take medication for mild sedation?
27:15Mm-hmm.
27:16Mm-hmm.
27:17Yeah?
27:18What's this?
27:19Patient that Ramya saw with Lucinda.
27:21Patient needed 10, not 40 milligrams of diazepam.
27:24Hang on.
27:25You're telling me that Ramya threw away 30 milligrams?
27:27Come on.
27:28It might not be Ramya's fault.
27:29Maybe they thought the patient needed that much.
27:30No, Oscar.
27:31Absolutely not.
27:3240 milligrams of diazepam for mild sedation.
27:33Mm-hmm.
27:34From the store, it is your responsibility
27:36to make sure you take the amount that's actually needed.
27:39I know.
27:40Right.
27:49Hi.
27:50Hi.
27:51Can I help you?
27:52Yes.
27:53My name's Dr. Georgia Jay from the Medical Investigation Unit.
27:55We're investigating a doctor who treated four of your former patients.
27:59Edith, were you two?
28:00Camilla Woodham, Alexander Taylor and Milo Hanbury.
28:03One of our doctors?
28:04She's called Dr. Lucinda Edwards.
28:06She's currently at the RH, but I was hoping you could tell me if she's ever worked here or
28:11has any connection to the clinic.
28:13The name isn't familiar, but I will check our staffing records.
28:17Thanks.
28:18No, no, she's never worked here.
28:19Oh.
28:20Has the clinic ever received a referral from Dr. Edwards?
28:25No.
28:26Or have you ever referred any patients to her at the RH?
28:29No, no.
28:30There's nothing.
28:31Her name isn't anywhere on our system.
28:33Okay.
28:34Can I get copies of the notes for the patients I mentioned?
28:39I'm afraid not.
28:40We would need written consent from each patient first.
28:43Fine.
28:44Can you contact and ask?
28:45Of course.
28:46Yeah.
28:47I'll let you know.
28:48Do you have to have a card?
28:49Oh, sorry.
28:50One.
28:51Edith was treated by a Dr. Eva Tate.
28:55Do you know if any of the others were?
28:57I can check.
29:03No, no, they all had different doctors.
29:06Besides Dr. Tate's on maternity leave, she hasn't worked here for six months.
29:11Right.
29:12I can tell you they were all successfully detoxed and rehabilitated during their time here.
29:17They were all completely drug-free when they were discharged.
29:21Yeah.
29:22We've broken that revolving door addiction patient tradition so often perpetuated by the NHS.
29:28Once our clients are discharged, they don't need to come back.
29:32They get what they pay for.
29:35But the patients I mentioned all relapsed and overdosed after leaving this clinic.
29:41You know Edith Arusu died?
29:43Well, that had nothing to do with the treatment they received here.
29:46Yeah, but it's not what they paid for.
29:49Right?
29:50No complaints have ever been made against the Gelder Clinic.
29:54Okay.
29:55Not yet, but if you keep focusing on getting patients out of the door quickly,
29:59instead of giving them proper treatment,
30:01it won't take a lot, will it?
30:03Is that everything?
30:05Yeah, for now.
30:08Thanks.
30:09Edith had taken a large amount of a dangerous opioid, fentanyl.
30:16It's impossible to determine whether she intended to take her own life or whether this was accidental.
30:22Whilst I can find no fault with the doctor's actions in relation to the outcome of Edith's overdose,
30:30I find it unacceptable that a doctor working in a high-pressure environment like A&E
30:35should be reliant on instruction from a senior to correctly treat an opioid overdose.
30:41There is, therefore, something amiss in the training of junior doctors within the Royal Hospital's A&E department.
30:49And as such, I shall write a Prevention of Future Deaths report recommending the Trust to review its medical education programme.
30:58I would like to give a narrative conclusion that Edith Owusu died following the self-administration of a large quantity of fentanyl,
31:10resulting in cardiac arrest and death.
31:14That is the end of my conclusion.
31:17I would like to thank you for your time, and please feel free to leave.
31:28Well, that could have been loads worse.
31:42Are you listening to a different verdict?
31:44Thank you so much for all your hard work today, Lucinda. You really did us proud.
31:49Hey, all right, Mike. Leave it. She did her best, yeah?
31:52Are you happy now?
32:06Excuse me?
32:08Edith's death wasn't my fault. I assume we're done.
32:12You know that's not how this works.
32:22Oh, really?
32:44Oh, mate, you're so lucky you were out of it. I mean, it was horrendous.
32:48Oh, really?
32:49You made me feel like the worst doctor in the world.
32:52I mean, all I do is try my best, and every time I get shut on, I mean, what is the point?
32:57Hey, our jobs make a difference.
32:59Do they?
33:00Yeah.
33:01Okay, how long have you been working on that audit for?
33:03And is it really going to save the department any money?
33:05Yeah. I actually, I think it will, yeah.
33:08I don't know. I think you should have recycled last year's audit like the rest of us.
33:11It's a tick box exercise, Oscar. Nobody actually cares.
33:15Being an A&E doctor is a privilege.
33:17And maybe, instead of complaining all the time, you should focus on your work, and then you wouldn't make so many mistakes, would you?
33:27Sorry, what the fuck have I done this time?
33:29Sorry, it may be my bad. Um, I may have mentioned a dispensing error that you may...
33:34What? When?
33:39Take a look at that.
33:43Lucina told me to get 40 milligrams, and I even questioned the dose at the time.
33:46Wait, I wouldn't worry about this, all right?
33:50My audits, listen, my audits aren't about individual mistakes, they're about saving money that we're wasting on chucking on news meds. Okay?
33:56Beth's gonna get over it.
33:57Right, so, Edith, Alexander, Camilla and Milo were all treated by different doctors at the Gelder Clinic.
34:11Like, even Tate wasn't even there when they overdosed, she was on maternity leave.
34:16So, Lucinda is still the only concrete link we have between them.
34:21Shit.
34:22Besides some relapsing and deliberately overdosing after discharge.
34:25Isn't it odd that they all tried to kill themselves?
34:29And using the same method, I mean, what are the chances?
34:34Isn't it more likely that they came out of treatment and accidentally overdosed because they'd been off drugs for a while?
34:43But, if that were true, why would Lucinda code them all as deliberate?
34:48Look.
34:52Do we have, uh, Edith's file here?
34:54Yeah, yeah, sure.
34:57Oh, yeah, here you go.
34:59All right, we asked Lucinda that in her first interview.
35:06And she said she'd change this to deliberate to ensure Edith got a psych review.
35:13She said it again at the inquest, but...
35:15What if she...
35:19What if she just didn't want anyone to know it was an accident?
35:23But what does she stand to gain by coding him as deliberate?
35:26She knew there were accidents.
35:28Because, when it's an accident, you look at what caused the accident.
35:36The drugs?
35:37I've been focusing on the wrong thing.
35:43Her parents said Edith stopped buying street drugs a long time ago.
35:47So...
35:49Where was she getting them?
35:50Where was she getting them?
35:51Where was she getting them?
35:52How did she get them?
35:56What happened?
35:58Where was she getting them done?
35:59What happened?
36:01Not at that time.
36:03What happened?
36:05How was she getting them done?
36:06We understand your disappointment at the coroner's conclusions.
36:13Edith deserved better.
36:15If those doctors had done their job properly, Edith would still be alive.
36:22Well, regarding that, we would really appreciate your permission to take a little look around Edith's flat.
36:33What for?
36:33Well, we're looking for anything that might tell us where she got the drugs she overdosed on.
36:43Are you trying to say that it was Edith's fault that she died?
36:47No, not at all. We feel there might be potentially something in there linking Edith to whoever supplied her with the sentinel that ended her life.
37:03Hmm. Is she behind the mirror?
37:08Nope.
37:10Behind the curtain?
37:13No.
37:15Mommy, Mommy, where are you?
37:17Is she on top of the bed?
37:24No.
37:24Hello?
37:49Camilla, hi.
37:50Camilla, hi.
37:50This isn't Rob.
37:52No, no, I'm the new doctor that took over from Rob.
37:56Okay, can we meet at Suffern Square?
38:01Yeah, I can meet you there in half an hour.
38:04Right. Okay, great.
38:07Okay, see you then.
38:12I'm in time and time, mate.
38:13Is she...
38:16Under the bed!
38:19I haven't been out at the house since the inkblast, please.
38:24Yeah, it's fine. Okay.
38:26Yeah? Yeah, yeah, fine, fine, fine.
38:28Are you going to be good for Daddy?
38:30Is that sticky?
38:31No, he's got stickers, please!
38:33Come and show me. What have you got there?
38:37Thank you again so much for this. We really do appreciate it.
38:41Okay, so that's...
38:43This key is for the front door,
38:45and this key is to eat its flat.
38:47Flat B.
38:49You're not coming in?
38:50Um, it's too difficult, um...
38:54Just put the key through the letterbox
38:56and when you're done.
38:58Oh, did you remember the gloves?
39:12Oh, yes.
39:13Um, well, I'll take this room and the kitchen
39:23and you take that first bedroom on the way in
39:26and the middle one
39:28and that bathroom.
39:29That's busted.
39:30All right.
39:30All right.
39:45Excuse me, er, Camilla?
39:48Yeah?
39:49Yes.
39:49Yes.
39:49Yes.
39:49Yes.
39:50Yes.
39:54Yes.
39:58We've actually met before I treated you
40:00a couple of months ago in A&E.
40:01Okay.
40:05Well, I don't pay this much
40:08just to be kept waiting, so...
40:10Oh, of course.
40:19Fentanyl 50 patches.
40:20Enough for a month.
40:22Did you say a month?
40:23Yeah, that's what Rob describes me.
40:32There's a week prescription.
40:35A week?
40:36What the fuck am I meant to do with that?
40:38I don't know.
40:39You figure it out.
40:40You're either going to take it or leave it.
40:45How do you, er, pay Rob?
40:46Do you pay him here or later?
40:47I pay the pharmacy, like I usually do.
40:50See ya.
40:53I don't know.
41:23I don't know.
41:23I don't know.
41:24I don't know.
41:29I don't know.
41:29Norma!
41:55Right, ready for some dinner darling?
41:58What are you doing?
42:04Eh, Abbie?
42:13Abbie?
42:16Come here.
42:28Come on, come on!
42:40Move!
42:42Move!
42:52Come on, move!
42:54Help in base four, please!
42:56Help!
42:58Please, help!
43:00Here!
43:01Tom?
43:02She wasn't breathing, she was just lying there.
43:06Calm down, take a breath and tell me what happened.
43:08I think she got hold of something.
43:09Her GCS is dropping.
43:10Some diazepam.
43:11Can you repeat it to you now, please?
43:12Is she going to be okay?
43:13You sure it was diazepam?
43:14Yeah, it was an empty strip of 10 milligram tablets lying next there.
43:16Why did you have that strength of diazepam lying around the house?
43:18I had a shoulder injury.
43:19I had a prescription.
43:20Okay, and how many tablets were left in the strip?
43:22I don't know, maybe a couple.
43:23Is she going to be okay?
43:24Even if there was only one?
43:25Yeah.
43:26I don't know.
43:27I don't know.
43:28I don't know.
43:29I don't know.
43:30I can't take a breath and tell me what happened.
43:31I think she got hold of something.
43:32Her GCS is dropping.
43:33Some diazepam.
43:34Can you repeat it to you now, please?
43:35Is she going to be okay?
43:36Are you sure it was diazepam?
43:37Yeah, it was an empty strip of 10 milligram tablets lying next there.
43:39Why did you have that strength of diazepam lying around the house?
43:41I had a shoulder injury.
43:44I had a prescription.
43:45Okay, and how many tablets were left in the strip?
43:47I don't know, maybe a couple.
43:48Is she going to be okay?
43:50Even if there was only one.
43:51Yeah, okay.
43:52She's...
43:53Tell me she's not going to die.
43:54Okay, she's going to need for Mazanel.
43:55Beth, could you give her 120 micrograms over 15 seconds and set up an infusion, please?
44:01She's not going to die, is she?
44:02She's going to be fine.
44:03She's not going to die, is she?
44:04She's going to be fine.
44:05She's not going to die, is she?
44:06Yes, please.
44:07Thank you, Sam.
44:08And could someone take Tom to the relatives' room, please?
44:09Yeah.
44:10Come on.
44:11She's just this way.
44:12Come on.
44:13Liz, it's Tom.
44:14You have to come.
44:15Come to the hospital.
44:16We're Nanny.
44:17It's Abby.
44:18She's really sick, right?
44:19So just come.
44:20Come to the hospital.
44:21Call me back.
44:22Call me back.
44:23Hey, are you all right?
44:24How can I help?
44:25The young lady who was just in here.
44:27I'm Here.
44:28I'm here, who's going to be.
44:29There?
44:30There!
44:31And none of them.
44:32You know what?
44:34You have to come.
44:36Come to the hospital.
44:37We're Nanny.
44:38It's Abby!
44:40She's really sick, right?
44:41So just come.
44:43Come to the hospital.
44:43Call me back, call me back.
44:44Hi.
44:45Hi.
44:46You all right?
44:47How can I help?
44:48Uh, the young lady who was just in here.
44:52I'm her GP.
44:54What young lady?
44:56The one who just paid you for her fentanyl prescription.
45:00She paid the normal NHS prescription charge like everybody else, so...
45:05I know she paid you extra.
45:09Can I speak to your manager, please?
45:13I don't want to cause any trouble. I would just like to meet them.
45:17Right, yeah.
45:19What are you? Thank you.
45:24Lucy, just pick up your phone. Why aren't you picking up?
45:49It's Tom. Pick up your phone. Call me back. Something's happened.
46:01Right, you can come through to the back.
46:05Abby... She's not well. Okay? Just come to the hospital.
46:10Are you? Are you alright?
46:11Abby? Abby's not well. She's taking some pills.
46:15He's waiting for you on the back of your uncle.
46:19She's not well, okay, listen, come to the hospital.
46:22Are you alright?
46:23Abby, Abby's not well.
46:25She's taking some pills.
46:26Lucinda, it's Beth.
46:27I need you to come into the hospital.
46:29She's waiting for you in the back if you want to come.
46:32Hello?
46:33Lucinda, it's Leo here.
46:34Would you want me to go and get him?
46:35Where are you?
46:36I need you to come into the hospital.
46:37There's a clue you possibly can, please.
46:38I'm not well coming to the hospital now.
46:49I need you to come into the hospital.
46:59I need you to come into the hospital.