“He’s very experienced and has a good presence. He’s a good advocate who handles the clients well and has good insight into the judiciary and how coroners approach cases.”
Chambers & Partners
Malcolm has been a Recorder since 1994
experience & expertise
Malcolm is not only able to get quickly to the heart of the matter but also and more importantly able to get the best out of all those whose interests he is asked to represent, whether in coronial, criminal or regulatory proceedings.
He is recommended as a leading Junior by Chambers & Partners, which has noted that he is an “extremely experienced and able advocate known for his ability to deal smoothly with both tribunals and clients.”
cases & work of note
Medical Practitioners Tribunal, April, June, August & December 2022:
Doctor found to have been teaching PLAB 2 students scenarios, said by the GMC to have been obtained dishonestly by debriefing students, in breach of their Non- Disclosure Agreements, who had earlier sat the PLAB 2 clinical examinations and which bore a remarkable similarity to those scenarios held securely on the GMC’s Database and therefore in breach of the GMC’s claims to confidentiality and copyright. Misconduct proved. Fitness to practise found to be impaired. Erased. Order made for the immediate suspension of his Registration.
Medical Practitioners Tribunal, November 2022:
Junior Doctor alleged to have had anal intercourse with a female flat mate without her consent. The Tribunal found that anal intercourse was proved and that it was sexually motivated. However the Tribunal did not find proof that the anal intercourse had been without the Complainant’s consent. No Finding of Misconduct. Fitness to practise therefore not impaired.
General Dental Council, July 2022:
Clinical Dental Technician (CDT) alleged to have acted outside his Scope of Practice (SoP) when left by a General Dental Practitioner (GDP) to fit a temporary fixed prothesis into the mouth of a highly anxious female patient. Facts not found proved as the CDT believed not only that he had the experience to fit the prothesis but also that he had been acting under the GDP’s prescription.
East London Coroners Court, March 2022:
Acting for Hertfordshire County Council (HCC) which had commissioned care for and placed a physically handicapped and vulnerable female resident, who lacked capacity pursuant to The Mental Capacity Act 2005, in supported living accommodation within the London Borough of Waltham Forest. Fire broke out in the early hours of a morning. Staff evacuated other residents but failed not only to implement her Personal Emergency Evacuation Plan (PEEP) but also to evacuate her leading thereby to her death from burns and the inhalation of fire products. HM Senior Coroner, sitting with a Jury in a lengthy Article 2 Inquest, investigated a number of issues which included the fitting and safe use of keypad door locks, the fire alarms and their systems, the hiring of staff, the training of staff in the event of an emergency such a fire and the overall general management and running of the accommodation. A Narrative Conclusion was delivered by the Jury, which highlighted failures in relation to the numerous issues investigated. HMC decided that there were no Grounds for a Regulation 28 in respect of HCC.
Medical Practitioners Tribunal, February & June 2022:
Foreign trained Doctor found to have provided dishonestly false and forged documents to the GMC in support of an Application to the GMC’s for a Certificate of Eligibility for Specialist Registration (CESR) in the field of Geriatric Medicine. Misconduct proved. Fitness to practise found to be impaired. Erased. Order made for the immediate suspension of his Registration.
Surrey Coroners Court, June and November 2021:
Acting for Surrey County Council (SCC) responsible for the Special Educational Needs (SEN) of a teenage boy who had been diagnosed as autistic. The boy was found dead by the side of a railway track, presumed to have committed suicide. HM Senior Coroner, sitting with a Jury in a lengthy Article 2 Inquest, investigated the boy’s educational background, SCC’s support for the Family generally and the range and suitability of schools and other services, including the Surrey Police, to be able to cope with the boy’s SEN. A Narrative Conclusion was delivered by the Jury, which highlighted failures in relation to the numerous issues investigated, which in turn led to a lengthy Prevention of Future Deaths (PFD) Hearing. HMC determined there were Grounds for a Regulation 28 in respect of all the Interested Persons (IPs) including SCC.
Medical Practitioners Tribunal, February & April 2021:
Junior Doctor alleged to have assaulted sexually in his hospital, provided accommodation a female whom he had met at a leisure centre and whom he had invited to have supper with him. The Police had decided not to charge the Doctor. Facts not found proved.
General Chiropractic Council, March 2021:
Experienced Chiropractor alleged to have failed to recognise a developing clinical picture of a ‘Red Flag’ condition known as Foot Drop, which is indicative of an injury to the L4/L5 disc with severe pressure on the lumbar nerve at that level. As a ‘Red Flag’, the condition requires an immediate referral to Accident and Emergency for an MRI, following which surgery may be required. The GCC’s Expert considered that the Chiropractor’s failure to recognise that developing picture fell below but not far below the standard expected of a registered Chiropractor. The Professional Conduct Committee acceded to an unopposed Submission that the Chiropractor was not guilty of Unacceptable Professional Conduct. Case concluded.
Medical Practitioners Tribunal, November 2020 and January 2021:
Dual qualified Medical Practitioner and Fellow of the Faculty of Pharmaceutical Medicine, whilst working for an international pharmaceutical company, was alleged to have downloaded indecent images of children on his personal computers. Acquitted in the Crown Court but the same facts were found proved by the Tribunal on the lesser civil standard of proof. Found Guilty of Misconduct. Fitness to Practice found to be impaired. Registrar directed to erase his Name. Order made with immediate effect.
Surrey Coroner’s Court, June 2017 and December 2020:
Representing a Nurse, who was one of two Nurses involved in the drawing up of a syringe containing phenytoin, which was then attached to a syringe driver prior to its administration into an eleven month old female child, who had had a seizure following her admission to Hospital as a result of seizures earlier that morning. The phenytoin had been prescribed by a Consultant Paediatrician. The syringe driver kept alarming because of high pressures. The Nurse then declined to administer the phenytoin manually, having questioned the clinical need for the phenytoin. A Trainee Paediatrician then administered the phenytoin manually under the direction of the Consultant Paediatrician. The young child arrested and could not be revived. The Inquest was adjourned part heard in June 2017 at the request of the Police to enable them to carry out further inquiries. The Inquest was resumed in December 2020 as the inquiries conducted by the Police had not led to any individual or corporate charges of gross negligence manslaughter. The medical cause of death was phenytoin toxicity. HMAC found that the system in place at the Hospital at the time of the young child’s death for the administration of phenytoin was sub-optimal, firstly, as to whether the phenytoin should have been diluted or undiluted and, secondly, in particular that national guidance for the administration of phenytoin had not been addressed or adopted by the Hospital in a timely manner and concluded that neglect had contributed to the young child’s death.
General Chiropractic Council, December 2020:
Experienced Chiropractor failed to act on a constellation of ‘Red Flags’ for a female patient in her late thirties, who had been treated previously for pelvic cancer but presented with upper to mid thoracic pain. The Chiropractor should have referred the patient for an immediate investigation, most likely to have been an MRI, which would have shown the spread of secondary tumours affecting the vertebrae. However the Chiropractor prescribed a short course of manipulation as he believed that the patient’s complaint was of a musculoskeletal nature. Shortly after that short course of treatment ended, the patient required emergency spinal surgery as she had collapsing vertebrae. Comprehensive admissions made. Found guilty of Unacceptable Professional Conduct. Admonished. Case concluded.
The Health and Care Professions Council’s Conduct and Competence Panel, February and July 2020:
Representing a Clinical Psychologist, registered in Scotland and acknowledged in Scotland to be well known in the diagnostic field of Autism, who faced the Panel in respect of three discrete sets of allegations.
Firstly, for misrepresenting herself as a Consultant Clinical Psychologist when in private practice and said by the Clinical Director of a Scottish NHS Mental Health Trust to be insufficiently qualified to use that title, albeit that it was not a ‘protected’ title.
Secondly, when asked by the Parents of a Teenager to undertake with his consent an assessment of his behaviour and in particular why he had been downloading indecent images of teenage girls and engaging with them on social media to act indecently, the Registrant diagnosed him as being autistic. The Registrant, in writing what she termed to be a clinic forensic assessment report, opined that the Teenager’s level of risk of re-offending was low. Both the use of the term ‘forensic’ and the assessment of risk were challenged. The former on the basis that the Registrant had not undergone any appropriate training to write a forensic report that could be put before a Sheriff if or when the Teenager fell to be sentenced. The latter on the basis that the Registrant had not used any standard tools needed for an appropriate assessment of risk. Therefore it was said that the Registrant had acted outside her scope of practice.
Thirdly, the Registrant was alleged to have claimed in her Curriculum Vitae to have held or carried out specific roles or duties in the NHS Community Mental Health Trust that had formerly employed her.
The Panel heard Expert evidence on behalf of both the Complainant and the Registrant, representing, respectively, both the clinical and the academic sides of the argument about the use of such diagnostic tools when assessing the risk of re-offending in a neurodevelopmental disorder, more often than not viewed incorrectly by many people as a mental health disorder.
All three sets of allegations were found proved by the Panel, which found in the case of the third set relating to the Curriculum Vitae that the Registrant had acted dishonestly.
The Registrant’s fitness to practise was found to be impaired, based on her misconduct. Her Registration was suspended for nine months with a review ordered.
North East Kent Coroner’s Court, January 2020:
Representing a Consultant Obstetrician and Gynaecologist. Parachuted into this extremely High Profile Inquest not only when the Inquest was already part heard but more importantly when the Consultant was in the course of her evidence as there had then arisen a conflict of professional interest between the Consultant and her employing NHS Trust.
Given a day’s adjournment to get on top of the many issues raised within the Inquest and the opportunity to see the Consultant in Conference with the Leave of the Assistant Coroner once he had released her from her Oath, the Inquest then continued.
The Consultant then accepted that she should have gone in from home during the late hours of the night to carry out the difficult delivery that the Locum Registrar believed and furthermore had persuaded the Consultant that he could carry out safely.
The Consultant admitted that she had made inappropriate enquiries during her evidence despite a warning from the Assistant Coroner that she was not to talk anyone. The Consultant purged her Contempt with a profound and unreserved Apology not only to the Assistant Coroner, which was accepted by him, but also to the Family.
The Assistant Coroner gave a lengthy Summing Up of the Facts, setting out the many failings that had occurred in relation to the Baby’s very tragic and avoidable death and made a number of Recommendations pursuant to Regulation 28.
Essex Coroner’s Court, January 2020:
Representing a NHS Hospital Trust when the Patient who was a thirty six year old Romanian, with a good command of English, married with a fourteen year old son, and who went into the Hospital for an Elective Repeat Caesarean Section (ERCS) after her membranes had ruptured. The Maternity Department was very busy. The Patient was persuaded by the Obstetric Consultant on duty to try for a Vaginal Birth After a Caesarean Section (VBAC), with a trial of Syntocinon, coupled with an epidural for pain relief, to help her labour on its way. The plan failed to work as there was not enough staff to manage her during the trial of Syntocinon.
The Patient stayed in hospital overnight. An Elective CS was planned to take place on the following day during the day. However a medical emergency within the Maternity Department derailed that plan and the Patient went into theatre at about 9.00 pm. A CS was performed. Her Daughter, now named after her, was born shortly afterwards. The Patient then suffered a massive haemorrhage, which led to further surgery to stop the bleeding and finally to a sub-total hysterectomy. Despite those steps, the Patient suffered a cardiac arrest and died in the early hours of the following morning.
There were a number of serious issues, including some conflicts within the evidence of what was said between the Anaesthetists and the Consultant Haematologist about the need for further bloods and blood products. These conflicts were not helped by the Trust having two Major Haemorrhage Protocols, one of which applied directly to obstetrics, of which the Consultant Haematologist, then in post for three months, was unaware. Neither Protocol referred to the other and the Protocol which applied to obstetrics was more liberal in what could be obtained from the Blood Transfusion Service (BTS).
There was mis-communication and / or poor communication within the Teams working on the Patient trying to save her as to who knew what about the blood products which had been obtained from the BTS and had been stored in the satellite fridge for use in theatre.
HM Senior Coroner for Essex delivered a Narrative Conclusion and was persuaded not to make any Recommendations pursuant to Regulation 28 given the steps already taken by the Trust and were in hand to address the many issues raised during the Inquest.
Wiltshire and Swindon Coroner’s Court, November 2019:
Representing a Community Mental Health Trust, responsible for the care of a twenty six year old male Resident in supported living who was then under the auspices of the County’s Early Intervention Team. The Resident’s mental health had begun to decline whilst at University to the point that his relationship with his Parents had become difficult and in time he had been sectioned. Diagnosed as a paranoid schizophrenic, the Resident did not always take and sometimes stopped taking his antipsychotic medication. Admissions to hospital followed. The Resident gained weight over time which led to concerns raised with him by the Early Intervention Team.
In the days leading up to his death, the Resident complained of being unwell physically, which led to an attempt by the staff to persuade him to see a GP but he declined to go. An appointment was then made for him to see a GP on the following day. The Resident attended the surgery but changed his mind about waiting to see the GP. The Resident was found dead some days later in his accommodation, there having been no check on him for some twenty four hours as was supposed to be the plan.
The Assistant Coroner returned a Conclusion of Death by Misadventure. He also made Recommendations pursuant to Regulation 28, sent both to Nice and the Trust, concerning the need for more information in certain guidance relating to the medication that the Resident had been prescribed when there existed the risk of diabetes.
Medical Practitioners Tribunal, October 2019:
Locum Junior Doctor working in Emergency Medicine in a hospital in South Wales arrived for work on the night shift in a condition both deprived of sleep and intoxicated through alcohol. Facts admitted. Found Guilty of Misconduct. Fitness to Practice found to be impaired. Registration suspended for four months, with immediate effect.
The National Registers of Communication Professionals working with Deaf and Deafblind People, August and October 2019:
Acting for the Regulator to prosecute a Registrant, then a Trainee on his way to becoming qualified as a Registered Sign Language Interpreter (RSLI), in respect of a series of discrete complaints relating to three areas of his practice.
Firstly, his failure to attend or attend in a timely manner meetings with clients who required a SLI to sign in circumstances where Deaf and Deafblind People needed professional assistance.
Secondly, his failure to interpret and sign appropriately when the performers at Pride Events held within England were singing very well-known songs and furthermore his failure to respond to offers of professional assistance from other SLIs.
Thirdly, his use of social media to list under his services as a SLI those of ‘Hands on Communication, Video Relay Services, Video Remote Interpreting, Translation (BSL/ Translators)’ at a time when his Registration had been suspended and when he was not a RSLI as such services required further specialist training.
Numerous allegations were found proved. The Panel also found that the Registrant had demonstrated a lack of integrity when he stopped interpreting at a particular Pride Event.
The Registrant’s Fitness to Practice was found to be impaired through his Serious Professional Misconduct. The Panel directed that the Trainee’s Name be removed from the Register.
Mid-Kent and Medway Coroner’s Court, September 2019:
Representing the local Ambulance Service, which responded on numerous occasions to calls from a young female in the care of social services who had moved from child to adult care. The young female, diagnosed not only as suffering from a Mild Learning Disability (MLD) but also with an Emotionally Unstable Personality Disorder (EUPD), tended or pretended to self-harm by claiming that she had overdosed on insulin. The police were invariably called out: they would then detain her pursuant to Section 136 of The Mental Health Act 1983 (MHA) so that she could be assessed appropriately. However the young female would thereafter refuse to co-operate. Unfortunately on one such call-out, the young female did not meet the criteria for detention under the MHA and so she was released by the police. Thereafter on what was to be the day of her death, the local Ambulance Service was called out to her three times in response to an assertion by her that she had taken an overdose of insulin, even though she did not suffer from diabetes. The young female again refused to co-operate and there was nothing more that could be done as she was assessed by Paramedics as having capacity within the terms of the MCA. Subsequently the young female was found in her flat, unresponsive and was then taken to a local hospital, where she was declared dead, due to a hypoxic brain injury following the unnecessary and uncontrolled self-administration of insulin. HMAC, in a Narrative Conclusion, determined that the young female had not intended to commit suicide on the balance of probabilities.
South London Coroner’s Court, July 2019:
Representing the Commissioners of Care for a mentally ill patient in a community hospital, who, when non-compliant with the conditions of his conditional discharge status, stabbed a nurse to death in the course of his employment. The mentally ill resident was subsequently sentenced to imprisonment for manslaughter.
Central & South East Kent Coroner’s Court, June 2019:
Representing the Family of a Scaffolder who fell from height in an unwitnessed fall on a building site and died from his injuries.
Inner West London Coroner’s Court, April 2019:
Representing the Family GP, whose elderly female patient was diagnosed as suffering from an abdominal entero-cutaneous fistula. She was placed on the local hospital’s waiting list for surgery but was not recalled in a timely manner for her pre-operative assessment and consequently she was removed from the waiting list. Following a visit to her GP and on enquiry by him, the female patient was placed back onto the waiting list but not reinstated to her original place on that waiting list. However, overall, it took some eighteen months before surgery was carried out, during which period insufficient attention was paid to the female patient’s weight loss. The delay in surgery treatment caused by the female patient’s removal from the waiting list and the hospital’s failure to reinstate her to her original place on the waiting list, together with a failure to act upon the clinical signs of deterioration in the female patient’s condition upon her pre-operative assessment were found by HMC to be gross failures in the provision and procurement of basic medical care and contributed to her ultimate demise and as such constituted neglect.
County Durham and Darlington Coroner’s Court, February 2019:
Representing a local hospital, where a middle aged female resident in a care home was taken following a fall. The resident, who was quadriplegic with limited ability to communicate and who lacked capacity within the terms of The Mental Capacity Act 2005 (MCA), was not appropriately examined by a Junior Doctor in A & E, when she should have undergone a full neurological assessment. The female resident died two years later from complications arising from her quadriplegia, due to a spinal cord injury as determined by the Jury in returning a Narrative Conclusion.
Pembrokeshire and Carmarthenshire Coroner’s Court, January 2019:
Representing the Family’s GP, whose middle aged male patient suffered from mental health issues decided, contrary to advice, to stop his medication. Following a RTA, the patient was detained under Section 136 Mental Health Act 1983, taken to a local hospital, examined and later discharged. Overnight, back at home, the patient assaulted his mother. The police arrested him and took him to a local police station, where in a cell he became extremely violent and needed to be restrained by five police and two detention officers. The Jury, in returning a Narrative Conclusion, determined that death had been caused by Positional Asphyxia due to Restraint following Acute Behavioural Disturbance.
West London Coroner’s Court, October 2018:
Representing the West London Mental Health NHS Trust. Female Patient, having not taken recently her anti-psychotic medication and whilst having recently used cannabis, died by falling / jumping from the ninth floor of a block of flats in an act of suicide to which neglect contributed. Appropriate intervention by the Metropolitan Police proved unsuccessful.
West London Coroner’s Court, September 2018:
Representing the London Borough of Hillingdon as the Enforcing Authority responsible for inspecting food outlets at Heathrow Airport. Natasha Ednan-Laperouse, who was fifteen in July 2016 and known to suffer from numerous allergies, chose an artichoke, olive and tapenade baguette believed by her to be suitable for her but later found to contain within the dough sesame to which she was allergic, collapsed and died on a flight to Nice. The Inquest looked at the application of both European and National Food Applications and how they were applied by both small and large companies such as Pret a Manger, as here.
South London Coroner’s Court, March 2018:
Representing a GP in the Ellie Butler Inquest before Dame Linda Dobbs DBE. Ellie Butler had been murdered by her Father, Ben Butler, who had been convicted and sentenced in June 2016 by Wilkie J at the CCC to imprisonment for life with a recommendation that he serve a minimum of twenty two years. Jennie Grey, Ellie’s Mother, who had been convicted of perverting the course of justice by lying in respect of the events on her return home following Ellie’s murder and child cruelty, was sentenced to imprisonment for forty two months. The scope of the Inquest was set to look at the period of time following the decisions by Hogg J in July and September 2012 to return Ellie to live with her Parents and the involvement thereafter of Social Services, the Independent Social Workers approved by Hogg J, the Schools attended by Ellie and the GP’s Practice.
Medical Practitioners Tribunal, December 2017:
ENT Surgeon, convicted in a Sheriff’s Court in Scotland and placed on an Order of Supervision for two years for downloading and possessing indecent images of young children, erased from the Medical Register.
General Dental Council, November 2017:
GDP faced a series of complaints regarding his failure to manage and treat appropriately a female patient, who presented in pain complaining of a large swelling in her lower right quadrant. As the GDP’s admitted standard of record keeping was poor, the GDP found himself in some difficulty recalling details of conversations with the patient as to prospective treatment options with all their risks and benefits and therefore the obtaining of informed consent. Nevertheless the Committee concluded that there had been a sufficiency of detailed discussions but found that the GDP had neither used a rubber dam nor established the working length of the canals nor taken a post-operative radiograph during root canal treatment and had used cresophene as a disinfectant at a time when the license for its manufacture had been cancelled. Furthermore, the GDP had failed to co-operate the GDC’s Inquiry. Misconduct proved. Fitness to practise found to be impaired. Conditions placed on the GDP’s Registration for two years.
Surrey Coroner’s Court, October 2017:
Representing a GP, with whom a sixty four year old male resident in a care home was registered as a patient. The patient had suffered all his life from autism, severe behavioural and learning difficulties and a disorder called ‘Pica’, whereby he picked up and ate items with no nutritional value such as cigarette ends. The patient, who had spent most of his life in care and / or residential homes, was unable to communicate with anyone. The patient was under the care of the local Mental Health Team, led by a Consultant Psychiatrist and as such the Team was responsible for supervising his anti-psychotic medicine, which was prescribed by the GP at the Team’s direction. Although the patient was reviewed and seen from time to time by the GP and his Partners, none of them had any clinical involvement in the patient’s final illness leading to his death from a gastric haemorrhage caused by a bleeding gastric ulcer. Advice was sought from the home’s own doctor who did not visit but who suggested that the patient was likely to be constipated and should receive appropriate medication. The Jury were extremely critical not only of how the home was managed and run but also of the care that the patient had received and concluded that those failures were gross and to which neglect had contributed. However there was no criticism of the GP and / or his Partners.
General Dental Council, September 2017:
GDP faced a series of complaints regarding her failure to manage and treat appropriately eight patients at a time when she had not long finished her vocational training and was therefore a relatively inexperienced GDP. Comprehensive admissions made in relation to the wide ranging clinical complaints. Misconduct proved. Fitness to practise found currently not to be impaired. Case concluded.
General Dental Council, July 2017:
GDP / Practice Principal faced a series of complaints regarding not only his failure to manage and treat appropriately five patients but also for making claims for payment of their treatment under NHS Regulations that were alleged to be inappropriate, misleading and / or dishonest. Admissions made in relation to the wide ranging clinical complaints and the claims for payment that were said to be inappropriate. Dishonesty not proved. Misconduct proved in relation to the making of the inappropriate claims for payment. Fitness to practise found currently not to be impaired. Case concluded.
Surrey Coroner’s Court, June 2017:
Representing a Nurse, who was one of two Nurses involved in the drawing up and priming of a giving set to dispense phenytoin, prescribed by or under the direction of a Consultant, which led to the death of a female patient. Inquest adjourned part heard at the request of the Police to enable them to carry out further inquiries.
General Dental Council, March 2017:
Orthodontist faced a series of complaints regarding his failure to manage and treat appropriately some twenty patients. Comprehensive admissions made. Fitness to practise found currently not to be impaired by reason of his Deficient Professional Performance. Case concluded.
Nottingham Coroner’s Court, November 2016:
Representing a Consultant Anaesthetist, who was not the Surgeon’s usual Consultant Anaesthetist and operating partner, involved in complex high-risk spinal revision surgery for a female patient, from whom the obtaining of informed consent had included the risks of haemorrhage and death. HM Coroner found that there were a number of communication failings pre-operatively, intra-operatively and post-operatively. The intra-operative failings resulted in the patient suffering a massive haemorrhage which caused hypoxic brain inquiry and led directly to the patient’s death.
Wiltshire and Swindon Coroner’s Court, September 2016:
Representing three GPs, providing a daily morning surgery and afternoon on call cover in HMP Erlestoke, who saw a forty-one year old male prisoner, then transferred in from HMP Bristol, where he had been previously prescribed Quetiapine for depression and Pregabalin for pain relief. Pregabalin is regarded in prison circles as a highly tradeable drug. As was customary at HMP Erlestoke, the prisoner signed the contract to keep safely any ‘In Possession’ medication, failing which his medication could or would be stopped. The prisoner reported that his Pregabalin had been stolen from his cell whilst his cell door was unlocked. Although the prisoner was prescribed analgesia for a complaint that he was experiencing headaches, a dose reducing only prescription for Pregabalin was issued. The prisoner commented to a nurse that he felt suicidal: an ACCT was opened and reviewed. Despite the reviews, the prisoner hanged himself in his cell. The Jury returned both a narrative conclusion and a short form conclusion, that of suicide.
City of Liverpool and the Wirral Coroner’s Court, September 2016:
Representing a GP, employed by a healthcare trust to work in HMP Liverpool, who saw a 25 year old male prisoner / patient known to have chronic poorly controlled asthma 29 days after his admission. The prisoner / patient’s presenting complaint was a lack of what he believed to be his prescribed medication. Following a comprehensive assessment and examination by the GP with medication prescribed and administered, the prisoner / patient returned to his cell where, more likely than not, he smoked spice and / or ingested a propranolol tablet, both contraindicated for asthma. A respiratory arrest leading to a cardiac arrest then followed. The Jury returned both a narrative conclusion and a short form conclusion, that of accidental death to which neglect contributed by reason of a failure to make available appropriate medication for him during the first 28 days of his custody.
General Dental Council, August 2016:
Dental nurse working for a GDP in a practice where CCTV footage, recorded over two days, demonstrated not only a high turnover of patients but also a very significant lack of any robust cross infection controls. Comprehensive admissions made. Misconduct proved. Fitness to practise found to be impaired. Conditions placed on the dental nurse’s registration for 12 months.
General Dental Council, June 2016:
GDP, twice visited by inspectors from the CQC, found not to be wholly compliant with the current national guidance in four areas, namely, insufficient arrangements to deal with medical emergencies, failing to have in place robust cross infection controls, failing to assess and monitor the quality of service provision to patients and failing to record sufficient details of clinical examinations in his dental records. GDP, also visited by inspectors from the HSE, found not to have any local rules and any maintenance records for his X-Ray equipment. Enforcement action taken. GDP referred to the GDC. Comprehensive admissions made. Misconduct proved. Fitness to practise found to be impaired. Registration suspended for nine months.
General Dental Council, April 2016:
Dental nurse / practice manager in a practice where the principal’s deteriorating health was a significant concern to the vocational trainees, staff and the local health board, investigated in respect of the dishonest amending of patient records retrospectively ahead of a combined practice inspection by the local health board and of dishonestly writing and signing a prescription for an analgesic for a patient presenting in pain at the surgery at a time when the patient could not be seen by a GDP as no GDP was then available or on site. The allegations of the dishonest amending of the patient records retrospectively were found proved. The allegation of dishonestly writing and signing a prescription was found not proved: however the writing out of a pre-signed prescription form, albeit at the dictation by telephone by a GDP, was proved and found to be not only outside her scope of practice but also misleading as any pharmacist would have been under the impression that a GDP had completed the whole form before signing. Misconduct proved in respect only of the dishonest amending of the patient records. Fitness to practise found to be impaired. Reprimanded.
General Dental Council, January 2016:
GDP, erased previously by the GDC in June 2005 and restored to the Register in July 2006, investigated in respect of numerous allegations of breaching cross infection controls by re-using single use items, in particular endodontic files, gloves and matrix bands: when challenged by the local health board, the GDP dishonestly submitted false invoices to cover up the re-use of those single use items. GDP admitted the dishonest submission of the false invoices but denied the allegations of re-use of single use items, which were found proved. Misconduct proved. Fitness to practise found to be impaired. Erased.
Medical Practitioners Tribunal Service, November 2015:
GP accused by long standing vulnerable female patient of vaginal and oral rape in a hotel bedroom. Allegations made to a senior hearing therapist, when consulted by the patient in respect of a diagnosis of tinnitus, three and a half years later during which time the patient had seen the GP in numerous consultations. Allegations completely denied by GP. Police decided not to charge the GP. Allegations of vaginal and oral rape found not proved. However the GP was found to have met the patient in a hotel bedroom almost two years after the alleged rapes. The GP was also found not only not to have been empathetic towards the patient but also to have failed to have made a comprehensive note of a consultation, secretly recorded by the patient, three and a half years after the alleged rapes, in which the patient asserted that not only was she thinking of killing herself but also that she blamed those thoughts on the GP for raping her. Misconduct proved. Fitness to practise found to be impaired. Registration suspended for four months.~
Oxford Coroner’s Court, October 2015:
Representing one of two named nurses responsible for the care of Connor Sparrowhawk, an eighteen year old male resident in a care home, diagnosed as an epileptic and suffering from a learning disability, found to have drowned in a bath. The male resident was known by the staff to have a habit of taking not showers but long baths and at times when there was little or minimal supervision of him. Both the NHS Mental Health Trust that owned and managed the care home and the staff were heavily criticised by the Jury as the death was preventable. Neglect was found to have contributed to the death in numerous respects, including a failure by the staff to carry out an adequate assessment of the care and risk management of a resident diagnosed as an epileptic with a learning disability, a lack of clinical leadership and a lack of adequate training and guidance by the management for the nursing staff.
General Dental Council, September 2015:
GDP, disciplined previously at the GDC in October 2014, further investigated in respect of his decisions to treat two elderly patients, by placing in one case a six unit bridge and in the other case a four unit bridge involving restorations on two teeth where implants had been placed surgically by another GDP. Each patient complained that the benefits and risks of the respective treatment plans had not been fully explained. Some admissions were made but lack of informed consent proved in both cases. Misconduct proved. Fitness to practise found to be impaired. Conditions imposed for a further period on the GDP’s registration making a total of thirty six months.
General Dental Council, June 2015:
GDP investigated in respect of his failures not only to diagnose decay in two teeth in the upper arch by taking appropriate radiographs but also later his decision to extract one of the two teeth without first explaining to the patient that there were other treatment options available, such as pulp extirpation followed by a sedative dressing or root canal treatment. Full admissions made including a failure to obtain informed consent for the extraction. Misconduct proved. Fitness to practise found not to be impaired. Inquiry closed.
Manchester South Coroner’s Court, April 2015:
Representing The Priory Hospital at Cheadle Royal where a seventeen year old female adolescent patient with a known history of self-harm tied a ligature of a wire from a spiral bound notebook around her neck following an extended and brilliant period of home leave and at a time where her observation levels had been reviewed and reduced on clinical grounds by her multi-disciplinary team and at a time when NHS England and others were seeking to find the adolescent patient a suitable therapeutic placement in the community.
General Dental Council, March 2015:
GDP investigated in respect of his decision to carry out orthodontic treatment for a female patient in her mid-forties, who was a heavy smoker and whose teeth were heavily compromised periodontally. Despite concerns raised by fellow professionals, the GDP continued with his management plan. Limited admissions made. Misconduct proved. Fitness to practise found to be impaired. Registration suspended for twelve months.
Cumbria Coroner’s Court, February 2015:
Representing The North Cumbria University Hospitals NHS Trust on behalf of the West Cumberland Hospital, where a nineteen year old female patient with a significant cardiac history underwent an appendicectomy during which an intra-abdominal haemorrhage was caused but not recognised immediately leading in a matter of hours to a cardiac arrest and death from hypoxic brain damage.
Maidstone and Tunbridge Wells NHS Trust, December 2014:
Representing the trust which pleaded guilty to a breach of Section 3 of The Health and Safety at Work etc Act 1974 for placing at risk a male patient undergoing routine laparoscopic left sided renal cyst deroofing surgery by failing properly to plan the surgery safely when a warming mattress known as ‘Hot Dog’ caused life changing burns to the patient’s right side. Sweeney J imposed a fine of £160,000.00 having given the Trust a discount of 33% for its plea indicated at the earliest possible opportunity and for its cooperation with the HSE.
General Dental Council, October 2014:
GDP investigated in respect of his decisions to treat a total of 12 patients, ten of whom underwent implant surgery and two of whom orthodontic treatment using ‘Invisalign’. Extensive admissions made. Misconduct proved. Fitness to practise found to be impaired. Conditions imposed on his Registration for 24 months.
General Dental Council, May 2014:
Dental technician investigated in respect of his decisions first to alter and then to refit a patient’s set of dentures before making a new set of dentures, both procedures going ahead without a dentist’s prescription. The patient complained to the GDC about the poor fit of both sets of dentures and about the Dental Technician’s attitude and behaviour towards him. Facts found proved. Misconduct proved. Fitness to practise found to be impaired. Registration suspended for four months.
General Dental Council, May 2014:
GDP investigated in respect of his decision to provide extensive and high risk dental treatment including new crowns, bridges and implants to an elderly female patient over a period of some eight years when the patient was no younger than 83 and no older than 92 at a cost in excess of £32,000. Much of the treatment failed and the patient’s daughter complained to the GDC as her mother was then a resident in a care home and arguably suffering from a lack of mental capacity, in the belief that the GDP’s motives were wholly financial and that his courses of treatment were neither clinically indicated nor justified and certainly not in her mother’s best interests. Some admissions made but the GDP was found to be financially motivated and dishonest. Misconduct proved. Fitness to practise found to be impaired. Erased.
South Yorkshire Coroner’s Court, November 2013:
Representing a spinal surgeon, who whilst performing a discectomy on a middle aged female patient, entered the spine at the wrong level, at L4/5 and not L5/S1, damaging an artery in the process and causing an intra-peritoneal haemorrhage which was not recognised immediately and which led in a matters of hours to a cardiac arrest and subsequent death.
Inner London West Coroner’s Court, July 2013:
Representing two Ambulance Paramedics called to attend a patient who had collapsed in a London street whilst in police custody and who was later to die whilst in police custody at a nearby police station.
The Inquiry into Hyponatraemia Related Deaths, Belfast, March 2012 and presently ongoing as the report is still due:
An Inquiry, chaired by Mr Justice O’Hara, into five deaths of children and young persons at The Royal Belfast Hospital for Sick Children during the years 1995-2004. Deaths said to have been caused by or related to hyponatraemia, representing in turn two Consultant Paediatricians.
Malcolm has been consistently recommended by both the leading legal directories as a leading Junior for professional discipline and regulatory law.
He is described by Chambers & Partners as “an extremely eloquent barrister who is full of integrity” and who “knows how to take the fight to the opposition.”
Other recent directory editorial includes:
- he is very intelligent and reliable;
- an excellent advocate;
- looks after his clients very well;
- a seasoned advocate who is particularly strong in contested hearings;
- he is a hard worker, knowledgeable, experienced and well-prepared;
- very impressive in a case in which he was instructed at late notice. He picked it up quickly and got on top of the detail. He was supportive of the client and communicated well with me;
- understands the process and knows exactly what it’s all about;
- very experienced in the field;
- prepares well and is highly professional;
- his experience makes itself obvious;
- he’s very experienced and has a good presence;
- he’s a good advocate;
- he is incredibly thorough;
- a class act;
- ;very impressive in tribunal;
- a senior junior who merits recognition for his long-standing practice;
- handles the clients well;
- can pick up complex cases and know all the nuances and subtleties;
- instructed in GDC cases;
- has good insight into the judiciary and how coroners approach cases;
- senior junior with experience in defending before the General Medical Council and General Dental Council;
- noted for his experience in the healthcare sector and his frequent instructions on GDC and GMC Fitness to Practise cases;
- commands a great deal of respect in the medical defence sphere;
- he provides robust advice and advocacy, seeing the wood for the trees on cases for NHS trusts;
- has a great deal of experience in appearing before regulatory bodies;
- a heavyweight in this area;
- handles a number of high-profile GDC and GMC cases;
- has years of experience in disciplinary matters acting for all kinds of medical practitioners before their respective professional committees;
- an extremely experienced and able advocate;
- known for his ability to deal smoothly with both tribunals and clients;
- the blood and thunder style of Malcolm Fortune attracts much comment from the market;
- his professional discipline work has grown out of a criminal practice and is none the worse for that; and
- well-crafted cross- examination skills.
In my teens I was torn between medicine and the law. I decided eventually to become a barrister. I set out to pursue a purely criminal practice which over some time I achieved, leading to my appointment onto the then Specialist List of Counsel instructed to prosecute by the Crown Prosecution Service, principally at the Central Criminal Court.
“This combination of acting as Counsel and sitting on the Bench has given me a really good bird’s eye view.”
However in 1979 when I joined this Set of Chambers, a new world opened up for me: the world of dental and medical crime and regulatory inquiries, often taking me into the related world of health and safety. I was appointed as an Assistant Recorder in 1989 and sworn in as a Recorder five years later. I was given my ticket to try Serious Sexual Offences in 2006 and appointed to sit as a Recorder at the Central Criminal Court in July 2015.
This combination of acting as Counsel and sitting on the Bench has given me a really good ‘bird’s eye view’. It has made me think – and very often rethink – not only how I would approach the task of asking questions or making submissions but more particularly asking myself: “what is it that would interest me and persuade me to act in a particular way if I was sitting on this case?”, so that I can then use that insight to present the case.
My long career now in both the civil and criminal jurisdictions gives me experience and skills gained over many years to appeal to and interest the Bench and/or any Committee or Tribunal.
Nevertheless, even with that wealth of experience there is always the next challenge to be faced, which is something I enjoy.
Malcolm adopts and adheres to the provisions of the privacy notice which can be accessed here.
For further details of Malcolm’s practice please click on the links to the left or contact a member of the clerking or client service team.
Bar Council Membership No: 12574
Registered Name: Malcolm Donald Porter Fortune
VAT Registration No: 244594739