Described as fit and healthy, Charlotte Foster from Newport in Shropshire in the UK had visited Dr Sunil Idicula Simon for back pain and shortness of breath, just three weeks before her death.

Insisting that the pain was “muscular in origin”, the doctor saw no signs of deep vein thrombosis and instead suggested she “get a massage” or have a spa day.

The doctor had failed to treat the side effects arising from the use of a contraceptive pill that he had prescribed for her five months ago. The patient had wanted to use the pill as a form of birth control and also as a treatment for her acne.

Foster went into cardiac arrest when she collapsed at work. Three days later, she suffered brain damage and died at the town's Princess Royal Hospital.

Pill carries double the risk of blood clots

The inquest revealed that Foster had undergone tests that she would be high-risk if prescribed the pill. Coroner John Ellery concluded it was more likely than not the patient would have survived had her pill - cyproterone - been stopped and treatment started when she saw the doctor.

In a statement, Foster’s parents Stephen and Cecilia said, “We are devastated at the sudden and unexpected loss of a very much loved daughter, sister, and granddaughter.

“Charlotte was a lively, intelligent, beautiful, and caring young lady who will be deeply missed by her family, friends and work colleagues.”

Doctor overlooked appropriate investigations

The doctor is accused of failing to consider stopping the prescription of the pill, recording an adequate history, or making considerations of deep vein thrombosis (DVT) or pulmonary embolism (PE).

It is alleged that Dr Simon had failed to arrange appropriate investigations after a telephone consultation on 24 December 2015 and a subsequent consultation on 4 January last year.

Records showed that during the consultation, he "failed to examine Patient A's respiratory system, legs or scapula and failed to record her pulse, oxygen saturations or safety netting advice given".

He is said to have failed to refer her to hospital or make arrangements for a follow-up consultation if her symptoms persisted. The GMC will discuss if arrangements for follow-up consultations if symptoms persisted or a consideration of stopping the pill prescriptions were considered.

In his ruling, the coroner said, "By the 4th of January 2016, on the evidence of family and friends and Charlotte's own texts, Charlotte's condition was increasingly poor and had been for some time fluctuating in severity.

"I accept the evidence of the family and friends and as a fact accept that Charlotte presented on January 4th as Mrs Foster described."

Claiming that the inquest had raised "areas of concern" which had been drawn to the attention of interested parties to the inquest, the coroner said he was reviewing whether to make a referral to the General Medical Council (GMC).

Dr Simon will face a misconduct hearing and is set to appear before a GMC investigation on 2 June where they will consider giving him a warning.

The notification document stated that "Dr Simon has indicated that he is not prepared to accept a warning as proposed by GMC case examiners, and has elected to have his case heard by the investigation committee at an oral hearing”. MIMS

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