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	England and Wales Court of Appeal (Criminal Division) Decisions
You are here: BAILII >> Databases >> England and Wales Court of Appeal (Criminal Division) Decisions >> Garg v R. [2012] EWCA Crim 2520 (30 November 2012) URL: http://www.bailii.org/ew/cases/EWCA/Crim/2012/2520.html Cite as: [2012] EWCA Crim 2520

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IN THE COURT OF APPEAL (CRIMINAL DIVISION)
ON APPEAL FROM LEEDS CROWN COURT
Mr Justice Globe
T20117554

		Royal Courts of Justice Strand, London, WC2A 2LL
		30/11/2012

The Lord Chief Justice of England and Wales:

1. This appeal by Sudhanshu Garg against a sentence of two years imprisonment imposed at Leeds Crown Court by Globe J on 25^th May 2012 was dismissed on 15^th November. These are our reasons.
2. The appellant is 44 years old, a man of positive good character and a highly qualified medical practitioner appointed as a Consultant Urologist at Bradford Royal Infirmary in March 2006.
3. In the morning of 22^nd August 2008, a Friday, Lisa Quinn was admitted to the Accident and Emergency Department of the hospital. She was 37 years old, and the mother of two children, aged 12 and 10 years. She appeared to be a healthy young woman, but she was complaining of abdominal pain and pain on passing urine, strong smelling urine, symptoms which had gradually become bad enough for her to seek medical help at hospital. She died in hospital on the following Monday evening.
4. The Urology Department comprised five specialist registrars and five consultants of whom the appellant was one, and if necessary locum registrars were called upon. Twenty four hour cover was provided both by a registrar and a consultant. The appellant was the urology consultant on duty throughout the weekend during which Lisa Quinn was a patient in the hospital. Although we understand the complexity of the environment which obtains in a large hospital ward of this kind, the appellant was negligent in his capacity as the head of the team of medical practitioners responsible for Lisa Quinn's care, which on occasions, at any rate, appears to have been dysfunctional. The appellant was also negligent in the performance of his responsibilities as the consultant in personal charge of her care as his patient. He became aware of her admission no later than the Saturday afternoon. On analysis, his negligence covered a fairly protracted period.
5. The appellant was charged with the manslaughter of Lisa Quinn on the basis of gross medical negligence. In due course he pleaded guilty. He did not intend the death of Lisa Quinn, nor indeed that she should come to the slightest harm. Nevertheless her death was a direct consequence of gross negligence on his part. The result is that she has left a grieving family, shattered by her death, to mourn for her, and his medical career is in tatters.
6. We were told, and we believe it to be correct, that this will be the first occasion since the Criminal Justice Act 2003 came into force on which this court has considered an appeal against sentence in the context of gross medical negligence. Our decision will no doubt be considered by other sentencing courts, but beyond broad general observations, this is not a guideline decision which purports to encompass the full ambit of sentencing in cases of manslaughter by gross medical negligence. Our decision reflects specific individual features of the case. Even in cases of medical gross negligence manslaughter, where the consequence of the harm in every case is identical, that is, the death of a patient, the level of culpability of the defendant will vary considerably. There will certainly be cases of greater culpability than this, and other cases where the culpability will be significantly lower. In the end, of course, all will be cases involving gross rather than simple negligence, and therefore liable to involve the perpetrator in a criminal prosecution rather than provide the victim with civil remedies only.

Facts

7. We summarise the facts in some detail, putting the appellant's personal failures into the broad context to which Mr Ellison QC drew our attention.
8. At 11.14 am on Friday 22 August, Lisa Quinn was admitted to the Accident & Emergency Department of the Bradford Royal Infirmary. She was complaining of the symptoms to which we have referred earlier. These symptoms were recorded by the admitting doctor, who made a provisional diagnosis of kidney infection, and ordered an x-ray to be taken. He reviewed the x-ray after she had been taken to the urology ward, formed the view that she was suffering from a kidney stone and prescribed an antibiotic (Gentamicine). It appears that neither he nor the x-ray department communicated his view that the x-ray suggested a possible obstruction. The omission of any x-ray from the notes sent from A&E was overlooked by members of the admitting urology team.
9. She was admitted to Ward 20 at 5.30 pm. The on-duty Urology Registrar devised a treatment plan: to continue the course of antibiotics and arrange for an ultrasound scan of the kidneys, ureter and bladder. A differential diagnosis 'acute pyelonephritis' was made. This is a urinary tract infection which has reached the pyelum of the kidney; and is a condition which can lead to pyonephrosis, which is an accumulation of infection around the kidney which may lead to sepsis. The purpose of the ultrasound scan was to discover whether there was a stone which was blocking the ureter, which would increase the risk of pyenophrosis as a result of what is termed a 'closed infection'. The prosecution expert evidence was critical of the Registrar in not treating the ultrasound scan as urgent and not recording the need for a scan on the medical notes, although there was a note to this effect on the 'plan'. The defence expert did not regard the ultrasound as essential at this stage, since the treating specialists were unaware that there was an x-ray showing a possible stone.
10. At about 6.30 am on Saturday 23 August Lisa Quinn, was found to be shaking with rigor and shortly afterwards her temperature was found to be 'spiking', which would have been consistent with an infection. At about 9.30 a new Urology Registrar (Mr Attique) took over. The Junior House Officer accepted that it had been his duty to put into action the plan to carry out an ultrasound scan either on Friday evening or Saturday morning and that he had not done so. Mr Attique saw Lisa Quinn at about midday. He noted that she was not responding to the antibiotic Gentamicin. He appears to have been unaware of the earlier plan to have an ultrasound or scan. In the early evening Mr Attique contacted a Microbiologist in the Hospital to tell him that Lisa Quinn's condition had worsened, and was advised to change the antibiotic (Meropenem). The Appellant had carried out a surgical procedure earlier that day and did not see Lisa Quinn in the company of Mr Attique until the late afternoon in Ward 11 (where she had been transferred) at the end of the ward round. This was the first time he had seen her.
11. The medical notes make no mention of this joint visit, but it is agreed that the Appellant would have known about her temperature and vital signs. He regarded her condition as an uncomplicated case of acute pyelonephritis which should have been responsive to antibiotics. The only available blood test results were those of blood taken the previous day.
12. Later that night, at about 11.00 pm, when the appellant and Mr Attique were visiting another patient, they looked at Lisa Quinn's chart. The appellant advised Mr Attique to continue the treatment, in the belief that there had been a response to the new antibiotic, and asked that the ultrasound scan be arranged for the following day. No instructions were left for the nursing staff.
13. The appellant accepted that he placed too much reliance on the information provided by Mr Attique, that he should have made more enquiries and that, if he had done so, he would have realised that Lisa Quinn was more seriously ill than he realised.
14. The prosecution evidence was that the response to Lisa Quinn's condition by the end of this visit on Saturday evening was grossly substandard. The request for an ultrasound, which had been identified as necessary on Friday, had still not been carried out, although there was an on-call radiologist available for the 24 hours from 9.00 am on Saturday to 9.00 am on Sunday. Nor had sufficient attention been paid to the nursing notes in relation to Lisa Quinn's general condition, including the recording of rigor earlier in the day and low blood pressure, both of which would have been consistent with sepsis. In short, nothing which was necessary to exclude the possibility of a closed infection had been done. The prosecution contended that it was significant that when he came later to change the records for 23 August he inserted the following: 'continue plan as above, partial response to antibiotics, arrange ultrasound scan, kidneys, ureter, bladder ... monitor urine output.'
15. On the morning of Sunday 24 August the nursing staff noted that Lisa Quinn had another bout of rigor, spiking temperatures and that her blood pressure was low. The request for an ultrasound scan had still not been filled out. At 11.00 am, when Mr Attique saw her, she asked him when the ultrasound was going to be carried out. He contacted the radiology department to arrange this and returned later to tell her that it would be carried out later that day. It seems that, because the radiology department was busy that day, it could not be carried out until 3.00 pm.
16. The appellant telephoned Mr Attique during the morning to find out how Lisa Quinn was. He was told that her creatinine levels were up (consistent with kidney malfunction) but was not told that her blood pressure was low. The appellant told Mr Attique that the ultrasound should be carried out as soon as it could be arranged. The appellant accepted that at this point, appreciating that Lisa Quinn was not responding to the antibiotic medication, he should have been much more pro-active in her treatment. She had been in hospital for two days and he had still not seen any imagery of her kidney and upper urinary tract so as to be able to exclude a blockage as the cause of her persisting infection.
17. The appellant saw her on the ward at about 1.30 pm and, on being told that she had a high temperature, said he would wait for the results of the ultrasound before seeing her again. It is said on the Appellant's behalf that he was not informed of the persistent problem with low blood pressure, nor that she was not catheterised for fluid balance monitoring. There was also a consistent pattern of reports which indicated that she felt well and appeared well; although the appellant accepted he was too much influenced by these when assessing her condition. Whatever may have been her appearance, there was a significant body of information to indicate that she was very unwell.
18. At about 1.00 pm, the radiologist who was on-call on Sunday was first made aware of the request for an ultrasound scan, the purpose of which was to discover the cause of Lisa Quinn's renal failure. The scan was carried out shortly before 4.00 pm. The radiologist was able to observe a right-sided obstructed kidney, whose cause was not clear; and she informed Mr Attique of these findings, and raised the possibility of a nephrostomy. A nephrostomy is a procedure which is usually carried out by an Interventional Radiologist, and involves inserting a catheter through the skin into the renal pelvis and the kidney, using either ultrasound or CT technology to direct the catheter. If a stone is blocking the ureter and preventing drainage of urine, a catheter inserted above the site of the blockage can drain the urine.
19. Mr Attique was informed of the results and said that he would speak to the appellant about it. After this the appellant visited the ward in the company of Mr Attique; but did not visit Lisa Quinn to monitor her progress or take steps to investigate her condition.
20. Subsequently, between 6-6.30 pm, Mr Attique contacted the Consultant Radiologist and told him that he had discussed the matter with the appellant who had decided that she needed a Nephrostomy. The appellant remained in touch with Mr Attique and suggested that Lisa Quinn be taken to Ward 21 where she could be monitored more closely. Following this, the Radiology Department contacted Mr Attique to ask when he wanted the nephrosomy done, indicating that they would prefer to wait until Monday when they could arrange for an Interventional Radiologist more easily. Mr Attique spoke to the appellant who said that the nephrostomy should be done as soon as it could be accommodated by the Radiology Department.
21. At some stage the Radiology Department suggested that the next step was to carry out a CT scan so as to identify the cause of the renal obstruction. There is expert evidence that this was unnecessary and that there was sufficient information to indicate that nephrostomy drainage should be carried out urgently. The appellant knew that the procedure could not be carried out at this point since there was no longer an Interventional Radiologist available in the hospital to carry out the procedure that night. The appellant accepted that he had still not investigated Lisa Quinn's condition sufficiently and that, if he had done so, he would have realised that the ultrasound findings indicated the need for drainage was urgent.
22. In the event a CT scan was carried out at 8.45 pm and the cause of the obstruction, a stone at the lower end of the right ureter, was discovered. Shortly after this the Radiology Department made contact with the appellant. The appellant decided that he did not want to adopt the alternative of operating that night (drainage by the insertion of a retrograde stent) if there was no Interventional Radiologist available as back-up. Accordingly he decided to wait and make a final decision on Monday, when an Interventional Radiologist would be available. There are two unresolved issues: first, as to whether personnel in the Radiology Department spoke to the appellant about the possibility of taking Lisa Quinn to the Leeds General Infirmary where an Interventional Radiologist was available; and secondly, as to whether that would have been regarded as a wholly exceptional course at the time. In any event, the appellant accepts that he had still not properly informed himself of his patient's condition; and that if he had done so, he would have recognised that he was faced with a rapidly developing and potentially life-threatening emergency which called for drainage that night.
23. At about 10.30 pm Lisa Quinn was transferred to Ward 21, by this time Mr Attique was concerned about her heart rate, high fever, low blood pressure, low urine output and low oxygen saturation. The admitting senior nurse was told that Lisa Quinn might be developing septicaemia.
24. The day shift on Bank Holiday Monday 25 August began at 7.30 am, and nursing staff noted that Lisa Quinn's blood pressure had dropped. At 8.00 am Mr Attique finished as Registrar on-call and handed over to the Locum Registrar. He told the Locum Registrar that Lisa Quinn had a blocked kidney due to a kidney stone and that the appellant would be arriving on the ward at 9.00 am. At 9.30 am the appellant rang the Locum Registrar to say that he would not be coming to the hospital that morning: he had now been on-call for eight days and had had a very poor night. It was pointed out on the appellant's behalf that there was evidence that this work-regime of sleeplessness and stress would affect the judgement of even the most robust practising clinician.
25. At 10.00 am the Locum Registrar assessed Lisa Quinn's condition and informed the appellant that she was well enough to undergo the ureteric stent procedure. The Locum Registrar then went to book the Operating Theatre for the procedure; and was told that there were other pre-booked and priority cases, and that the Theatre would not be available until after 1.00 pm, unless there was dire emergency, in which case another theatre would be opened and staff called in, He made contact with the appellant, who told him that he intended to perform the ureteric stent procedure and asked if he thought Lisa Quinn could wait. The Locum Registrar said he thought she could. At some stage during the morning the Radiology Department was contacted and informed that the nephrostomy was not going ahead and that the Urology team would be operating. The appellant accepted that if he had taken proper steps to investigate Lisa Quinn's condition it would have been apparent that she was not fit to be operated on that Monday morning.
26. The appellant arrived on the ward at about noon. The results of the blood test came back at about this time; and for the first time he began to appreciate the true seriousness of his patient's condition. When he looked at the CT scan he also realised that the stone was higher than he had appreciated the previous day; and this made him realise that a ureteric stent procedure could not be carried out. At about 2.00 pm the appellant contacted the Radiology Department to say that the patient's condition had deteriorated and to ask if the nephrostomy could be performed. It was agreed that the Interventional Radiologist on-call would come into the hospital to carry out the procedure. It was also agreed that Lisa Quinn should be taken into Intensive Care in view of her condition. This was not possible because the Intensive Care Unit was full. However, she was cared for by the outreach team of the Intensive Care Unit; and was also seen by a Consultant Anaesthetist, who told the appellant that he thought she was well enough for a nephrostomy. The Consultant Anaesthetist recommended the insertion of a venous central line, repeat blood gases and ventilation, and asked that the Intensive Care Unit should be informed when she returned from the procedure.
27. It was not until 3.45 pm that Lisa Quinn was taken from Ward 21 for the nephrostomy procedure. This was carried out successfully by the on-call Interventional Radiologist. However a review of an x-ray taken later that evening showed excessive fluid on her lungs and, on return to the ward soon after 5.00 pm, her pulse rate increased, her saturation levels fell further and her respiratory rate increased. No one had followed the recommendation that a venous central line be inserted and, although its importance was now recognised by the Locum Registrar, there were delays in inserting it. At 6.35 pm Lisa Quinn suffered a cardiac arrest and was found to have widespread fluid on her lungs and secretions in her throat. The oxygen levels were so low as to be unreadable. Despite the efforts of the cardiac 'crash team', she died at 7.28 pm.

The breaches of duty

28. The case against the Appellant can be summarised as four principal breaches of duty. (1) Failing to ensure that Lisa Quinn's clinical condition was properly identified. (2) Failing to identify or diagnose the possibility of closed renal infection and the development of sepsis. (3) Failing to arrange urgent interventional treatment for a closed renal infection, of which there was early evidence in the form of the A&E x-ray and the patient's clinical condition. (4) Failing to arrange a transfer to an appropriate hospital after 8.00 am on the morning of Sunday 24 August. There was expert evidence which demonstrated that if active intervention had been instituted, even as late as the evening of Sunday 24^th August, she would probably have survived, and her prospects of ultimate survival only became remote by the Monday. This was 48 hours after her condition first came to the attention of the appellant. The medical experts instructed by the prosecution expressed the view that the breach of duty in this case constituted a very serious departure from normal professional standards and that no reasonably competent consultant in this discipline would have failed to take action to exclude a closed infection, or have failed to take timely action to institute effective intervention. The Crown's case was that these breaches of duty were causative of Lisa Quinn's death, and that cumulatively they amounted to a disturbing picture of a failure to take action to treat a 37 year old woman in otherwise good health, who would have survived but for the neglect.
29. The appellant, by his basis of plea, acknowledged criminal breach of duty in the following respects. First, having become aware that Lisa Quinn had been admitted under his care as the consultant urologist on call, he failed to investigate promptly whether she had or might have a blocked right urethra. Second, he failed to ascertain or pay due regard to the available results of blood culture, x-ray and clinical results and symptoms, which suggested that she was suffering from deteriorating renal function and was at risk of life threatening sepsis, and thereafter to ensure that her condition was investigated sufficiently urgently and treated sufficiently promptly. Third, he failed to arrange for a percutaneous Nephrostomy and by the means thereof to ensure drainage of the infective process with sufficient urgency.

The appellant's conduct following Lisa Quinn's death

30. The appellant was on his way back to the hospital when he was informed of Lisa Quinn's death. It was the first time he had to deal with the death of a patient since he had been a consultant; and it is clear that he was deeply upset by it. He reviewed the medical notes with the locum registrar and it became apparent that he was concerned about what the notes showed. He then set about changing them.
31. The following morning the Locum Registrar informed the Coroner's Office of the death and notified the cause of death, as agreed with the appellant, pulmonary oedema, secondary to renal failure, secondary to acute tubular necrosis, secondary to urinary sepsis.
32. The appellant filled in a cremation certificate and gave inaccurate information in relation to the question which asked whether there was any reason to suspect that the death was due directly or indirectly to (among other things) neglect. As a result the Coroner's Office was not alerted to the possibility that her death was due to negligence. The prosecution accept that this was done with a view to deflecting an internal investigation by the hospital; nevertheless, as a result, the body was cremated and no post mortem examination was carried out. However, it is right to note that there had been no internal investigation in relation to any delay in care at this stage, and the only real issue so far as the Coroner was concerned was the cause of death.
33. On 2 September the medical notes were examined by the Hospital Medical Director who was concerned to see what appeared to be retrospective entries inserted into the records by the appellant. Further enquiries also indicated that a number of notes and charts were missing. When challenged about this on 5 September, the appellant denied removing sections of the case notes and said that he had made the retrospective entries before Lisa Quinn's death. However, on the night of 7 September the appellant called at the home of a fellow consultant urologist. He seemed very disturbed and looked ill. He said that he had removed records, changed entries and had tampered with Lisa Quinn's notes. He said he did it after her death and that he did not know why he had done it. Subsequently he admitted removing the original history sheet and replacing it with a false history sheet, trying to copy the writing of another doctor. Among other changes, he had also replaced the original fluid balance charts with altered charts so as to conceal the fact that there was a significant and uncorrected positive fluid balance; and had changed a clinical record so as to show him attending Lisa Quinn at 9.00 am on the morning of Saturday 23 August and again at 4.00 pm. So far as the records for Sunday 24 August were concerned, the appellant had inserted an entry demanding to know why an ultrasound scan had not been conducted.
34. In mitigation it was submitted that. although the appellant made some changes which were intended to make Lisa Quinn's condition appear less serious, most of the changes were additions which were intended to reflect the true position more accurately than they had been reflected in the notes. However that may be, the appellant took steps to conceal his neglect, by falsifying medical records and clinical notes by altering them, and substituting pages within them to conceal his inactivity. In particular the fluid balance charts were altered in an attempt to conceal the fact that her intake of fluid significantly exceeded the output. This was directly related to the fact that the appellant appreciated that one of the contributory factors leading to death had been fluid overload. What is more the observation charts were altered by the insertion of a higher blood pressure reading so as to conceal the evidence that the patient was in fact suffering from low blood pressure, which in itself would have been an indication of sepsis. Moreover the effect of some of his own entries on the records was to conceal the fact that the patient was not responding to anti-biotics, and to attempt and convey the impression that the appellant had been chasing up the absence of any ultra-sound scan. As the judge put it, the appellant was trying to present a false picture suggestive of an improvement in her condition while she was in hospital over the weekend, whereas her condition was deteriorating, and a false report was provided to the panel at the hospital dealing with suspected untoward incidents.

The arrest

35. In late September 2008 the appellant was arrested on suspicion of gross negligence manslaughter and interviewed. He supplied a prepared statement, and declined to answer any questions. He denied that he had been responsible for gross negligence manslaughter. In a second statement he explained that he had taken the death of his patient very hard and he felt personally responsible because she had been admitted to hospital under his care. He said that he had been anxious and had had difficulty sleeping and that he had been prone to anxiety because of a number of different personal and medical problems of his own. However he sought to claim that the junior doctors had made no records of his ward rounds on the Saturday and the Sunday, and sought to shift some of the blame to nursing staff for failing to monitor the patient closely enough. He asserted that there was no reason why an ultrasound scan should not have been carried out on an urgent basis on the Saturday, and he expressed concerns about the standard of care provided by the junior medical staff when he was absent. He did however admit falsifying the records, and he set out in very careful detail the various alterations for which he had been responsible. His explanation for doing so was that he had been so overwhelmed with anxiety and stress about the death of his patient and the internal investigation at the hospital to think rationally.
36. He was reinterviewed in February 2009. He supplied another prepared statement. To the extent that he suggested that he was unaware that an X-ray had been conducted on 22^nd August, the statement was inaccurate. According to the medical records he had personally examined the X-ray on the evening of the Saturday. The X-ray showed evidence suggestive of a stone blocking the right kidney. As the evidence was not definitive, an ultrasound and possible CT scans would have been necessary.

Personal mitigation

37. The judge was provided with powerful character references. He acknowledged the pressures and responsibilities bearing on the appellant, and indeed his heavy workload before and during the weekend. He also examined and directed himself not to under-estimate the level of reliance the appellant placed on junior members of the medical staff. He recognised that some of their actions may have contributed to this tragedy, but as he put it, the appellant's inactivity and failures were the ones that were paramount. He took account of the consequences to the appellant, involving the loss of his employment, his financial security and his good reputation, and the level of remorse which the judge believed was genuine.
38. A psychiatric report provided an analysis of the appellant's history of psychiatric problems, and recorded that he suffered from anxiety and depression as a result of Lisa Quinn's death, and appeared to be a broken man. There was no recommendation in the pre-sentence report. It recorded that the appellant accepted his culpability and was deeply remorseful. There was no real risk that he would re-offend or cause serious harm to the public.
39. Full credit was given for the appellant's guilty plea, which the judge considered was greatly to his credit.

The sentence

40. The basis of the argument that the sentence was manifestly excessive was that the judge adopted too high a starting point and failed to take sufficient account of the significant personal mitigation, including the impact of the offence on the appellant's own family and life, his psychiatric problems, and the delay in the case coming to trial. We were also invited to consider some further, post sentence material which underlines the impact of the prison sentence on the appellant himself, which we did.
41. We must examine the main thrust of Mr Ellison's submissions. He began by drawing attention to some of the sentences imposed in medical gross negligence manslaughter cases decided before the Criminal Justice Act 2003 (the 2003 Act) came into force, and comparing them with sentences in gross negligence manslaughter of different kinds. This was not because Mr Ellison overlooked the impact of the 2003 Act on sentencing in cases involving homicide or the increased level of attention which is now paid to the consequences for the victim of an individual crime, nor indeed the decision of this court in Appleby (Attorney General's reference No. 60/2009 (Declan Appleby and others) [2010] 2 Cr App R(S) 46. His argument was that prior to its implementation medical gross negligence cases were regarded as requiring levels of punishment at a more modest level than those appropriate to different forms of the offence of manslaughter by gross negligence. Whatever may be the increased level of sentencing for all cases of homicide, that perceived distinction between different types of gross negligence manslaughter should not be eroded.
42. Assuming that such distinctions can be identified by reference to the broad heading which can be given to the different ways in which gross negligence manslaughter can occur rather than the individual facts which give rise to the prosecution, we agree that there is nothing in the legislation or subsequent decisions of this court which suggests that any long established balance drawn between different types of gross negligence manslaughter should now be recalibrated. Nevertheless, two clear principles which follow the implementation of the 2003 Act have been identified in the sentencing decisions of this court. First, s.143(1) of the Act, focussing direct attention on the harm actually caused by the offence, always involves harm at the highest level. Second, the effect of schedule 21 of the 2003 Act has been to increase the punitive element in sentences for murder, and this has had an inevitable effect on sentences for manslaughter on the basis that the statutory intention was to underline that crimes which result in death should be treated more seriously and dealt with more severely than before. (See Wood (Clive) [2010] 1 Cr App R(S) 2: R v Appleby (Attorney General's Reference No 60/2009: R v Holtom [2011] 1 Cr App R(S) 18: and R v Barrass [2012] 1 Cr. App. R(S) 80, the latter two decisions both involving manslaughter by gross negligence.)
43. In Barrass Rix LJ observed:

"… Appleby we consider has created a situation in which there has now been a step change in the tariff in sentencing in such cases (that is gross negligence manslaughter cases) each of which of course ultimately rests on its own particular facts, but in general by reference to a proper consideration of the … fatal consequences of the offences".

44. In Holtom the same point was emphasised in different language. Sweeney J observed:

"… there is now greater emphasis to be placed on the fatal consequences of a criminal act … A similar consideration applies to cases of manslaughter by gross negligence in the work place".

45. The decisions in Holtom and Barrass demonstrate that the principles enunciated in general terms in relation to sentencing in manslaughter cases in Wood and Appleby apply to cases involving gross negligence manslaughter generally. There is no special exception when manslaughter occurs in the context of gross medical negligence.
46. It is of course self evident, and Mr Ellison was at pains to underline the importance of ensuring a proper assessment of the culpability of the individual defendant. He explained a number of features of the case to us, which we have endeavoured to summarise in their proper context in the detailed summary of the facts. In essence, Mr Ellison submitted, and we see the force of the submission, that the appellant was by no means the only person involved in the treatment of Lisa Quinn who had failed to exercise proper professional care of her. Nevertheless, as we have explained, he was in charge of the team responsible for her care, and his responsibility went far beyond mere failures of oversight and supervision of those for whose work he was responsible. Mr Ellison drew attention to the appellant's previous good character, the destruction of his medical career, his genuine remorse, and the damaging psychological impact on him, his guilty plea, and the long period between the date when he was first charged with manslaughter, and the eventual decision that he should be imprisoned. We have also considered evidence about the severe impact of the sentence on him.
47. With these considerations in mind we come to the starting point reached by the judge, three years imprisonment, subject to the full discount for the guilty plea. We have emphasised that so far as the medical negligence itself is concerned there will be more serious cases, and cases where the relative culpability of the defendant is less serious than it was here. The essential feature of culpability in this case is that, in relative terms, the negligence of the appellant while Lisa Quinn was a patient in hospital continued for a lengthy period. Although no express warning was given to him by anyone else about the risks to which the patient was being exposed, there were a number of different occasions when, if he had not fallen significantly below the standards of accepted practice, the dangers would have been identified, and the consequent risks averted. There is the additional aggravating feature, involving the amendment and alteration to the records by the appellant in the hope of evading responsibility for his actions. Although we recognise that this may not have been directed to the possibility of the evidence considered at the Coroner's Inquest, and certainly not to the possibility of a criminal prosecution for gross negligence manslaughter, the documents which demonstrated that he, and indeed others for whom he was responsible, had fallen well below the necessary standard were of importance to any internal inquiry. Perhaps most important of all, these records represented what was supposed to be the true history of this patient's stay in hospital and the circumstances which led to her death. These records should be sacrosanct. The amendments and alterations to them were designed to be a cover up. That is a serious matter of aggravation.
48. In these circumstances the sentence imposed by the judge, making due allowance for the mitigating features which he clearly identified, was not manifestly excessive. Accordingly the appeal was dismissed.