A coroner has decided to refer a GP to the General Medical Council (GMC) following the death of a 23-year-old woman at the beginning of this year. This follows an inquest which concluded that Charlotte Foster died from the untreated side effects of the combined oral contraceptive pill Dianette.

Senior Coroner for Shropshire, John Ellery, announced at the conclusion of the inquest on 28 July 2016 that due to the areas of concern raised during the inquest he would receive further submissions from interested parties to determine whether any further action was needed in relation to Dr Sunil Simon.

The Coroner concluded on 19 August that a referral to the GMC from him as the coroner was appropriate and that the public interest required that a referral comes from the coroner in this case so that all the areas of concern raised at the inquest can be considered. Dr Simon had made a self-referral to the GMC on 16 August. The Coroner added that the purpose of the referral was not to duplicate the process but to underscore its importance.

The family welcomed the coroner’s decision. In a joint statement they said:
“Nothing can ever bring our beautiful Charlotte back to us but we hope that this referral by the coroner will ensure that lessons are learned from her death and that it may spare another family from going through the same agony.”

The lawyer representing the family at the inquest, medical negligence specialist Suzanne White from the law firm Leigh Day, said: “We are pleased that the coroner had decided to personally refer Dr Simon to the GMC in the hope that a thorough investigation can be undertaken and the mistakes made in Charlotte’s case are never repeated.”