A doctor carried out an "unrecognised technique" on a pensioner who died in hospital after a heart attack, an inquest has heard.

Dorothy Beard was taken to the University Hospital of North Durham after collapsing at her home in Stanley on November 15, 2018.

The 79-year-old was given CPR in the ambulance and further resuscitation when she arrived in the accident and emergency department.

A team of doctors and nurses carried out CPR in hospital but she showed no signs of life and resuscitation was stopped after it was unanimously agreed by the medics that nothing further could be done to save her.

Dr Magnus Rodriguez, a consultant in emergency medicine, then went on to place an open hand on the right side of Mrs Beard's neck and applied gentle pressure.

He told the inquest, being held at Durham Miners Hall, that he was trying to stop agonal breaths - gasps that a patient may take when they are dying - to prevent distress being caused to her family.

He told a colleague he had seen this technique being carried out during his intensive care training. However the doctors present did not recognise it and their seniors were informed.

The colleagues had not seen or heard about this technique before, the inquest was told.

University Hospital of North Durham


It was said the matter was fully investigated by the police and the General Medical Council however no further action was taken against Dr Rodriguez and there was no evidence of an unlawful act.

The hearing was told that Dr Rodriguez's actions did not contribute to Mrs Beard's death and would not have stopped any agonal breathing.

It was explained by experts that agonal breathing was not a sign of life but a reflex of a dying person.

Dr Jennifer Bolton, Home Office pathologist, said: "In some individuals, the very bottom of the brain, the brain stem, still functions at a very reflex level. It's simply that it's lagging behind the rest of the body.

"It's the brain stem that is causing agonal breathing. The patient is not aware of it. It can sound awful for family to hear but the patient is unable to hear it because the rest of the brain has died. It's just the remnants of electrical activity at the base of the brain causing this gasping.

"It's a reflex, not controlled triggered breathing. It is not recognised breathing, not sufficient to keep you alive. There would not be any activity in the heart, her pulse would have stopped."

Dr Bolton further said that Dr Rodriguez's action of placing his hand on her neck could not have stopped the agonal breathing.

Giving evidence, Dr Rodriguez told the inquest he put the pads of his fingers on Mrs Beard's neck to check there was no carotid pulse.

He added: "I continued to put gentle pressure on the carotid artery. I estimate I did this for approximately one minute. I did this to ease the distress caused by agonal breathing."

He said he had misunderstood and misinterpreted the technique that he thought he saw another doctor perform during training at another hospital and accepted it was unrecognised in the UK.

He also said he had never used it before and had since attended an "observership in palliative care" and carried out learning to fill the gap in his knowledge.

"I have never used this technique before. I did it instinctively," said Dr Rodriguez. "My aim was to ease distress caused by agonal breathing. However I now know that it was not something that could be done.

"I now appreciate that was not a recognised technique. At the time, I did believe it was a recognised practice. I was devastated to learn since then the technique is not recognised."

Dorothy Beard, pictured in the late 1950s when she won a Miss Savoy beauty contest in South Shields

He added: "At the time, that was something I thought I had seen before when I was undergoing specialist training."

The inquest also heard that Mrs Beard was taken to the Freeman Hospital in Newcastle after she started having chest pain three days before her death.

On November 12, an operation was carried out to open a blocked artery in her heart and place a stent inside. The procedure was deemed to be successful and blood flow in the artery was restored. Mrs Beard was allowed home two days later.

However, Mrs Beard suffered an "unpredictable and rare complication" - a rupture was caused in the sac around her heart on November 15, which led to her death.

Mrs Beard's daughter Stephanie Beard asked why her mother was not given a coronary bypass.


Dr Rajiv Das, a consultant cardiologist at the Freeman, said the risks in such situations could be high.

"It is to do with the safety of the procedure," he added. "Under general anaesthetic, having a chest open while an artery is blocked, there's ongoing muscle damage - the risk for that patient is too great."

The operation they carried out, under local anaesthetic, was one that "is established across the world", he said.

Speaking after a verdict of natural causes was given, Dorothy's daughter Stephanie said: “I got home and I was overwhelmed. I have never been able to grieve for my mother.

“I was grief stricken this afternoon. I think it has been an absolute nightmare. I'm completely mentally and physically exhausted.

“It has just escalated and escalated. I knew after the post-mortem my mum died of natural causes.

“I feel like 'what was it all for,' we’ve had to deal with losing my mam and this.

“I don’t feel relief. I think I feel like today I’ve lost my mam. I think I’ve been holding onto this case for 26 months to keep her near me.”