It wasn’t the nicest of experiences. Being dragged into an inquest in a coroner’s court. It seemed so unfair: I wasn’t given the post mortem report prior to the inquest. The pathologist (general pathologist, with no subspecialty interest in oncology nor have seen many such cases) thought that the patient died from acute lung injury due to the treatment I have given, and I had to give my defence without any prior preparation. In the end the verdict was aginst me.
I was furious. I brought the case back and discussed it in an oncology centre, in a meeting with 2 medical oncology consultants, 4 different clinical oncology consultants, an oncological cardiothoracic surgeon and 2 radiologists with subspecialty interest in oncology. After reviewing the case, everyone felt that the verdict was wrong and the patholgist was mistaken to attribute the acute lung injury to my treatment. The timescale were all wrong, he had treatment too long ago prior to the acute respiratory eposide. Lucky for me, the patient has a CT of his thorax about a week before his death which showed no lung parenchymal abnormalities. This confirmed that the ARDS had developed between the date of that scan and his unfortunate demise. That CT scan was done about 6 months since I had given him radiotherapy for a critical 67% malignant tracheal stenosis. More likely than not he would have developed his ARDS from undetected viral infection, or aspiration, or allergic reaction to antibiotic treatment in his disctrict hospital for presummed lung infection etc etc.
I felt a bit vindicated. One of my colleagues in the meeting suggested that I should write to the pathologist.
It was a really traumatic experience. Thank God my fury over the sense of injustice settled quite quickly as I reflected: what does God want me to learn through this experience. Surprisingly I started to feel very calm when I learn to be humble under God’s hand through this bitter humiliating unfair experience. Sometimes in life, the important thing is not to get vindicated so that the wound to my pride can heal. Perhaps it is more important that the wound doesn’t heal, so that pride can be replaced by humility. Yes, even when I am right. 
