"For more than one patient to die in a doctor's surgery in a doctor's lifetime would be extremely unusual and I think there are aspects around that degree of monitoring of deaths and particularly the certification of deaths that we need to look at in a considered way, " he said.

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The boy's chin and lip were bruised and his lip cut inside, which in the doctor's opinion were caused by his chin forcefully striking a hard surface that, because of the degree of force, caused the bleeding to the brain.

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