I think it would be a good move for people to read the Misra case to which the coroner referred. Its not that difficult to understand for non-lawyers.
The key is in para 66 where the Court of Appeal said as follows:
"....
The jury concluded that the conduct of each appellant in the course of performing his professional obligations to his patient was "truly exceptionally bad"...."
You can read it here
https://www.casemine.com/judgement/u...d03e7f57eb152b