(1) Diane Hopkins & (2) Frances Ryan v HM Coroner for Swansea and Neath Port Talbot [2018] EWHC 1604 (Admin) Judgment here.

This was a straightforward application of the High Court’s power under s13 Coroners Act 1988 to quash the determinations and findings made at an inquest and order a new one, in the light of new evidence.  But the facts make surprising reading and reveal important lessons for coroners.

Mrs Pokoyski was an 85 yr old care-home resident. After a series of strokes left her paralysed she required a puréed diet. Her family were concerned that she was often being inappropriately fed in a reclining position so causing her to choke. One day she was said by care staff to have suffered a ‘bad episode” of vomiting and aspirated vomit; she became ill, struggling to breathe; she was taken to hospital but died a few days later.

Following a post-mortem examination a consultant histopathologist, Dr Thomas, gave the cause of death as “aspiration pneumonia with locally advanced carcinoma of the lung”. However, at the inquest Dr Thomas changed his opinion. Having heard the factual witness evidence he said he now wasn't clear if choking had occurred and that the food material he saw in the lungs might have come from the stomach rather than from aspiration. Dr Thomas now gave a different cause of death - pneumonia caused by lung cancer - which the assistant coroner accepted as part of his conclusion.

However, the deceased’s daughters had legitimate concerns about how their mother had been fed and and so after the inquest obtained an independent expert pathologist’s opinion. Professor Soilleux gave a damning analysis of Dr Thomas’s evidence. Not only had the original cause of death been correct, but the deceased had died from the worst aspiration pneumonia this expert had ever seen under the microscope.

R (Maughan) v HM Senior Coroner Oxfordshire and others [2018] EWHC 1955 (Admin) 26 July 2018 judgment here.

In a roller-coaster judgment the High Court has revolutionised the approach to the conclusion of suicide in the coroner’s courts and has determined that whether the deceased died as a result of suicide is to be determined on the civil standard of proof - on the balance of probabilities.

Judgments such as this are an extremely important reminder to all lawyers of the dangers of making the assumption “it must be right because that’s how it has always been”. Applying the doctrine of stare decisis means the Court would doubtless now say to us all that "whatever you have all been assuming was always the case, you were actually always wrong".

The Claimant submitted that decades (if not centuries) of case law had established that a verdict of suicide at an inquest could only be returned on the criminal standard of proof; Leggatt LJ and Nicol J, however, found that the authorities simply did not bear this out.

The findings of fact and conclusions can be viewed and downloaded here.

HH Peter Rook QC has today handed down his findings of fact and conclusions in respect of the inquest into the death of Private Sean Benton, a trainee soldier, at Deepcut Army Barracks on 9 June 1995.   

He has concluded that Sean died as a result of suicide when he shot himself with a SA80 rifle causing five wounds to the chest. He has found that no third party fired any shots during the incident that led to Sean’s death.

The initial inquest into Sean’s death held a month after his death lasted less than a day and also came to a verdict of suicide. However that inquest was overturned by the High Court in October 2016 when a fresh inquest was ordered.  

The second inquest, commenced in February 2018 and was held to, in part, satisfy the state’s obligations under Art 2 ECHR to proactively investigate certain deaths.

Having heard evidence from 172 witnesses over 40 days of court sittings HH Peter Rook QC has provided narrative describing the circumstances in which Sean came by his death.

Having considered psychiatric expert evidence the judge has concluded that Sean Benton had an undiagnosed evolving Emotionally Unstable Personality Disorder which meant that he would have had great difficulty coping with significant disappointments and stressful life events. On 8 June 1995 Sean had learnt that an application was being made for his discharge from the army, and, profoundly affected by this decision, Sean decided to take his own life.

R (Adath Yisrosl Burial Society and anor) v HM Senior Coroner Inner North London (Costs) EWHC 1286 (Admin) (25 June 2018) Judgment here 

In the closing chapter of a case that has attracted wide media comment, the Divisional Court has now considered whether costs should be awarded against the North London Coroner, whose ‘cab rank’ policy for addressing the administration of deaths in her area, challenged by religious groups who considered that it amounted to indirect discrimination, was quashed in April.

In the substantive case, discussed here, the court held the Senior Coroner’s policy to be irrational and unlawful. She had wrongly fettered her discretion to expedite deaths where there was a particular need or religious imperative to do so.

The remaining question, therefore, concerned costs. In particular, whether the court should follow the general rule in CPR 44.2(2)(a) that in civil actions, including applications for judicial review, the unsuccessful party be ordered to pay the costs of the successful party, notwithstanding that the Defendant was a judicial officer.

As the Court of Appeal has previously made clear in Davies[1], although the award of costs is discretionary, the fact that a coroner loses a case as a Defendant is an insufficient basis, in and of itself, on which to make an adverse costs order against him or her.

The fact that a coroner loses a case is an insufficient basis, in and of itself, on which to make an adverse costs order against him or her.

R (Parkinson) v HM Senior Coroner Kent, Dartford and Gravesham NHS Trust and Dr Hijazi (Interested Parties) [2018] EWHC 1501 (Admin) Judgment here (15 June 2018)

In a tour de force judgment, that deserves plaudits for its several pages of lucid exposition of the application of Art 2 in respect of deaths associated with medical treatment, the Divisional Court have re-affirmed that the Art 2 investigative obligation will not be engaged if what is being alleged amounts to no more than medical negligence by healthcare staff.

Although Art 2 rights could be infringed if an individual’s life is knowingly put in danger by the denial of access to life-saving emergency treatment, the state’s Art 2 obligations do not extend to circumstances where a patient is considered to have received deficient, incorrect or delayed treatment.

That conclusion is perhaps of little surprise given the very recent and authoritative statement of the relevant principles set out by the Grand Chamber of the European Court in Fernandes v Portugal [1] (see our earlier blog).  Indeed once Fernandes was decided in December 2017 the main part of the Claimant’s judicial review claim was already thoroughly holed below the water line.  Mr Parkinson nevertheless sought to urge upon the Court that, if necessary, it should decline to follow decisions of the ECtHR.

Launching the final torpedo, the Divisional Court made it clear that only in exceptional circumstances would the courts in this country decline to follow the jurisprudence of the European Court of Human Rights. Fernandes was to be followed: and, on the facts, there had been no arguable breach of Art 2.

R (Lyttle) v (1) Attorney General (2) HM Senior Coroner for Preston [2018] EWHC, 25 May 2018 Permission decision here

In a useful reminder of the constitutional position of the Attorney General, this Administrative Court decision has made it clear that should the Attorney General refuse to give a fiat this will be the end of the road for any Claimant hoping to make an application under s.13 of the Coroners Act 1988 for a fresh inquest.

Unlike Judicial Review proceedings, where permission to proceed with a claim is sought from the High Court, applicants hoping for an order for a fresh inquest under s.13 Coroners Act 1988 must first seek permission to proceed (a fiat) from the Attorney General. As with the High Court Judicial Review permission stage, the purpose of the fiat is to weed out unmeritorious or frivolous claims.   But unlike the High Court – where refusal of permission on the papers may be followed by an oral permission hearing -   the Attorney General’s decision, which is always made on the papers, will be final.

The Attorney General is answerable to Parliament, not to the Administrative Court in this respect, hence challenging the fiat decision in the High Court is not only futile but, as in the present case, the applicant also risks having costs awarded against them when the Attorney General inevitably succeeds.

R (Maguire) v Assistant Coroner West Yorkshire  [2018] EWCA Civ 6 (17 January 2018)  Judgment here. 

In a sequel to our earlier blog piece the Court of Appeal have delivered their judgment upholding the decision of Mr Justice Holroyde[1] who had found that the Assistant Coroner had been correct to decline to hear oral evidence from nine children who had contact with the killer of their teacher on the morning of her death, and who had heard his threats to kill and/or knew he was carrying a knife,  but had not revealed this to any adult before the death.

The Lord Chief Justice noted that under the Coroners Act 1988 and its predecessors, a coroner was required to examine such witnesses as appeared “expedient” [2] and whilst the formulation is different in the 2009 Act[3] which simply empowers a coroner by notice to require a person to attend to give evidence or to produce evidence, nevertheless, the change has not affected the basis upon which a coroner’s decision to decline to call or seek evidence may be challenged, which is on the usual Judicial Review grounds.[4]  

In dismissing the appeal on all grounds the Court of Appeal endorsed the Coroner’s approach of balancing the value of the evidence against the potential harm to the pupils of giving evidence.   In this case, given the absence of any relevant policies or rules regarding reporting the presence of knives in school, it was very difficult to see how the proposed questioning of the nine pupils would have any value at all. Exploration of the individual child’s thinking in connection with the decisions he or she made that morning when confronted with knowledge of what the killer was saying and doing was not within the scope of the inquest. The decision not to call these witnesses was therefore plainly rational. 

R (Adath Yisrosl Burial Society and anor) v HM Senior Coroner Inner North London and The Chief Coroner of England and Wales (Interested Person) EWHC 969 (Admin) (27 April 2018)   Judgment here.

This is an unhappy case all round. The silver lining is that the Divisional Court went out of its way to facilitate some public education about that most fundamental and cherished of rights, the principle of equality.  Anyone wanting a crash course in: absolute and qualified rights, justification, indirect discrimination and proportionality and the PSED (the public sector equality duty) should head straight to paragraphs 93 to 143 and make an entry on their CPD form.  But the take away point is this: 

People are different. Treating them equally does not mean treating them the same.

The specific issue was whether the Coroner could and should fast track the administration of deaths of Jewish people or whether religion should be left out of account altogether, so that each death, and family, should await their turn in the coronial queue.

The Divisional Court decided that specific point (in appropriate cases they can and should) and then explained what equality means. We suffer discrimination not only when we are treated differently to someone in an analogous situation but also when, being different, we are not treated differently. We are not all the same, one size does not fit all and if we are to be treated equally, a balance must always be struck.

The Annual Coroners Statistics for 2017 that have been published this month, may not be top of the reading list for many inquest practitioners, however they are always worth a summary glance, as the figures reflect the huge volume of work that Coroners deal with behind the scenes that is often not appreciated when there are more headline grabbing inquests or judicial review cases to be reported.

The key trends (which it is well worth knowing about) are summarised here, along with important, new information about research demonstrating the reliability of non-invasive post mortem examinations by enhanced CT scanning (PMCT) and why greater use of that modality is strongly to be encouraged. 

Summary of the Annual Report 

There were 229,700 deaths reported to Coroners last year. However, the annual number crunching reveals only two notable year on year changes once the impact of DOLS deaths is taken into account: first, a welcome reduction in deaths of those detained under the Mental Health Act and second, a massive increase in the number of non-invasive post mortem examinations conducted.

Key figures

  • 11% fewer deaths reported

  • 18% fewer inquests opened

  • 22% reduction in mental health deaths

  • 120% increase in non-invasive post-mortem examinations.

Lopes de Sousa Fernandes v Portugal (Application no. 56080/13) (ECtHR Grand Chamber, 19 December 2017) judgment here.

The ECHR Chamber judgment in Lopes (15 December 2015) had the potential to expand the situations where a Middleton style “Article 2 inquest” would be required. The Chamber judgment appeared to widen the scope of Article 2 protections to incorporate errors of judgment on the part of health professionals and miscommunication between hospital departments. If poor judgment calls and miscommunications were now to be considered a substantive breach of Article 2 then many hospital deaths would require an inquest fully compliant with Middleton principles. It was perhaps only the unavailability of the judgment in English that held back the flood. [1]

If poor judgment calls and miscommunications were now to be considered a substantive breach of Article 2 then many hospital deaths would require an inquest fully compliant with Middleton principles.

However, the Grand Chamber of the European Court of Human Rights (“the Court”) has now reversed the previous Chamber judgment and held, by a 15:2 majority, that there was no violation of the substantive limb of Article 2 in respect of ‘merely’ negligent hospital treatment.

The judgment provides important clarification on substantive Article 2 claims and would appear to limit such claims in the healthcare sphere to cases of a denial of life-saving treatment caused by systemic/structural issues rather than individual error. The Court has now made clear that “mere error or medical negligence” is not sufficient.[2]

The case however remains of relevance for inquest practitioners as the Court upheld the finding that there had been a violation of the procedural limb of Article 2 owing to the delay in implementing the extant state structures to investigate the death.