Inexperienced Pathologists and Costs against Coroners

Written by: Amy Street
Published: 29 August 2018

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

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.

This was probably suicide: the criminal standard of proof is no longer required.

Written by: Bridget Dolan KC, Debra Powell KC
Published: 26 July 2018

R (Maughan) v HM Senior Coroner Oxfordshire and others [2018] EWHC 1955 (Admin)

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.

Sean Benton ‘Deepcut’ Inquest – Coroner’s conclusions returned

Written by: Bridget Dolan KC
Published: 18 July 2018

Deepcut inquest findings of fact and conclusions

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.

Costs against Coroners: Paying for a cab rank rule

Written by: Elliot Gold
Published: 25 June 2018

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

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.

Emergency Hospital Treatment & Article 2 Inquests: Fernandes applied to domestic law

Written by: Bridget Dolan KC
Published: 17 June 2018

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

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.