HM Senior Coroner for Cornwall And the Scilly Isles [2024] EWHC 2673 (Admin). 22 October 2024. Judgment here
Where a Coroner has conducted an inquest and, through no fault of their own, done so on the basis of an incomplete picture of the circumstances surrounding the death, both the interests of the bereaved and the public interest will make a fresh investigation and inquest both necessary and desirable in the interests of justice.
In this recent example of a Senior Coroner seeking to overturn their own inquest after new information has come to light, the High Court efficiently heard together and granted two applications brought under s.13 Coroners Act 1988. In each case, substandard surgical care had first been implicated in the death some years after the original inquests had concluded
The background
In 2017 and 2013 inquests had been heard into the deaths of two patients who each died having suffered internal bleeding whilst under the care of the vascular surgery unit at the Royal Cornwall Hospital.[1] It was thought at the time that the deaths had been from a recognised complication of the necessary surgery.
In January 2019 the Royal Cornwall Hospitals NHS Trust asked the Royal College of Surgeons to carry out an Invited Service Review (‘ISR’) into aspects of the work of the vascular surgery unit at the hospital and, in particular, the work of a consultant vascular surgeon (‘the surgeon’). The ISR identified serious patient safety issues in relation to patients of the surgeon, and a need for improvement in multi-disciplinary processes at the hospital.
In respect of one of the deceased the ISR had revealed shortcomings in how his consent was obtained before his elective operation and in his care and treatment during his operation. In the other case the surgeon was said by the ISR to have proceeded with the operation despite (i) a low platelet count (ii) a lack of informed consent regarding the risks of the procedure and (iii) had delivered substandard treatment to her.
That fresh evidence called into question the medical cause of death recorded at the initial inquests, and undermined the factual findings and conclusion recorded. The fresh evidence raised the possibility that the deaths were not (as had it had previously been understood) due to a recognised complication of necessary surgery but, rather, were contributed to by acts and/or omissions of the surgeon.
Applying the principled approach from the Hillsborough[2] case the court was satisfied that “the emergence of fresh evidence which may reasonably lead to the conclusion that the substantial truth about how an individual met his death was not revealed at the first inquest.. [made] it both desirable and necessary in the interests of justice for a fresh inquest to be ordered”.
As cogent evidence was now available which pointed to these deaths having been contributed to by unacceptable standards of treatment and care by the surgeon and by deficiencies in the processes then in operation at the hospital, both the interests of the bereaved, and the public interest, required a fresh investigation. Whilst it was not necessary for the Coroner to show that it was probable that fresh investigations would now lead him to make different findings; on the evidence now before the Court, it did seem likely that the findings recorded at a fresh investigation would in each case differ from those made at the original inquest. The determination and findings of the original inquests were therefore quashed so that the Claimant Senior Coroner might now hold fresh inquests.
Rachel Spearing of Serjeants’ inn Chambers was instructed by HM Senior Coroner for Cornwall and the Scilly Isles. There was no Defendant to this part 8 claim, and the interested parties (the family of the deceased and the NHS Trust) supported the order sought.
Footnotes
[1] One of the cases had initially been heard by the Senior Coroner who at that time was an Assistant Coroner in the area, the other was heard by a different Assistant Coroner.
[2] See HM Attorney General v HM Coroner of South Yorkshire (West) [2012] EWHC 3783 (Admin) at paragraph 10.