Re AB (Application for reporting restrictions: Inquest) [2019] EWHC 1668 (QB)
When seeking any order it always helps to make the right application, to the right court, following the right procedure. Although when it does go horribly wrong it at least provides valuable learning for the rest of us.
So make sure you are sitting comfortably, and get ready to be educated by Mr Justice Pepperall dishing out a lesson on making an application for reporting restrictions in respect of an inquest.
Inquest into the death of Geoff Gray, 20.6.2019 (Findings of fact)
In what must be a coronial first an assistant coroner has issued a ‘PFD report’[1] (available here) directed at the Chief Coroner suggesting he may be able to take action himself to prevent future deaths by issuing guidance to coroners regarding post-mortem investigations after shooting cases.
On 20 June 2019 HH Peter Rook QC[2] concluded the second inquest into the death of Geoff Gray. Geoff was 17 years old when he died from two gunshot wounds to the head at Deepcut Barracks in Surrey in 2001. Evidence heard at the fresh inquest revealed that very soon after Geoff’s body being found the assumption had been made by attending civilian and military police and by the coroner’s officer that Geoff’s death was a suicide. Therefore only a ‘routine’ coronial post-mortem was requested which was performed on the day of the death.
Two earlier deaths of young trainees from gunshot wounds[3] at the same barracks in 1995 were also both investigated with ‘routine’ coronial post-mortems. In one case the post-mortem had been carried out by a general histopathologist, who had no experience of performing an autopsy following a death from high velocity gunshot wounds.
But, as the expert forensic pathologist in Geoff Gray’s case stated,
“shooting cases are not routine…if you make assumptions early on in the investigation, then there is the likelihood, and indeed the probability, that vital evidential material is lost”.
Inquest into the death of Geoff Gray, 20.6.2019 (Findings of fact)
The long running second inquest into the death of Private Geoff Gray at Deepcut Barracks ended yesterday when HH Peter Rook QC[1] returned a conclusion of suicide.
Geoff was only 17 years old when he was found dead from gunshot wounds in the grounds of the Officers’ Mess at approximately 01.10 hours on 17 September 2001. This fresh inquest, which was ordered by the High Court in 2017, had, in particular, explored whether Geoff had been shot by another person who had then moved his body to the location where it was found.
Ministry of Justice/ONS, 9.5.2019
One death is a tragedy; half a million – well, 541,627 to be precise – is a statistic.
The Coroners Statistics Annual Bulletin 2018 (which covers the year to end of 2018) has just been released. It is, as always, an invaluable guide to the workload of coroners around the country and possible trends for the future.
The overall bad news is that more of us are dying. Total deaths reported to the ONS have risen year on year, from 484,367 in 2011. The projected figure of 541,627 deaths in 2018 continues that trend and is set to be the highest total since 1999.
The coroners statistics of course only address those deaths a coroner needs to be told about (those thought to be violent, unnatural or unexplained or of someone in state detention): the good news is that there are less of those.
Of the several things to note in the latest figures the headline is that the removal of the requirement to report deaths of those subject to a Deprivation of Liberty Safeguard (‘DOLS’) authorisation has changed the statistical landscape.
It is rare that healthcare staff are seriously dishonest in their evidence to an inquest, although sadly such conduct does at times happen. Even when criminal prosecutions are not subsequently pursued, this recent appeal is a strong reminder of the seriousness with which such conduct should be taken and the professional consequences for those who seek to dishonestly hide their errors.
“Honesty, integrity and trustworthiness are ‘the bedrock’ of any nurse’s professional practice”.
As this case makes clear, courts will not look lightly upon dishonesty to a Coroner: it runs the risk of prejudicing an inquest which is flatly against the public interest.