The Duty of Candour shows its teeth

From the jaws of the Care Quality Commission this month comes the first ever fine issued for breach of the Duty of Candour[1]. Bradford Teaching Hospitals NHS Foundation Trust have been given a fixed penalty notice for £1,250 for failing to apologise to a bereaved family within a ‘reasonable’ time.

A baby had been admitted to Bradford Royal Infirmary in July 2016. Delays in diagnosis and missed opportunities to admit him had been recorded as a notifiable safety incident, yet the family were not informed of this and did not receive any apology until October (writes the CQC).

The CQC’s action does not relate to the actual care provided to the child, but rather to the fact that the NHS Trust was slow to inform the family that there had been delays and missed opportunities in his treatment.

Apparently the hospital identified and reported their breach to the CQC themselves, and have implemented an awareness-raising programme across their staff to avoid this happening again. Whilst in theory the CQC have powers of prosecution, in the circumstances, this relatively small fine seems more proportionate.

It is “probably suicide” in Northern Ireland too

In the matter of Steponaviciene’s Application [2018] NIQB, 16.11.18

As coroners, lawyers and the bereaved wait to find out how the Court of Appeal will decide the Maughan case this coming April[1], a decision from across the Irish Sea has looked in detail at the English and Welsh Divisional Court’s decision in Maughan and found no flaws in its “careful and persuasive” reasoning. For the time being at least, the issue of whether the deceased died from suicide should be decided on the balance of probablities in Northern Ireland just as in the English and Welsh Coroners’ courts.

In a detailed judgment McCloskey J has also laid some of the groundwork for anyone resisting the English appeal[2]. In considering the arguments in Steponaviciene’s Application the judge reviewed nine cases put before him that the court had not been referred to in Maughan at first instance. Roundly dismissing the suggestion that any of these cases rendered the Maughan decision per incuriam, the judge lamented that one of the “unfortunate repercussions of the internet explosion was the routine inundation of electronically available judicial decisions belonging to multiple levels in the hierarchy of the legal system without proper regard to the doctrine of precedent.

A potential murder revealed: Should the cumbersome s.13 process still be necessary?

Re: The inquest into the death of Helen Bailey [2018] EWHC 3443 (Admin)

It is “elementary 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, will normally make it both desirable and necessary in the interests of justice for a fresh inquest to be ordered”. So stated the Lord Chief Justice when ordering the fresh Hillsborough Inquests[1].

It might then be thought that a Senior Coroner overturning their own (or their predecessor’s) inquest on the grounds of significant fresh evidence pointing to the death being a homicide would be a simple process: after all the Coroner is hardly likely to have misjudged the importance of that new evidence recently revealed. Yet the cumbersome requirements under s.13 Coroners Act 1988 mean that a Senior Coroner who believes that justice requires a fresh inquest must still follow the time consuming two stage process of, first, applying to the Attorney General’s Office for permission to make an application[2] and once that permission is inevitably granted, follow a second and separate process of making an application to the High Court.

Costs against Coroners: being “neutral” means staying neutral, a partisan Coroner risks an adverse costs order.

R (Paul Worthington) v Senior Coroner for Cumbria [2018] EWHC 3386 (Admin)

Many will recall the much publicised judicial review brought by the Adath Yisroel Burial Society[1], which led to the Senior Coroner for Inner North London’s “cab rank” burial policy being quashed. When it came to costs, the Court held that the Coroner had “crossed the line” from merely seeking to assist the Court on aspects of law and procedure into arguing the correctness of the decision under challenge. At that point she was no longer protected by the general rule that coroners who remain neutral in judicial review challenges to their decisions should not be held liable for the applicant’s costs[2]. Partial costs were awarded against her.

Even ‘neutrality’ in the face of an inevitably successful application will not necessarily mean costs will be avoided if the Coroner behaves unreasonably. In Hopkins the Swansea Coroner unreasonably refused to sign a consent form when the bereaved family’s s.13 application was clearly bound to be successful. The Coroner was ordered to pay all the applicant’s costs from service of the claim[3].

In another much discussed case this year of Maughan[4] (concerning the lawfulness of the Coroner’s directions on the standard of proof for suicide) the Coroner advanced reasons why the guidance on which his directions had been based was “arguably correct”, yet was said to have maintained a “neutral stance” – perhaps hoping to avoid the potential adverse cost consequences of losing the claim (although the outcome was a score draw and the judgment does not suggest that any application for costs was made either way).

The defendant Coroner in the recent Poppi Worthington case[5], through his counsel, sought to maintain that he too was taking a “neutral stance”. The three judge Divisional Court (which included the Chief Coroner) disagreed, observing that the Coroner had, in practice, sought to persuade the Court that the claim should be refused.

“Both parties clearly sought to persuade us, to the best of their considerable ability, that their submissions should be preferred.”

The Court noted that, despite the Coroner’s asserted ‘neutrality’, had the claim been successful, the Claimant would have been entitled to his costs against the Coroner.

Poppi Worthington’s abuser fails to remove an account of his acts from the Record of Inquest

R (Worthington) v Senior Coroner for Cumbria [2018] EWHC 3386 (Admin)

When public funding for deserving families at inquests is so hard to come by it is mystifying how the Legal Aid Agency can make a decision to spend their limited funds on an apparently unmeritorious challenge to inquest conclusions by one who was involved, in the most appalling way, in the circumstances leading to the death of the deceased.

In the Worthington case, the acknowledged motivation of the abusive father in bringing his challenge was to try to hide his actions in the lead up to his daughter’s death from those who might look at her Record of Inquest (ROI) in the future, yet his claim was brought with the benefit of public funding.

Poppi’s death

The account of how Poppi Worthington met her death is an extremely sad and disturbing story. Poppi was 13 months old when she died at her home. When Mr (now Lord) Justice Peter Jackson considered this case in the family court proceedings in 2014 and 2016[1] he concluded that in the hours before Poppi’s death, the Claimant, her father, had perpetrated a penetrative anal assault on her, either using his penis or some other unidentified object. Poppi died shortly afterwards from a cause which the Judge was unable to ascertain.

The fresh inquest held in 2017[2], revisited the issue of whether Paul Worthington had sexually assaulted Poppi prior to her death and, if so, whether that had caused or contributed to her death. In a detailed document of over 100 pages the Coroner set out his reasoned factual findings on the extensive expert and factual evidence. He concluded that Paul Worthington had anally penetrated Poppi in his bedroom and then left Poppi to sleep beside him in such a position that her breathing was compromised, either due to the position of the bedclothes, her position within the bed, or overlaying, or a combination of all three. The anal penetration had not caused her death. Rather, the Coroner concluded that Poppi had died from asphyxia resulting from obstruction of her airways whilst she was asleep in her father’s bed.

The Judicial Review claim

Paul Worthington specifically accepted that the Coroner was required to make a finding of fact as to whether a penetrative assault had occurred. He did not challenge that finding. Indeed he could hardly have done so given that a High Court judge had twice previously come to a similar conclusion about his despicable abuse of his baby daughter.

Mr Worthington’s complaint was that the Coroner had recorded in box 3 of the Record of Inquest[3] that:

“…at some time after 2.30am, [Poppi] was taken from her cot to a double bed where she was anally penetrated. She subsequently went to sleep in the double bed with an adult sleeping close to her… her ability to breathe was compromised by her unsafe sleeping environment…”

Mr Worthington judicially reviewed the Coroner’s conclusion. His case was that the words above in italics trespassed into the wider circumstances of the death in a way that was not permitted in a non-Article 2 inquest. As the anal penetration had not caused Poppi’s death, he argued it could not be relevant to “how” she died, and so should not have appeared on the Record of  Inquest.