Whittle v HM Coroner North West Wales [2025] EWHC 236 (Admin) judgment here
What were you doing on 24 November 1994? Can you describe the things you said or heard that day or explain the rationale for any significant decision you made. If I tell you that is the year Nelson Mandela was first elected president of South Africa, Kurt Cobain died and Forrest Gump was released does that help you at all?
On rare occasions a judgment of the High Court in an uncontested case will provide very little explanation of what has gone on to lead to the decision. Yesterday a judgment was handed down in such a case. Rather unsatisfyingly it is not really explained how or why the Senior Coroner here “encouraged”, the Claimant’s application to hold a fresh inquest into the death of a psychiatric patient so many decades after his first inquest ended, or perhaps more appositely, how the fresh inquest that has now been ordered can fully, frankly and fearlessly investigate this death, and compensate for the inadequacies of the first, if there are now no medical records remaining, no witness statements, no details preserved of staff involved in events and any witness still living will have to recall matters that occurred three decades ago.
At the first inquest into Mr Whittle’s death, heard on 22 February 1995 the Coroner recorded in box 3 of the Inquisition:
“Deceased had been admitted to the psychiatric unit at Ysbyty Gwynedd, Bangor but left through the window of an interview room and climbed over the roof and away. He was found the following morning flat on his back on a concrete track underneath a bridge carrying the A55 expressway. He was found at 7.50 AM on 25 November 1994.”
Alongside these brief circumstances an “open verdict” was recorded “there being no evidence to show how he came to be where he was found.”
It is explained in the judgment that the deceased had been displaying clear signs of mental disorder when picked up by police and taken to hospital on 24 November 1994. The doctor told his brother (the Claimant) and his father that he was seriously ill and required further psychiatric evaluation before being discharged. When asked if they could take him home, the doctor said he would speak to the deceased. The doctor returned to say that the deceased had decided to stay at the hospital for treatment. The claimant and his father then heard a loud bang. They were informed that he had broken a window, climbed down a sloping roof and left. Mr Whittle was found dead the next morning by a passing cyclist under the North Wales Expressway.
Insufficient Inquiry?
In 2024 the Claimant, applied under s.13 Coroners Act 1988, for an order to hold a fresh inquest. He asserted that there had been insufficient inquiry at the original inquest into (among other things): (i) the risk the deceased posed to himself; (ii) whether he required detention under the Mental Health Act 1983; (iii) whether acts or omissions of hospital staff had caused or contributed to the death and (iv) how the deceased was able to abscond and the steps taken to look for him when he did. Evidence said to have been given by the doctor at the original inquest (that the deceased had signed himself out of the unit) was disputed.
Unsurprisingly, after thirty years there were now no medical records or staff records from the time available. No other detail is given in the judgment regarding what evidence had been heard at the original inquest or even how long the inquest hearing had lasted. It is not made clear whether any coronial records beyond the ROI (such as any witness statements or notes of evidence) still existed. It might be assumed that there were some records showing that the first inquest had been a perfunctory process, given that the Senior Coroner agreed with the Claimant’s case that there had been insufficiency of inquiry at the original inquest and so supported his application to quash that inquest and order a fresh one.
It is unfortunate that no detail about the quality of the first inquest has been made public. It may well be that the Whittle family were very badly served by the first coronial investigation and there has never been anything like the inquiry into their relative’s death that they were entitled to and deserved. Contrast this case with the judgment in Earl v HMC East Sussex (see our blog here) where the numerous inadequacies of the initial police investigation and subsequent inquest were clearly set out.
What evidence was likely to now be available regarding the death is also completely opaque. So too the thorny issue of how an inquest might now reasonably be conducted, given the apparent absence of any medical records or staff records and, one might reasonably assume, no useful memory of events on the part of those potential witnesses who might be found alive.
However a Court of Appeal Judge and a High Court judge were satisfied that the interests of justice required a fresh inquest. Coulson LJ commented that “a full and fearless inquiry would need to address the factual matrix of his mental health deterioration, including conversations with his fellow student and police surgeon” (perhaps tricky to accurately recall those conversations if they were not recorded at the time). His Lordship also considered that “for it to be a meaningful inquest, particularly for the family,”….“important questions are whether the deceased was detained, whether he had capacity, how he was able to escape, what action was taken by the hospital to recover him, what the high risk strategy being instituted was, and what was done by the police in order to locate someone about whom they also had concerns.” (If North Wales police can find the floppy disc[1] holding their records of the steps taken to locate a missing psychiatric patient three decades ago this blogger will be very impressed).
Of course inquests can be properly conducted decades after events – the inquests into the 96 deaths at Hillsbrough being but one important example, helping the families and survivors in their search to get to the truth of what happened on that day. But in such cases there is often a wealth or contemporaneous documents that can assist the inquiry and earlier statements that might jog faded memories.
Here the Coroner was of the view that a meaningful inquest could be conducted, even if some issues remain ultimately unresolved and even where there may be no access to records and statements due to the passage of time. In situations like this perhaps the significant importance is that an inquiry that is meaningful for the bereaved is conducted.
But in the absence of further elucidation of the facts in this judgment, a concern for all coroners must be that this case could open the floodgates of applications under s.13 Coroners Act 1988 for fresh inquests where the original inquest was held in a manner that was unremarkable last century, and which recorded all the essential matters that the statute then required, but would not meet the standards of today’s more exacting coronial inquiries.
A Procedural Warning
Whatever the unexplained background might be, that the Court was not going to stand in the way of an agreed position becomes clear when one gets to the second half of this judgment and the five pages of judicial sophistry required to find a loophole in a procedural tangle created by the claim not having been served in time.
Within six weeks of the grant of the Attorney-General’s fiat to bring a s.13 challenge the claim form must be filed at the Administrative Courts and must be served upon all persons directly affected by the application.
This claim had been filed in person at the Bristol Civic Justice Centre for issue by the court two days before the six week deadline, and at the same time an un-issued copy was served on the Coroner. The Court Office had accepted the papers, but a few days later had rejected the paper based forms, requiring the claim to be filed electronically. The sealed claim form was eventually issued shortly after the six weeks deadline expired, that sealed version was not served by the Claimant on the Coroner until a couple of months later.
Service out of time was a clear breach of the rules and so fatal to the claim. After considering and rejecting a number of different ways to rectify the error the solution the court arrived at was to extend time for service. However the judgment strongly emphasises that this was an unusual case, as among other points it was accepted that the relevant delay occurred at the Court Office, leading Coulson LJ to remark that “if HMCTS wish to adopt an entirely paper-free process, the least they can do is to explain that to a court user, who bothers to attend personally to file a paper claim.”
In circumstances where the application was not challenged it was deemed just and proportionate to extend time. However those making a s.13 application in future should ensure they ask for the claim to be issued well before the six week deadline for service expires, as this case makes it very clear one should never assume that an extension of time for service will be granted.
Footnotes
[1] Readers born this century please ask your parents to explain what the odd square symbol you click on to save a Word document is meant to be.
Sebastian Naughton of Serjeants’ inn Chambers represented an Interested Party in this case.