Change the law to make Reports to Prevent Future Deaths work

Written by: Christopher Johnston KC
Published: 16 June 2017

The Grenfell Tower fire shows the need to give coroners’ recommendations more teeth.

On 28 March 2013 the coroner, after verdicts were returned on the deaths of six people in Lakanal House in 2009, made important and potential life saving recommendations (see for example her Letter to the Secretary of State for Communities and Local Government). These were made under then rule 43 – now the Coroners (Investigations) Regulations 2013 reg 28 and 29.

The government in over 4 years does not appear to have acted upon that report. Has the time not come to ensure that such vital recommendations are not ignored?

These coroner reports are usually made after an exhaustive review of the situation – and with the ability of all interested parties to make submissions. They are written after a review of the key issues undertaken with more forensic precision and over a far greater time than can usually be afforded by Parliament. Hence my “off the cuff” suggestion on Twitter that key coroner recommendations should be afforded a status akin to a negative statutory instrument: i.e. binding unless parliament overrules. This would force government to act and avoid life-saving issues being kicked into the long grass. In any event Parliament should act now to ensure coroners’ reports are not ignored in the future.

A death behind closed doors, but an Inquest in public

Written by: Jamie Mathieson
Published: 22 May 2017

R (T) v HM Senior Coroner for the County of West Yorkshire [2017] EWCA Civ 318

A young woman arrived at A&E with her mother. They were carrying a shoebox. Inside the shoebox was the body of a baby girl.

The baby’s mother, aged 19, had kept her pregnancy a secret and delivered the child alone, in her bedroom six days earlier. She said she never heard a cry and did not know whether the baby had been born alive. She hid the body in a shoebox under the bed. Three days later her mother had discovered the box. The women then kept the events from other family members and waited out the weekend before taking the body to hospital.

Examinations by a pathologist and specialist neuro-pathologist left the death unexplained: there was no identified natural disease or injury. Nor could they decide whether the baby was alive at birth. The CPS reached the view that there was insufficient evidence to charge anyone with a criminal offence. The woman’s initial allegation that her conception had followed a rape was withdrawn after police investigations revealed a consensual sexual relationship.

When the Coroner proposed to hold an inquest into her baby’s death the young woman brought a case to the High Court, arguing that the Coroner had no such power and that her identity should be kept anonymous. She lost decisively on both counts.

“the conduct of the Claimant was not in any sense a private matter”

Inquest representation: Is there a contractual right to “closure”?

Written by: Katie Gollop KC
Published: 4 May 2017

Shaw v Leigh Day (A firm) [2017] EWHC 825 QB

Attention family representatives! Absolutely nooo pressure at all, it’s just that if you don’t get your client the closure they want out of an inquest, now you can be sued for damages for causing them distress. That is the effect of this recent High Court decision.

The tweetie-birds-round-head inducing litigation saga is set out in more detail below. In a nutshell, Mrs Shaw’s elderly father had a cardiac arrest following complications of a trans aortic valve procedure (TAVI). She instructed Leigh Day, one suspects on a private basis (although this isn’t clear from the decision), and there was an Article 2 inquest at the end of which the jury concluded that the death was an unintended result of a therapeutic procedure and made no criticisms of anyone.

The inquest left Mrs Shaw dissatisfied and, so far as she was concerned, lacking answers to key questions. Even though there has been since been a successful negligence action against the hospital and the surgeon, the High Court has now cleared the way for her to claim £5,000 for mental distress from Leigh Day caused by what she says is the poor job they made of getting disclosure and representing her at the inquest.

Self-defence and Inquests: Subjective or Objective Reasonableness?

Written by: Bridget Dolan KC, George Thomas
Published: 31 March 2017

R (Duggan) v Asst Coroner North London and (1) Metropolitan Police Commissioner (2) Serious Organised Crime Agency (3) IPCC (4) DS Belfield (5) DC Faulkner (Interested Parties) [2017] EWCA Civ 142

Mark Duggan’s fatal shooting by Metropolitan Police officers gave rise to widespread public disorder across the country. The inquest jury’s finding that the cause of death was “lawful killing” has, unsurprisingly, remained matter of public debate and given rise to several legal challenges.

The Court of Appeal has now held that:

“There is nothing in either domestic legislation or the jurisprudence of the ECHR which requires that, in every case where a self-defence justification is raised at an inquest, a specific direction must be given to the jury that, in deciding whether a belief of imminent threat was honestly and genuinely held, the reasonableness or unreasonableness of that belief from the viewpoint of the person claiming the defence is a relevant consideration.”

Inquest juries, DOLS and the law of unintended consequences

Written by: Bridget Dolan KC
Published: 31 January 2017

R (Ferreira) v HM Senior Coroner South London [2017] EWCA Civ 31

Reading about the 1888 Victorian Railway Commissioners case when studying for the bar I always wondered what it might look like if the ‘floodgates’ so fiercely guarded by judges in those old judgments were actually prised open. Well now I know.

The combination of the Mental Capacity Act ‘Deprivation of Liberty Safeguards’ and the Supreme Court’s 2014 Cheshire West[1] decision have produced a legal tsunami that has deluged the Court of Protection. This has been followed very closely by a smaller but equally damaging tidal wave that inundated Coroners’ Courts once holding an inquest into the death of any person who was the subject of a MCA DOLS authorisation was deemed mandatory.

If the appellant had won this present case, and a death in a NHS hospital due to the physical illness of someone lacking capacity had amounted to a death when deprived of liberty (so in state detention), and therefore required a jury inquest, then the already swamped Coroners Courts might have finally submerged.

Happily, however, the watery metaphors can now dry up, as a combination of the Policing and Crime Bill (soon to be given Royal Assent) and the Court of Appeal’s most recent common sense judgment in the Ferreira case have firmly rebuilt the levee around the Coroners’ Courts, handing a few sandbags to the Court of Protection at the same time.