Caroline is regularly instructed in inquests acting for bereaved families, individual interested persons and for public or corporate bodies including ‘Article 2’ and jury inquests. The vast majority of inquests she attends relate to deaths arising in or linked to provision of healthcare such as in hospitals, care homes and deaths in custody, which dovetails with her clinical negligence work.
She will accept appropriate instructions on a CFA and has also provided representation pro bono for families instructed through AvMA.
All cases have been anonymised.
Hospital related deaths.
- Inquest touching the death of KDD: Rider of Neglect as a consequence of an accumulation of failings by the hospital trust. Deceased was suffering from sepsis against a background of cholecystitis for which there was a delay and shortcomings in relation to diagnosis and treatment. The deceased died 3 days after being admitted to hospital. The trust accepted that the deceased would probably have survived with correct treatment. Instructed by the family on a CFA. No PFD report
- Inquest touching the death of LH: A complicated case where the deceased had previous bariatric surgery on a background of mental health issues. She attended her GP and a dietician before being admitted to hospital with significant weight loss, the cause of which was never identified before her death. Instructed by the family.
- Inquest touching the death of LH: Instructed by the family in relation to deceased who died in hospital of Group A streptococcus on a background of acute pre – eclamptic toxaemia and HELLP syndrome shortly after giving birth. Her deterioration was wrongly attributed to recovery from general anaesthetic given prior to emergency C – section and there was no obstetric review. The factual background was complicated by incomplete records relating to blood pressure, some of which had been made retrospectively. Narrative conclusion.
- Inquest touching the death of RH: Instructed by AvMA, pro bono. Representing the family of a child who died of infection during a course of chemotherapy treatment for myeloid sarcoma.Pro Bono.
- Inquest touching on the death of JS: Caroline was instructed by AvMA on behalf of the family. JS died after a hip replacement operation. Following conclusion of the inquest, but before publication of a Regulation 28 report relating to loss of JS’s CPAP machine, the trust’s representatives wrote to the Coroner challenging the making of the Regulation 28 (PFD) report. Caroline made representations that the Coroner had no authority to retrospectively withdraw the Regulation 28 report relying, inter alia, on the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) -v- Assistant Coroner for East London and the PFD was published thereafter. Pro Bono.
- Inquest touching on the death of BG: Instructed by the family to advise in relation to the death of BG who died of diabetic keto – acidosis as a consequence of his undiagnosed diabetes. The civil claim was settled prior to the inquest taking place. Instructed by the family on a CFA.
- Inquest touching the death of KV: Inquest relating to a death from aspiration pneumonia following a vomiting episode when being fed through a PEG tube. Instructed on behalf of the care home. Narrative conclusion. No PFD report
- Inquest touching the death of HP: Inquest relating to death following a fall in a care home causing head injury which resulted in a slow bleed from a vein in the brain. Instructed on behalf of the care home. Conclusion of accident. No PFD report.
- Inquest touching the death of IL: Representing care home. Fall resulting in fractured hip. Conclusion of natural causes contributed to by hip fracture. No criticism of care home. No PFD report.
Deaths in Custody
- Inquest touching the death of AQ: 6 day Article 2, jury inquest touching on the death of a prison resident who died of plastic bag asphyxiation following an unsuccessful suicide attempt by similar means 3 weeks earlier. Issues concerning the ACCT process and assessment of risk of self -harm/suicide. Instructed by healthcare provider. Suicide plus narrative. No PFD report.
- Inquest touching the death of RM: Article 2, jury inquest concerning prison resident with capacity who declined nutrition and hydration. The medical cause of death was 1a. acute kidney injury 1b. Inanition with various co – morbidities included at 2. Legal discussion as to whether short – forms of suicide and/or misadventure would apply in the circumstances. The Coroner determined suicide was not safe to be left to the jury and the refusal of nutrition/hydration by the deceased did not fall within the definition of misadventure as the refusal was an intended act but the evidence was that the deceased was aware of the consequences. A Narrative conclusion was left to the jury. Instructed by healthcare provider. No PFD report.
- Inquest touching the death of SP: 5 day Article 2, jury inquest. Deceased died of asphyxia. The pathologist suggested including at 1b. Neck compression in the context of mixed drug intoxication (cocaine, benzodiazepine, methadone). Methadone had been correctly prescribed by prison healthcare and the Coroner accepted submissions made by Caroline to direct the jury that, “substance misuse” at 2 better reflected the evidence. Instructed by healthcare provider. No PFD report.
- Inquest touching the death of PD: Instructed by local authority in relation to the death of a man who had been asked to leave the family home because of reports of domestic violence. The deceased was a diabetic and was placed in accommodation by social care where he was found deceased. A narrative conclusion. No PFD report.
- Inquest touching the death of JH (2019): Caroline was instructed to advise by a local authority following the apparent suicide of a young boy with learning difficulties who had been subjected to bullying.
Caroline provides seminars and training as well as having articles published in the AvMA newsletter.