The conclusion is not the end of the matter
Park Square BarristersMays v HM Senior Coroner for Kingston Upon Hull & The East Riding of Yorkshire, Divisional Court, 1st December 2021
On 1st December 2021 Janine Wolstenholme appeared on behalf of the Senior Coroner in the Divisional Court, before Lady Justice Simler, Mrs Justice May and HHJ Teague QC, the Chief Coroner for England & Wales, in respect of the Claimants’ Section 13 application (Coroners Act 1988) to quash the inquest, following the emergence of new evidence.
The Claimants are the parents of Sally Mays, died on 25th July 2014 aged 22 years. Sally suffered with emotionally unstable personality disorder. On the day of her death Sally had, accompanied by her CPN, who felt she was at risk of fatal self-harm, attended her local acute admissions unit seeking admission. Following what the Senior Coroner found in the inquest to be an “illogical, quixotic, and unconscionable decision”, Sally was refused admission. The Senior Coroner found there were gross failings in Sally’s management, which escalated her distress and contributed to her reactive self-harming behaviour. Following the refusal to admit Sally she died later that evening from an overdose and asphyxiation. The Senior Coroner concluded there had been opportunities to prevent Sally’s death and she died as a consequence of neglect.
The Claimants did not seek to, nor could they said the court, criticise the Senior Coroner. The application arose because after the inquest had concluded it came to light that shortly after Sally had been refused admission, but while she was still alive, her CPN had a conversation with a Consultant Psychiatrist, who knew Sally, in the car park. The CPN did not document the conversation because it was deemed to be informal however, nor did she, nor the consultant, reveal this conversation during in an internal Trust investigation, part of which considered why Sally’s case had not been escalated by the CPN in light of her concerns about the refusal to admit her. This information was also withheld from the Coroner in what the court, in the extempore judgment, determined was a conscious decision to do so both before and during the inquest, following discussions between the CPN and consultant.
The withholding of information from the Coroner was considered by the CPS, GMC and the Trust however these bodies sought to investigate why the conversation was withheld, rather than the details of it and whether it presented a further opportunity to intervene with Sally. Moreover, these investigations did not amount to public scrutiny of the material and did not involve Sally’s family, such that the State’s Article 2 investigative obligations had not in fact been discharged. In all the circumstances the public interest required the inquest be quashed.
Even though the family did not seek to interfere with the Senior Coroner’s conclusion, in which he found that the high bar for neglect had been met, the court concluded there was a prospect further findings of fact would be made, and such findings may have the additional benefit of important lessons being learned. Thereby emphasising the potential importance of the investigatory process and findings beyond the conclusion.
While acknowledging that it could not bind the Senior Coroner, or otherwise interfere with his wide discretion on how to adduce evidence at the future inquest, the court endorsed the idea of the Senior Coroner, should he see fit, admitting the transcript of the previous hearing pursuant to Rule 23 and hearing from witnesses on the car park conversation.
It appears, in light of the broad meaning of documents, the Senior Coroner would not need a printed transcript and a copy of the recording of the evidence would suffice, thus providing a proportionate avenue to rehearing the matter while preserving the quality of the evidence, given that the original inquest ran to eight days and took place over six years ago (October 2015).
Janine Wolstenholme is on the Attorney General’s A panel of civil counsel and has extensive experience of coronial work, including complex Article 2 inquests and representing Coroners in Section 13 and judicial review proceedings. She also acts in linked civil claims.