Complexities, Complications and Causation
R (Olabode) v HM Area Coroner for Manchester City & Manchester University NHS Foundation Trust: Reviewing a Coroner’s consideration of complex medical evidence.
Facts
The Claimant sought judicial review of the Area Coroner’s findings of fact and conclusion at the end of an inquest into the death of her 12-year-old daughter, Victoria.
Victoria was admitted as an in-patient at the NHS Trust, an interested party to the judicial review proceedings, when she suffered a fatal stroke that was a complication of sickle cell disease.
An internal investigation by the Trust concluded that there were a series of failures in the care provided, including: a failure to conduct any imaging over a weekend, the absence of a multidisciplinary review, the failure to document neurological observations and the timing of an exchange blood transfusion. The Trust initially considered that these shortcomings were causative of Victoria’s death, a position that was rescinded after considering further expert evidence.
At the initial inquest hearing, evidence was heard from eight medical experts, each providing their own opinion on the medical cause of death and causation. Their evidence was conflicting and intertwined. After two days of oral hearings, it was decided that further reports would be required to assist the Area Coroner in making sense of these complex medical opinions. After an adjournment, a further two days of hearings were conducted.
In his findings of fact, the Area Coroner did not accept that earlier imaging would have led to a significant escalation in Victoria’s care. Ultimately, although he found that there were failings in her care, none of those failures more than minimally contributed to her death on the balance of probabilities. He returned a short-form conclusion of “Natural Causes”.
Issues to be determined in judicial review claim
The Claimant sought judicial review on the following grounds:
- The Area Coroner had found that because it could not be established on the balance of probabilities that a scan on 6 July 2019 would have shown subarachnoid bleeding and as such, he could not find that any additional treatment would have been administered over the weekend. The Claimant argued that in making these findings of fact, the Area Coroner had irrationally failed to consider the evidence of Professor Kirkham (Neurologist). The Claimant argued that the Area Coroner had made an error by treating the neuroradiology evidence as the sole and decisive evidence as to whether there was a neurological event over the weekend and/or the sole basis upon which treatment decisions could be made.
- The Area Coroner had unreasonably discounted the evidence of Dr Kirkham (Neurologist) in respect of causation on the basis that it was inconsistent with the evidence of two other experts, Professor Stivaros (Consultant Paediatric Neurologist) and Dr Grainger (Consultant Paediatric Haematologist).
- In its final presentation at the hearing, under Ground 3, Mr Howells argued on behalf of the Claimant that if he succeeded on Ground 1, he was entitled to relief because if the Area Coroner had failed to consider the key issue of an alleged failing in care, his findings of fact and conclusion of natural causes might have been different.
Judgment
The claim for judicial review was dismissed. The Judge considered that the Area Coroner had conducted the inquest in a “very thorough manner”. The Judge’s opinion is summarised succinctly at paragraph 114:
“I consider that the Defendant is to be commended for producing such a concise but detailed judgement which on any view engaged with the key issue of whether scanning should have been ordered in Victoria’s case and whether the failure to do so contributed to her death. The Defendant logically moved through the analysis, finding the failure in relation to the scanning, then addressing what the consequences of that were, before turning to the hypothetical scenario of whether the failure to conduct an exchange transfusion on 6 July 2026 made a more than minimal contribution to Victoria’s death.”
The Court concluded the following on each ground:
Ground 1: Following lengthy analysis of the arguments before the Court and the evidence available to the Area Coroner, the Judge concluded that the Area Coroner did not err in leaving out of account the neurological evidence of an appropriate treatment plan as alleged under Ground 1. The Area Coroner had properly contextualised the evidence and focussed appropriately on the key issues that, on the evidence, might have contributed to Victoria’s death, namely the delays in scanning and the timing of the exchange transfusion.
Ground 2: It would not be fair to read the Area Coroner’s findings of fact as a rejection of Professor Kirkham’s evidence on causation outright. In any event, even if this was an error by the Area Coroner, it was not material to the overall conclusion in this section of his findings. Ground 2 largely became academic upon the dismissal of Ground 1.
Ground 3: The Judge accepted that if failings in care that more than minimally contributed to Victoria’s death had been identified, a narrative rather than “natural causes” conclusion was appropriate. However, as Ground 1 had been dismissed, the argument under Ground 3 became academic.
Key takeaways
This case was decided wholly on the facts. However, there are some important practical lessons to be learned:
- In this case, the Area Coroner had invited, but not ordered, the interested persons to provide an agreed list of issues prior to making his findings of fact and conclusion. Practically, the Judge considered it was regrettable that the parties did not provide such a list. The Area Coroner had considered that such a list would have assisted him. Practitioners would be well-advised in inquests involving complex causation issues and a multitude of medical opinions to heed this warning [see para 113 of Judgment].
- This case was considered unusual by the Judge. Judicial review claims are an exercise in identifying public law errors in an underlying decision, rather than re-assessing the facts. The Judge was initially concerned that she was being asked to conduct a “very find tooth comb” exercise, which has been discouraged in earlier authorities. However, she recognised that because the contended public law error under Ground 1 was an alleged failure to deal with a key issue, it was necessary to conduct a very close analysis of the evidence herself [see para 115 of Judgment].
The Judgment can be found here: https://caselaw.nationalarchives.gov.uk/ewhc/admin/2026/810
Sophie Cartwright KC represented the Trust in the judicial review. View Sophie’s full profile here.
Georgia Banks is a tenant in Chambers who specialises in inquests, inquiries, clinical negligence and personal injury. Visit her profile for more information.
