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The Challenge of Proving Prevention: The Inquest of Linda O’Brien v Assistant Coroner

The High Court rejected an application for judicial review in the case of <a href="https://www.exchangechambers.co.uk/wp-content/uploads/2025/02/AC-2023-MAN-000263-Sharon-OBrien-v.-HM-Assistant-Coroner-for-Sefton-Knowsley-and-St-Helens-Judgment.pdf">O’Brien v HM Assistant Coroner for Sefton, Knowsley and St Helens</a> which limited the scope of the inquest into the death of Linda O’Brien. Linda's family contended that had her ex-partner, who was subject to a restraining order but present at her flat on the day of her death, been arrested one month prior, her death might have been prevented. The judicial review was of a decision taken by Mr Graham Jackson, HM Assistant Coroner, on 15 March 2023 that there was no coronial causation established linking previous conduct by officers of the Merseyside Police and the events resulting in Linda’s death.  Background and scope  Linda O’Brien died on 9 May 2020 after falling from a fourth-floor window at the age of 49. Her ex-partner, Alan McMahon, was the only other person present in her flat at the time. Mr McMahon was subject to a five-year restraining order due to a history of previous violence towards Linda.  One month prior to her death, on 7 April 2020, four police officers attended Linda’s flat, finding Mr McMahon present and intoxicated. The officers were unaware of his restraining order and maintained that they had checked relevant police databases which showed no reference to the restraining order. They maintained that if they had been aware of the order, they would have arrested him for breaching it.  On 9 May 2020, Mr McMahon called the emergency services when Linda fell from the window. The police attended and arrested Mr McMahon on suspicion of murder. A postmortem examination of Linda’s body found she was significantly intoxicated, and additional injuries were present which suggested possible prior assault.  On 19June 2020, Mr McMahon was sentenced to 20 months’ imprisonment for breach of restraining order and theft. The accusation of murder was not proceeded with.  On 7 June 2022, a pre-inquest review hearing was held, and a request for a second pre-inquest review hearing was made. On 15 March 2023, after considering submissions by the Claimant and Merseyside Police, the Coroner made the decision that there was no coronial causation between the events involving police officers on 7 April 2020 and events on 9 May 2020. He decided the inquest should focus solely on the events of the night Linda died, excluding the failure to arrest Mr McMahon on 7 April. Consequently, the inquest's scope was limited, and the police's prior failures were considered only as background information.  The Claimant was given permission for judicial review of this decision on the grounds that the Coroner had erred in “prematurely and irrationally deciding that there [was] no causative connection between the acts and omissions of Merseyside Police and the death of Linda O’Brien and thereby unlawfully limiting the scope of the investigation.” [28] They argued that earlier police action could have prevented the death and that the police’s failure to act should have been fully investigated.  Outcome  The High Court, in its judgment handed down in February 2025, dismissed the application for judicial review.  The court acknowledged that had Mr McMahon been arrested earlier, he might have been in custody on 9 May 2020, and it was therefore “possible that Linda’s death would not have occurred.” [42] However, this scenario was deemed "entirely speculative" [42] and unsupported by evidence. It was held that a substantive causative link could not be established on the balance of probabilities, and there was insufficient evidence to demonstrate that Mr McMahon would have been in custody on the date of Linda's death. It could not be proved that, on balance, “anything done or not done by police officers on 7 April or subsequently more than minimally, negligibly or trivially contributed to Linda’s death.” [47]. Therefore, the Coroner was entitled to rule the police conduct out of the scope of the inquest, and the decision to limit the scope of the inquest was upheld.  The Court also rejected the claim that the inquest required a jury under section 7 of the Coroners and Justice Act 2009 due to potential police failings. As no probable causative link could be shown, the threshold for requiring a jury was not met.  Commentary  This case underscores a broader and enduring tension within coronial law: the need to balance the public interest in accountability with the evidentiary thresholds that define and constrain a coroner’s jurisdiction. Bereaved families may look to the inquest process for a fuller understanding of the circumstances surrounding a death, particularly in cases involving domestic abuse, institutional failings, or missed safeguarding interventions. But the law remains tightly bound to legal causation. The critical legal distinction between what is possible and what is merely speculative remains at the heart of the decision in this case.  While the police's failure to arrest Mr McMahon on 7 April 2020 was a significant oversight, the court's decision reflects the difficulty in establishing a direct link between this failure and Linda's subsequent death. The ruling highlights the legal principle that inquests must be based on evidence that can establish causation on the balance of probabilities, rather than on speculative scenarios. As a result, even serious institutional shortcomings may fall outside an inquest’s formal remit if they cannot be shown to have contributed, more than minimally or trivially, to the death.  Lucy Evanson is part of the Inquests Team at Parklane Plowden. Lucy’s profile can be accessed <a href="https://www.parklaneplowden.co.uk/our-barristers/lucy-evanson/">here</a>.

Morrow v HM Assistant Coroner for Merseyside (Sefton, Knowsley & St Helens) [2025] EWHC 935 (Admin)

Summary  The High Court rejected an application made by the brother of the deceased pursuant to Section 13 of the Coroners Act 1988 to hold a fresh inquest and, in so doing, provided insight into the differences between the expectations of family members of the deceased and the purpose of the inquest process; particularly where there is the potential for overlap in determining issues of civil or criminal liability.  The Claimant’s application for a fresh inquest was predicated on concerns (that were mirrored by his wider family) that his sister’s mental health had not been appropriately managed by the relevant NHS Trust during her life, and that those failures had contributed to her death in April 2021 but were overlooked by the initial inquest and/or that there were failures in the inquest process which necessitated a fresh inquest being heard.  In identifying that, the Coroner’s conclusion that Zoe Morrow’s death was drug-related was a rational one. There was no evidence to suggest that it was necessary or desirable in the interests of justice to order a fresh inquest.  Background  An inquest into the death of Ms Morrow, the scope of which was determining the immediate cause of her death – rather than in relation to the concerns raised by her family regarding her treatment in the months prior – was held in March 2022 and recorded her cause of death as having been ‘1A Mixed Drug Toxicity’ – a finding supported by post-mortem and toxicological analysis showing that multiple drugs (with overlapping adverse effects) were in her blood at the time of death.  That the scope had been set in a narrow way appears to have been the subject of (at least some) challenge at the initial inquest, with particular reference having been made to the Coroner’s decision not to call live evidence from two treating Doctors and instead choosing to read their evidence into the record pursuant to Rule 23 of the Coroner’s Inquest Rules 2013.  The Claimant sought a fresh inquest pursuant to Section 13 (1) and (2) of the Coroners Act 1988 on multiple grounds, viz:  <ol style="list-style-type:lower-roman" class="wp-block-list"> <li>That failures in treatment were overlooked and that the coroner did not appropriately consider a conclusion of suicide;</li>  <li>That the family were prevented from speaking or giving evidence;</li>  <li>That relevant evidence was overlooked;</li>  <li>That there had been collusion between the Coroner and the Trust;</li>  <li>The reading of statements from treating Doctors (as opposed to calling them to give live evidence, as referred to above);</li>  <li>The addition of late evidence;</li>  <li>A lack of guidance on inquest procedure.</li> </ol>  The High Court has the power to order a fresh inquest pursuant to Section 13 (1) (b) where it is necessary or desirable in the interests of justice to do so and it is envisaged that scenarios in which that necessity could arise include (but are not limited to) insufficiency of inquiry, rejection of evidence and procedural irregularity. The framing of the Claimant’s application was potentially consistent with each such scenario but, in dismissing the application, Lady Justice Whipple observed ‘there appears to have been a mismatch between the family’s expectations of what they could achieve at this inquest and the reality of the Coroner’s investigation’.  The application  It is clear that the Court was able to deal with some of the issues raised above more swiftly than others, in particular finding that there was no evidence of collusion between the Trust and the Coroner (the finding that he had made was his own and one which he had been entitled to make) and did so having appropriately considered the toxicological evidence, with some evidence that the family had wished be considered falling outside the scope of the inquiry, a point returned to below.  In part, some of the remaining basis of the Claimant’s application appears to stem from correspondence which was intended for him, which explained which live evidence would be called and which statements would be read was not received (and could in fact now not be located) – an administrative oversight which perhaps lead to a situation where there was understandable upset from the family when it became apparent that they were not being called to give evidence. Whilst such administrative failures are always regrettable, the Court was however clear in its conclusions that the family had been allowed to speak appropriately at the inquest, including questioning the witnesses that gave live evidence and that (missing correspondence notwithstanding) appropriate efforts had been made to ensure that they understood the inquest process.  As previously indicated, it is clear that the central underlying theme of the Claimant’s application was the belief that the original inquest was unsatisfactorily narrow and that this narrow definition impacted on the cogency of the conclusion, including an alleged failure to appropriately consider a conclusion of suicide. Had they been able to do so, the family would have adduced evidence which they believed showed that Ms Morrow had intended to end her life in the months and weeks prior to her death.  The conclusion reached by the Coroner – that Ms Morrow’s death was drug related – was a factually correct one and was reached in a situation where the status of the evidence before him was not sufficient to reach a conclusion of suicide on the balance of probabilities.   It is perhaps easy to see why a bereaved family might feel (as indeed appears to have been the case with the wider Morrow family) that concentrating solely on the events immediately prior to death without consideration of context provides an unnuanced answer to the question of how the deceased died. This viewpoint might be particularly strongly held so in scenarios such as this, where the witness called to give evidence on behalf of the Trust was attending to give evidence about the Trust’s review, with the intention of identifying shortfalls in Ms Morrow’s care – although taking a step back, it appears that this evidence was more likely of use in determining whether a Prevention of Future Deaths report was indicated.  However understandable the mismatch in expectations might be, the Coroner in the initial inquest was entitled to exercise his discretion to limit the scope in the manner that he did and, taking another step back, one can see that if the scope of the inquest was set too widely, it is possible that the inquest would have strayed into an investigation into a potential civil liability, expressly contrary to Section 10 (2) of the Coroners and Justice Act 2009.  Clearly, the Court arrived at the conclusion that the original Coroner had exercised his discretion appropriately in both his determination of scope (and it is a notable observation that, regarding the limitation to the scope of the inquest, Lady Justice Whipple was of the view that ‘most coroners would…have made a similar decision in the circumstances’) and in determining from whom live evidence was to be heard.  There was, therefore, no substantial defect in the first inquest and the inquiry which did take place was sufficient as a matter of law.  Adam Chadwick is part of the Inquests Team at Parklane Plowden. Adam's profile can be accessed <a href="https://www.parklaneplowden.co.uk/our-barristers/adam-chadwick/">here</a>.

Police, Misadventure, and the Limits of Article 2: R (Robinson) v HM Assistant Coroner for Blackpool & Fylde [2025] EWHC 781 (Admin)

Introduction  The High Court has provided important clarification on the circumstances in which Article 2 of the ECHR is automatically engaged following a death involving police contact.  The Court’s analysis has significant implications for future inquests where the boundaries of “state responsibility” are in issue.  Factual Background  On 11 March 2021, Mr Robinson was stopped by armed police officers in Blackpool.  After a car chase, he exited the vehicle and was restrained on the ground.  During the course of the restraint, he placed a plastic-wrapped package (later identified as containing drugs) into his mouth.  Officers attempted to prevent this, but the package became lodged in Mr Robinson’s throat and he quickly became unresponsive.  Officers started CPR and paramedics arrived promptly, but despite efforts to resuscitate him, Mr Robinson was pronounced dead.  A post-mortem determined that the cause of death was upper airway obstruction due to the package in his throat.  At the inquest, the coroner had deferred the decision as to whether Article 2 was engaged until after the evidence had been heard.  Following the evidence, the coroner declined to engage Article 2. The jury returned a short form conclusion of misadventure.  The coroner also wrote a “letter of concern” to the National College of Policing to address issues around the training of officers around the removal of drug packages.  No Prevention of Future Deaths (PFD) report was made.  The family sought judicial review on 3 grounds:  <ol class="wp-block-list"> <li>The decision that Article 2 was not engaged.</li>  <li>The coroner’s summing up to the jury was insufficient.</li>  <li>The failure to issue a PFD report.</li> </ol>  First Ground: Article 2  The Applicant submitted that the procedural obligation under Article 2 was automatically triggered and that the coroner had erred in finding otherwise.  The argument was twofold:  Firstly, that the case fell within a category where Article 2 is engaged automatically.  Secondly, in any event, there was an arguable breach of the state’s positive operational duty to protect life.  It was contended that the categories of case where Article 2 is engaged automatically are not closed.  The Applicant proposed that the following categories should be recognised as giving rise to automatic engagement:  <ul class="wp-block-list"> <li>An unnatural death occurring while in the involuntary (lawful or unlawful) custody or control of the state.</li> </ul>  <ul class="wp-block-list"> <li>An unnatural death following the deceased committing an intentional act liable to cause himself harm in the presence or control of the police.</li> </ul>  <ul class="wp-block-list"> <li>A death where police are aware that the person has swallowed a package posing a risk to life.</li> </ul>  <ul class="wp-block-list"> <li>A death in custody or control where the person enters a medical emergency of which police were or should have been aware.</li> </ul>  <ul class="wp-block-list"> <li>A death following the use of force by police in the course of an arrest or physical control.</li> </ul>  The Applicant argued that Mr Robinson’s death clearly fell within one or more of these expanded categories.  Furthermore, it was submitted that the police knew or ought to have known that Mr Robinson was at real and immediate risk of death, thereby triggering the positive operational duty under Article 2.  Conclusion  Mr Justice Kerr rejected the Applicant’s submissions and reaffirmed the orthodox position that the categories of automatic Article 2 engagement remain limited and are not lightly extended.  The Court accepted the approach in Morahan [2022] EWCA Civ 1410, quoting Popplewell LJ in that the circumstances of the death must be such that:  “They fall into a category which necessarily gives rise, in every case falling within the category, to a legitimate ground to suspect state responsibility by way of breach of a substantive article 2 obligation” (Morahan at [122(7)]).  Mr Justice Kerr found that the proposed new categories advanced by the Applicant lacked a sufficient degree of certainty or inevitability to justify automatic engagement.  While Mr Robinson had been under a degree of physical restraint, he was not in “custody or detention” in the relevant Article 2 sense.  In relation to the operational duty, the Court found that the coroner had correctly considered whether there was an arguable breach of the duty to protect Mr Robinson’s life.  However, the coroner had considered the evidence, particularly the officers' rapid response and the provision of first aid and concluded that no such arguable breach had occurred.  The Judge held that this reasoning was legally sound and open to the coroner on the evidence.  Second Ground: Coroner’s Summing Up  The Applicant argued that the coroner’s summing up failed to adequately guide the jury on key issues.  In particular, in relation to the police’s conduct during the restraint and the timing of medical interventions.  Conclusion  The High Court rejected these criticisms.  Mr Justice Kerr held that the summing up, while brief, was fair and legally sufficient.  The jury had seen all the relevant evidence and were repeatedly reminded that they were the judges of fact.  The coroner’s directions were not biased or flawed, and the jury’s preference for misadventure verdict reflected their own view of the facts, not flaws of the directions given.  Third Ground: PFD Report  The Applicant argued that the coroner’s decision to send a “letter of concern” instead of a PFD effectively avoided the statutory reporting regime in favour of an informal mechanism.  Reliance was placed on the Chief Coroner’s Revised Guidance No.5. which stressed that the “concern” threshold is low.  Conclusion  The coroner’s refusal to issue a PFD report was upheld.  Mr Justice Kerr found that the statutory duty only arises where the coroner forms the view that both a risk of future deaths exists and that actions should be taken to prevent them.  Although the coroner recognized the risk and sent a “letter of concern” he had found that there was no sufficient basis to believe that action was required to prevent future deaths.  Mr Justice Kerr found no legal error in the coroner’s reasoning or decision.  It was emphasised that this is a matter of discretion for the coroner, not an obligation.  Commentary  This case affirms the narrowness of the circumstances in which Article 2 is automatically engaged in the context of deaths involving police contact, particularly outside formal detention settings.  The Court reaffirmed that the existing categories of automatic engagement are intentionally limited.  Expansion requires a clear and necessary link between the factual category and the likelihood of state responsibility.  The judgment also clarifies the threshold for the operational duty it is not enough that there was some general risk.  The officers must have known (or ought to have known) of a real and immediate risk to life and failed to take reasonable steps to avoid it.  Notably, the case demonstrates the reluctance to conflate police presence or control with detention in the absence of formal arrest or custodial status.

Leila Benyounes Acts for Family in Tragic Baby Death Inquest

Baby E was a five-week-old baby who tragically died from complications of a congenital heart defect which had not been detected until after she had died.  Baby E’s mother is an insulin dependant type 1 diabetic which is known to increase the risk of a congenital heart defect. Her mother’s identical twin sister also has a congenital heart defect. The heart defect had not been suspected or identified at Baby E’s anomaly scan and fetal echocardiography had not been performed during the pregnancy.  Baby E was admitted to the neonatal unit for 8 days following birth and for suspected infection and required respiratory support. She did not undergo an echocardiogram in life which would, on the balance of probabilities, have identified the heart defect and would have resulted in different management.  Following discharge from hospital, Baby E was seen by various health professionals including GPs on three occasions, a midwife and a health visitor. Her parents had concerns about symptoms of a cough, reduced feeding and vomiting after feeds.  Baby E’s parents became increasingly concerned and she was taken to hospital where she was diagnosed with bronchiolitis, received oxygen, but suddenly stopped breathing and tragically could not be resuscitated.  A post mortem examination found that Baby E had a genetic cardiac defect which had led to her death. It was held that earlier identification of the defect would have meant that she probably would not have died when she did.  The Coroner issued a Regulation 28 Prevention of Future Deaths Report following the conclusion of the inquest due to concerns about the importance of early identification of congenital cardiac defects because of the risks they present.  Leila was instructed by <a href="https://www.irwinmitchell.com/our-people/rebecca-dawson" target="_blank" rel="noreferrer noopener">Rebecca Dawson at Irwin Mitchell Solicitors</a>.  Leila Benyounes is Head of the Inquests Team at Parklane Plowden Chambers and is ranked as Band 1 by Legal 500 for Inquests and Inquiries. Leila has been appointed to the Attorney General’s Treasury Counsel Panel A since 2010. Leila is appointed as an Assistant Coroner in two coronial areas. Leila regularly represents interested persons in a wide range of inquests including Article 2 jury inquests and complex medical matters.  Her full profile can be accessed <a href="https://www.parklaneplowden.co.uk/barristers/leila-benyounes" target="_blank" rel="noreferrer noopener">here</a>.

Coroners Statistics 2024: Key Trends

On the 8th May 2025 the Ministry of Justice published the Coroners Statistics 2024, providing an overview of deaths reported to coroners in England and Wales during the past year.  The headline findings show that:  <ul class="wp-block-list"> <li>191,636 deaths were reported to coroners in 2023, a 7% decrease from the previous year and the lowest figure since 1995.</li>  <li>Post-mortem examinations were ordered in 38% of cases, slightly down from 2022, continuing a gradual long-term decline.</li>  <li>Inquests were opened in 30,184 cases, accounting for 16% of all reported deaths, maintaining a consistent trend.</li>  <li>Jury inquests remained rare, comprising just 1% of all inquests.</li>  <li>The median time to complete an inquest was 30 weeks, reflecting a continued improvement in timeliness since 2020.</li> </ul>  The report also identifies several key trends:  <ul class="wp-block-list"> <li>“Natural causes” remained the most common inquest conclusion, followed by “accident/misadventure.” Conclusions of “suicide” and “open” have remained relatively stable.</li>  <li>There is notable regional variation in the use of post-mortems and inquest opening rates, highlighting differences in local practices and population profiles.</li>  <li>The overall reduction in reported deaths may reflect both changes in registration practices and longer-term demographic trends following the COVID-19 pandemic period. COVID-19 deaths are likely to be considered to be deaths from natural illness and as such not reportable to coroners.</li> </ul>  These figures suggest that coroners are managing workloads more efficiently, while ensuring that inquests remain a key part of the investigatory process into unexplained or unnatural deaths.  You can read the full report and analysis on the GOV.UK website:  <a href="https://www.gov.uk/government/statistics/coroners-statistics-2024/guide-to-coroners-statistics" target="_blank" rel="noreferrer noopener">https://www.gov.uk/government/statistics/coroners-statistics-2024/guide-to-coroners-statistics</a>  Julia is a member of the Inquests and Inquiries Team and Head of the Family Team at Parklane Plowden Chambers. <a href="https://www.parklaneplowden.co.uk/our-barristers/julia-nelson/" target="_blank" rel="noreferrer noopener">Her full profile can be accessed here</a>.

Neglect Found to Have Contributed to Death Where There Was Post-Operative Bleeding

Abigail represented the family of Maxine Spittlehouse who underwent a total abdominal hysterectomy at Kinvara Private Hospital on 16 July 2024. The Deceased was being treated as an NHS patient.  Post-operatively, Mrs Spittlehouse suffered significant pain. She then deteriorated overnight with symptoms including pain, tachycardia, reduced urine output, and reduced, and later unrecordable, blood pressures.  Mrs Spittlehouse’s overnight care was provided by a single junior doctor and two nurses. During the night, the two nurses had repeatedly expressed their concerns about Mrs Spittlehouse’s deterioration and stated that they felt that she needed to be transferred to Rotherham District Hospital where post-operative bleeding could be definitively diagnosed and treated.  The Coroner found Mrs Spittlehouse had started to suffer with internal bleeding at around 01:30 am and that by 3:30 the junior doctor had thought that this was the cause of Mrs Spittlehouse’s deterioration. Nonetheless, the junior doctor did not seek input from Mrs Spittlehouse’s treating consultant surgeon until after 5am. During that telephone conversation, the Coroner found that the junior doctor failed to convey important information regarding the woman’s deterioration and the consultant failed to ask questions to enable him to identify that Mrs Spittlehouse was suffering with internal bleeding.  There was then a further delay in transferring Mrs Spittlehouse to a hospital that was equipped to deal with the internal bleeding until after Mrs Spittlehouse had suffered a cardiac arrest after 07:30. Mrs Spittlehouse died of a hypoxic brain injury arising from the cardiac arrest.  The Coroner found that there were cumulative failings on the part of the junior doctor and consultant surgeon in failing to ensure that basic checks were made to identify if Mrs Spittlehouse was bleeding internally. These included not obtaining blood results earlier, not escalating concerns to the consultant surgeon earlier and not effecting transfer of Mrs Spittlehouse to a hospital where her internal bleeding could be treated.  The Coroner concluded that the high threshold for a finding of neglect as part of her narrative conclusion was met and that, ultimately, Mrs Spittlehouse’s death was avoidable.  Abigail was instructed by <a href="https://www.medical-solicitors.com/about-us/christine-brown/" target="_blank" rel="noreferrer noopener">Christine Brown</a> and <a href="https://www.medical-solicitors.com/about-us/gita-sarda/" target="_blank" rel="noreferrer noopener">Dr Gita Sarda</a> at Medical Solicitors. Their press release can be found <a href="https://www.medical-solicitors.com/news/inquest-support-for-family-of-fatal-private-hysterectomy-patient/" target="_blank" rel="noreferrer noopener">here</a>.  Further details reported by <a href="https://www.bbc.co.uk/news/articles/c14xd166e08o" target="_blank" rel="noreferrer noopener">the BBC</a>.

Challenging the Suitability of Expert Witnesses in the Coroner’s Court: R (Gamesys Operations Ltd) v HM Senior Coroner Inner London South [2025] EWHC 659

In this judicial review claim, the Administrative Court considered the extent of the coroner’s discretion to call expert evidence and whether expressing an opinion on a matter renders an expert unsuitable due to bias.  Facts  In preparation for an inquest into the death of Mr Adams, who had died in 2020 from cardiac arrhythmia and an overdose of medication, the coroner intended to explore whether gambling, or an undiagnosed gambling addiction, had contributed to his death. Professor Dame Clare Gerada was instructed as an expert in gambling addiction/disorder.  The Claimant and interested party in the inquest, Gamesys Operations Ltd, objected to her appointment claiming that she was biased. Instead, they proposed the instruction of Dr Frazer, a consultant psychiatrist with expertise in gambling disorders.  In response, the coroner chose to instruct both Professor Gerada and Dr Frazer. This failed to satisfy the Claimant, and they issued a judicial review claim. After being refused permission on the papers at first, they renewed their application at an oral hearing. The application was heard by Mrs Justice Lang.  Allegations of bias  The Claimant’s core submission was that Professor Gerada was biased on the basis that she was a “leading antigambling campaigner” who held a fixed and strong negative view on gambling herself. They further submitted that she was unsuitable because she had previously publicly advocated for gambling to be recorded as a causative factor in suicide inquests, led the NHS primary care gambling service funded by “Gamble Aware” and had recently given written evidence to a Select Committee Inquiry contrary to the position of the Claimant.  The Claimant also made allegations of personal conflicts of interest because Professor Gerada had previously been recommended to the coronial court by the family’s solicitors, Leigh Day, her son was a solicitor at Leigh Day and because until 2014, Mr Adams and his family had attended the GP surgery where she practised.  Grounds of challenge  There were four grounds of review:  <ol class="wp-block-list"> <li>The coroner had failed to take into account of or did not accord sufficient weight to concerns about independence and impartiality raised by the Claimant in making his decision on expert evidence.</li>  <li>Professor Gerada was so obviously partisan that her appointment as expert infected the coroner with bias or gave reasonable apprehension of bias.</li>  <li>The coroner’s decision was irrational because no reasonable coroner would have appointed Professor Gerada as an expert witness.</li>  <li>The coroner did not provide adequate reasons for his decision.</li> </ol>  The family of Mr Adams opposed the Claimant’s application for judicial review, largely on the basis that Professor Gerada had exercised her duty of independence to the court on numerous occasions and was well-placed to assist the coroner on the issues being investigated.   Judgment  Wednesbury unreasonableness  The Court re-asserted the well-established principle that the coroner’s duty to ensure that relevant facts are fully investigated encompasses a broad discretion on which expert witnesses to call. When the exercise of that discretion is challenged, the Court must consider whether it is Wednesbury unreasonable.<a href="#_ftn1" id="_ftnref1">[1]</a> Mrs Justice Lang commented that the threshold is very high and it is clear that the Court “cannot dictate what witnesses the coroner calls”.<a href="#_ftn2" id="_ftnref2">[2]</a>  Irrationality  The Court found that the Claimant had no prospect of success in a rationality challenge. The expertise and qualifications of Professor Gerada were convincingly strong and different to those of Dr Frazer. By inviting both to give evidence, the coroner had made a scrupulously fair and balanced decision.  The suggestion that the coroner had not taken into account the Claimant’s concerns about impartiality and independence was not credible given the extensive submissions the coroner had invited on the subject. The weight afforded to those concerns, and the balance given to the family’s opposing position, was a matter for his discretionary judgment and not for the Court.  In this respect, Mrs Justice Lang noted the Claimant’s own interests in protecting its business reputation and success. She commented that protecting those interests was not the purpose of the inquest, but in any event, it was apparent that the coroner would ensure that evidence given by Professor Gerada did not go beyond the circumstances of Mr Adams’ death and stray into the political aspects of safeguarding potential problem gamblers.  Bias and fairness  Finally, the Court found that in assessing the lawfulness of the coroner’s approach, the most important consideration is one of fairness. Independence and impartiality of an expert may be relevant in considering fairness, but the test is not one of apparent bias, as the Claimant submitted.  In the context of an inquest, the test for fairness must be broad to encapsulate the inquisitorial nature and very broad powers of the coroner. Accordingly, a conflict of interest compromising the independence of an expert will ordinarily only arise when their opinion is or may be influenced by their personal interests. In applying this principle, Mrs Justice Lang found that Professor Gerada was not an unsuitable expert due to her professional interests in and views on addiction and gambling disorders as she was capable of adhering to her duty of independence. The alleged personal conflicts raised by the Claimant were immediately dismissed on the basis that those connections were insufficient to give rise to any arguable conflict.  Ultimately, the Court found that the coroner had conducted the proceedings in a scrupulously fair way and the allegation that inviting Professor Gerada to give evidence infected the coroner with bias was unarguable and had no prospects of success.  Comment  Unsurprisingly given the coroner’s wide discretion, the Administrative Court will be slow to interfere with a coroner’s decision on witnesses. Even when an expert has previously expressed apparently partial views on an issue, it will be difficult to bar them from giving evidence at an inquest when they are capable of adhering to their duty of independence.    It may not have assisted the Claimant that they challenged the coroner’s decision before any expert evidence had been written or conclusions made. The Administrative Court is likely to be even slower to interfere with a coroner’s procedural decision when the impact on the conclusion of the inquest has not yet crystallised. It appears, in this case, the coroner went above and beyond to maintain the fairness of the procedure and as a result, the Court was bound to respect his decision-making.  The judgment is available <a href="https://www.bailii.org/ew/cases/EWHC/Admin/2025/659.pdf" target="_blank" rel="noreferrer noopener">here</a>.  <a href="https://www.parklaneplowden.co.uk/our-barristers/georgia-banks-pupil/" target="_blank" rel="noreferrer noopener">Georgia Banks</a> is a second six pupil in Chambers and can now receive instructions in personal injury, clinical negligence and inquests.  <hr class="wp-block-separator has-alpha-channel-opacity"/>  <a href="#_ftnref1" id="_ftn1">[1]</a> R (McGuire) v Assistant Coroner for West Yorkshire [2018] EWCA Civ 6.  <a href="#_ftnref2" id="_ftn2">[2]</a>  R (Lin) v Secretary of State for Transport [2006] EWHC 2575 (Admin), at paragraph 56, per Moses LJ).

Woman Dies Following Weight Loss Surgery and ‘Woeful’ Private Healthcare

A prominent North East businesswoman received “woeful” care following weight loss surgery at a private hospital, and died as a result of complications.   Nicola Fisher underwent a gastric sleeve operation at Spire Washington Hospital and developed a leak from her stomach as a consequence.   Following emergency NHS surgery in June 2023, less than two days after her discharge from Spire Washington Hospital, Nicola underwent several more rounds of surgery at Sunderland Royal Hospital over the following seven months due to ongoing complications.  At the inquest into her death, held at Sunderland Coroner’s Court, it was revealed that appropriate observations were not done by nurses at Spire Washington Hospital before her discharge, and medications were not given as expected. Nicola’s pre-discharge blood test results were also not checked prior to discharge.  Karin Welsh, assistant coroner, branded these failures “woeful” and said it had hampered her attempts to understand Nicola’s health at the time of her discharge, and establish whether there were missed opportunities to identify the leak and operate prior to her developing extensive infection in her abdomen.  Bharat Jangra, instructed by <a href="https://www.slatergordon.co.uk/our-experts/john-lowther/" target="_blank" rel="noreferrer noopener">John Lowther</a> at Slater and Gordon, acted on behalf of Nicola’s husband, Peter, at the inquest.  This matter has received considerable coverage in the press:  <a href="https://www.dailymail.co.uk/news/article-14559119/Vibrant-businesswoman-died-multiple-organ-failure-following-weight-loss-surgery.html" target="_blank" rel="noreferrer noopener">Daily Mail </a><a href="https://www.thenorthernecho.co.uk/news/25051446.sunderland-businesswoman-died-gastric-sleeve-surgery/" target="_blank" rel="noreferrer noopener">Northern Echo</a> <a href="https://www.sunderlandecho.com/health/coroners-report-into-death-of-washington-woman-following-gastric-surgery-highlights-woeful-aftercare-experienced-at-private-hospital-5059233" target="_blank" rel="noreferrer noopener">Sunderland Echo</a>

Missed Opportunities to Carry Out an Assessment During Mental Health Crisis

Megan Crowther represented the family of a young man who died after he jumped from the Wearmouth Bridge in Sunderland, whilst suffering an exacerbation of Schizoaffective Disorder. The Deceased had been recently been detained under the Mental Health Act for treatment and was discharged from hospital, around two months before his death, under a Community Treatment Order which allowed for him to be detained again under the Mental Health Act if he required further treatment.  The Inquest heard evidence that the Deceased had revealed an attempt to take his own life around two weeks before his death and as a result, the community treatment team were planning more regular checks on the Deceased. Unfortunately, over the following weekend, the Deceased called the Crisis Team in extreme distress and requested he be admitted to hospital. The Deceased was categorised as ‘very urgent’ for which a face to face assessment was expected within four hours. That did not take place. The Deceased phoned the Crisis Team several times over the following two days and repeated that he had plans to end his life, leading to a statement in his final phone call that he would jump from the bridge unless he was transferred to hospital or new accommodation. The Deceased was known to hear voices, specifically in his accommodation. Unfortunately, the Deceased jumped from the bridge within twenty minutes of the final phone call. There was no assessment of the Deceased in the 48 hours between his first phone call and his sad death.  The Coroner found that there were missed opportunities by the Crisis Team to carry out an earlier assessment of the Deceased, and that an assessment should have been carried out before he died. The Court heard evidence that if the Crisis Team had determined that the Deceased could not be managed in the community at this time, then the Responsible Clinician would have detained the Deceased under the MHA for further treatment. There was also a missed opportunity to call the police when the Deceased made a specific threat to jump from the bridge.  <a href="https://www.parklaneplowden.co.uk/our-barristers/megan-crowther/" target="_blank" rel="noreferrer noopener">Megan Crowther</a> practices clinical negligence, personal injury and inquests. She regularly represents interested persons in a wide range of inquests including complex medical matters and Article 2 inquests.

Attorney General’s Regional Panel

Parklane Plowden are pleased to announce that three of our members have been appointed to the Attorney General’s Regional Panel.  <a href="https://www.parklaneplowden.co.uk/our-barristers/bronia-hartley/" target="_blank" rel="noreferrer noopener">Bronia Hartley</a> and <a href="https://www.parklaneplowden.co.uk/our-barristers/richard-ryan/" target="_blank" rel="noreferrer noopener">Richard Ryan</a> have been appointed as Regional B Panel counsel from the 1st of March 2025 for a period of five years.  <a href="https://www.parklaneplowden.co.uk/our-barristers/may-martin/" target="_blank" rel="noreferrer noopener">May Martin</a> has been appointed as Regional C Panel counsel from the 1st of March 2025 for a period of five years.  The government relies on the Panels for advice and representation and seeks candidates of the highest quality. Competition for places is fierce.  We’d like to congratulate Bronia, Richard and May on their appointments.   If you would like to get in touch with our clerking team, you can do so via <a href="mailto:clerks@parklaneplowden.co.uk" target="_blank" rel="noreferrer noopener">clerks@parklaneplowden.co.uk</a>.

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01 October 2025 | Court of Protection Grandstand

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Morrow v HM Assistant Coroner for Merseyside (Sefton, Knowsley & St Helens) [2025] EWHC 935 (Admin)

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